Predicting long-term (> or = 5 years) event-free survival in multiple myeloma patients following planned tandem autotransplants

Microparticles and PD1 interplay added a prognostic impact in treatment outcomes of patients with multiple myeloma

Although multiple myeloma (MM) is still considered as an incurable disease by current standards, the development of several combination therapies, and immunotherapy approaches has raised the hope towards transforming MM into an indolent, chronic disease, and possibly achieving a cure. We tried to shed light on the expression of PD1 and different Microparticles (MPs) in MM and their interplay as a mechanism of resistance to standardized treatments, in addition, find their associations with prognostic factors of symptomatic MM. Thirty patients with newly diagnosed and chemotherapy naïve active MM, along with 19 healthy participants of comparable age and sex were recruited, after diagnosis of MM; blood samples were collected from both patients and controls for flow cytometric detection of CD4+, CD8+, CD4+PD1+, and CD8+PD1+T cells, total MPs, CD138+ MPs, and platelet MPs. MM patients had statistically significant higher levels of TMPs, CD138+ MPs compared to their controls, while PMPs exhibited no significant difference between both groups. Statistically significant higher percentages of CD8+, PD1CD8+, PD1CD4+T cells were detected in patients compared to controls, while the latter group had a significantly higher percentage of CD4+T cells than MM patients, patients who did not achieve complete response, had significantly higher percentages of PMPs, CD138+MPs, PD1+CD8+, PD1+CD4+, and CD8+T cells (cutoff values = 61, 10.6, 13.5, 11.3 and 20.1 respectively), (p-values = 0.002, 0.003, 0.017, 0.001 and 0.008 respectively). Microparticles and PD1 expressions were associated with proliferative potential and resistance to Bortezomib-based treatments, our results suggested that they played a crucial role in myeloma progression.

Impact of Pre-transplant and Post-transplant Remission Status of Patients on Survival in Newly Diagnosed Multiple Myeloma

The overall survival (OS) in patients with multiple myeloma (MM) has increased in the last decade due to the introduction of proteasome inhibitors, immunomodulatory drugs and monoclonal antibodies as well as an extensive combination of autologous stem cell transplantation (ASCT) for suitable patients. The objective of this study was to examine the impact of pre-transplant and post-transplant remission status of patients on survival in newly diagnosed multiple myeloma. Two hundred and four patients with newly diagnosed MM who received an ASCT in our HSC transplant center at Hacettepe University Hospital between the years of 2001 and 2018 were evaluated in a retrospective manner. The median follow-up period was 35.9 months (range 4.2-206.4) for the entire group. The 5-year OS for pre-transplant remission status CR/VGPR patients and pre-transplant remission status PR or less patients were 79% and 68%, respectively (p = 0.09). The 5-year PFS for pre-transplant remission status CR/VGPR patients and pre-transplant remission status PR or less patients were 62% and 45%, respectively (p = 0.23). The 5-year OS for post-transplant remission status CR/VGPR group was 72% and for post-transplant remission status PR or less group was 60% (p = 0.02). The 5-year PFS in post-transplant remission status CR/VGPR patients was 48% and post-transplant remission status PR or less patients was 36% (p = 0.03). This study focuses on determination of survival outcome based on the best response obtained before and after ASCT and particularly highlights the significance of reaching CR and VGPR.

Defining cure in multiple myeloma: a comparative study of outcomes of young individuals with myeloma and curable hematologic malignancies

Advances in therapy in recent years have led investigators to challenge the dogma that multiple myeloma (MM) is incurable. We assessed overall (OS) and progression-free survival (PFS) of young patients ( ≤ 50 years) with MM and compared outcomes with follicular lymphoma (FL), diffuse large B-cell lymphoma (DLBCL), and Hodgkin lymphoma (HL). All patients ≤ 50 years with newly diagnosed MM (n = 212), FL (n = 168), DLBCL (n = 195), and HL (n = 233) between 1 January 2005 and 31 December 2015 were included. Observed vs. expected survival was summarized by standardized mortality ratios (SMR). Compared to the background US population, excess mortality risk was seen at diagnosis in all four cancers, SMR 19.5 (15.2–24.5) in MM, 4.2 (2.3–7.2) in FL, 13.0 (9.2–18.4) in DLBCL, and 5.2 (2.6–9.3) in HL. We reasoned that cure would most likely occur in the first 3 years after diagnosis and be reflected by an overall survival probability similar to the background population. From the 36-month landmark, excess mortality risk was seen in MM (SMR 20.7 [14.7–28.3]) and FL (SMR 3.8 [1.5–7.8]), but not with DLBCL (SMR 3.1 [0.8–8.0]) or HL (SMR 0.9 [0.0–5.1]). MM patients have 20-fold excess mortality risk compared to the background population at diagnosis and at 3 years after diagnosis, suggesting that MM remains an incurable cancer.

Analysis of long-term survival in multiple myeloma after first-line autologous stem cell transplantation: impact of clinical risk factors and sustained response

The widespread use of high-dose therapy and autologous stem cell transplantation (ASCT) as well as the introduction of novel agents have significantly improved outcomes in multiple myeloma (MM) enabling long-term survival. We here analyze factors influencing survival in 865 newly diagnosed MM patients who underwent first-line ASCT at our center between 1993 and 2014. Relative survival and conditional survival were assessed to further characterize long-term survivors. Achievement of complete response (CR) post-ASCT was associated with prolonged progression-free survival (PFS) in the whole cohort and with significantly superior overall survival (OS) in the subgroup of patients receiving novel agent-based induction therapy. Landmark analyses performed at 1, 3, and 5 years post-ASCT revealed that sustainment of any response had a highly significant influence on survival with no significant differences between sustained CR and sustained inferior responses. Furthermore, outcome was independently improved by administration of maintenance therapy. A subset of patients did experience long-term survival >15 years. However, conditional survival demonstrated a persistent risk of myeloma-associated death and cumulative relative survival curves did not show development of a clear plateau, even in prognostically advantageous groups. In conclusion, in this large retrospective study, sustained response after first-line ASCT was found to be a major prognostic factor for OS independent of depth of sustained response. Administration of maintenance therapy further improved outcome, supporting the hypothesis that interventions to prolong responses achieved post-ASCT may be essential to reach long-term survival, especially in the setting of persisting residual disease.

Efficacy of a referral center for patient-centered care in multiple myeloma: a cohort study

BACKGROUND

Within the Brazilian Unified Health System (SUS), Referral Centers (RCs) are care facilities that provide specialized services. The objective of this study was to evaluate the efficacy of care provided to patients with multiple myeloma (MM) at a specialized RC (Hospital de Clínicas de Porto Alegre Referral Center for Multiple Myeloma, CRMM-HCPA) and to compare quality of life between patients with MM treated at CRMM-HCPA and those treated at non-RC facilities.

METHODS

A 6-month cohort study was conducted in patients with MM receiving thalidomide from the Rio Grande do Sul State Health Department and treated at CRMM-HCPA and patients receiving treatment at other, non-RC care facilities. Thirty-two patients were included in the study, 19 from CRMM-HCPA and 13 from other institutions. To analyze the efficacy of care provided at CRMM-HCPA, the main outcome measure was the time from diagnosis to referral for autologous hematopoietic stem cell transplantation (HSCT). This outcome measure was assessed using questionnaires specifically designed for this study. Quality of life was also assessed, using the SF-36 questionnaire.

RESULTS

Time from MM diagnosis to referral for autologous HSCT in each group was measured only in patients aged ≤ 65 years (n = 25); of these, 15 were recruited from CRMM-HCPA and 10 from other institutions. In this analysis, there was a significant difference (p = 0.036) in time elapsed between diagnosis and referral for autologous HSCT, which was significantly shorter for patients treated at CRMM-HCPA (median, 9 months; IQR, 8.5-14.5) than for those treated elsewhere (median, 24 months; IQR, 16-24). On quality of life analysis, there was a significant difference in the Social Functioning domain of the SF-36 questionnaire, which relates to performance of social activities (p = 0.02).

CONCLUSIONS

The Referral Center model provided seems to be a more efficient treatment strategy as compared with other health care facilities, as it enabled a reduction in time to transplantation. Patients treated at CRMM-HCPA demonstrated greater ease in performing social activities, with less interference from physical or emotional problems.

How we manage autologous stem cell transplantation for patients with multiple myeloma

An estimated 22 350 patients had multiple myeloma diagnosed in 2013, representing 1.3% of all new cancers; 10 710 deaths are projected, representing 1.8% of cancer deaths. Approximately 0.7% of US men and women will have a myeloma diagnosis in their lifetime, and with advances in therapy, 77 600 US patients are living with myeloma. The 5-year survival rate was 25.6% in 1989 and was 44.9% in 2005. The median age at diagnosis is 69 years, with 62.4% of patients aged 65 or older at diagnosis. Median age at death is 75 years. The rate of new myeloma cases has been rising 0.7% per year during the past decade. The most common indication for autologous stem cell transplantation in the United States is multiple myeloma, and this article is designed to provide the specifics of organizing a transplant program for multiple myeloma. We review the data justifying use of stem cell transplantation as initial management in myeloma patients. We provide selection criteria that minimize the risks of transplantation. Specific guidelines on mobilization and supportive care through the transplant course, as done at Mayo Clinic, are given. A review of the data on tandem vs sequential autologous transplants is provided.

Review of molecular diagnostics in multiple myeloma

Multiple myeloma evolves clinically from monoclonal gammopathy of undetermined significance through smoldering disease, active myeloma with end organ damage to a preterminal phase of extramedullary disease and marrow collapse. The molecular equivalents of such clinical observation can now be defined as genetically dormant, genetic crisis and genetic chaos (popularly termed malignant myeloma). Patients may present for the first time in any one of these stages. Not surprisingly, clinical outcomes for multiple myeloma are variable and the prospects for therapeutic responsiveness are defined by the stage at presentation. We describe here a genetically driven definition of high- and low-risk myeloma and offer guidelines for the adoption of routine diagnostic testing. We define high-risk disease as the presence of t(4;14), t(14;16), deletion 17p13 by FISH or the presence of hypodiploidy or deletion of chromosome 13 by conventional cytogenetics. By default, other patients are not considered high risk. Thus, as a minimum, we recommend routine testing for t(4;14) and 17p13 deletion by FISH and conventional cytogenetics. This classification will identify multiple myeloma patients at high genetic risk for early progression after conventional therapies.

Tandem autologous/reduced-intensity conditioning allogeneic stem-cell transplantation versus autologous transplantation in myeloma: long-term follow-up

PURPOSE

Results of allogeneic stem-cell transplantation (allo) in myeloma are controversial. In this trial autologous stem-cell transplantation (auto) followed by reduced-intensity conditioning matched sibling donor allo (auto-allo) was compared with auto only in previously untreated multiple myeloma.

PATIENTS AND METHODS

In all, 357 patients with myeloma up to age 69 years were enrolled from 2001 to 2005. Patients with an HLA-identical sibling donor were allocated to the auto-allo arm (n = 108) and patients without a matched sibling donor were allocated to the auto arm (n = 249). Single (n = 145) or tandem (n = 104) auto was optional. Conditioning for the auto arm was melphalan 200 mg/m(2); conditioning for the allo arm was total-body irradiation 2 Gy plus fludarabine 30 mg/m(2)/d for 3 days. Median follow-up time was 61 months. Primary end point was progression-free survival.

RESULTS

Progression-free survival at 60 months was significantly better with auto-allo than with auto [corrected] alone (35% v 18%; P = .001), as was the risk of death and of relapse in the long term (P = .047 and P = .003, respectively). Overall survival at 60 months was 65% versus 58%, and relapse incidence was 49% versus 78%. Complete remission rates were 51% and 41%, respectively (P = .020). Nonrelapse mortality at 24 months was 12% after auto-allo compared with 3% in the auto group (P < .001). The incidence of grade 2 to 4 acute graft-versus-host disease (GvHD) was 20%, and the incidence of limited and extensive chronic GvHD was 31% and 23%.

CONCLUSION

In patients with previously untreated multiple myeloma, long-term outcome with respect to progression-free survival, overall survival, and relapse rate is superior after auto-allo compared with auto only. Nonrelapse mortality is at a reasonable level in both groups.

Multiple myeloma: biology of the disease

Multiple myeloma (MM) is a clonal B-cell malignancy characterized by the aberrant expansion of plasma cells within the bone marrow, as well as at extramedullary sites. Decades of scientific research are now beginning to unravel the intricate biology that underlies the pathophysiology of MM. In particular, the roles of cellular differentiation, molecular pathogenesis, and oncogenes involved in the natural history of MM are becoming clearer. This has enabled the identification of specific cytokines, adhesion molecules, and stromal cells that affect MM cell development, disease progression, and treatment responses. This review describes our current understanding regarding the biology of MM, and how this has led to a robust pipeline of novel therapeutic agents with the potential to overcome resistance to existing MM therapies and, therefore, further improve outcomes in patients with MM.

Germline polymorphisms as modulators of cancer phenotypes

Identifying the complete repertoire of genes and genetic variants that regulate the pathogenesis and progression of human disease is a central goal of post-genomic biomedical research. In cancer, recent studies have shown that genome-wide association studies can be successfully used to identify germline polymorphisms associated with an individual's susceptibility to malignancy. In parallel to these reports, substantial work has also shown that patterns of somatic alterations in human tumors can be successfully employed to predict disease prognosis and treatment response. A paper by Van Ness et al. published this month in BMC Medicine reports the initial results of a multi-institutional consortium for multiple myeloma designed to evaluate the role of germline polymorphisms in influencing multiple myeloma clinical outcome. Applying a custom-designed single nucleotide polymorphism microarray to two separate patient cohorts, the investigators successfully identified specific combinations of germline polymorphisms significantly associated with early clinical relapse. These results raise the exciting possibility that besides somatically acquired alterations, germline genetic background may also exert an important influence on cancer patient prognosis and outcome. Future 'personalized medicine' strategies for cancer may thus require incorporating genomic information from both tumor cells and the non-malignant patient genome.

Preclinical studies of novel targeted therapies

The bone marrow (BM) milieu confers drug resistance in multiple myeloma (MM) cells to conventional therapies. Novel biologically based therapies are therefore needed. Preclinical studies have identified and validated molecular targeted therapeutics in MM. In particular, recognition of the biologic significance of the BM microenvironment in MM pathogenesis and as a potential target for novel therapeutics has already derived several promising approaches. Thalidomide, lenalidomide (Revlimid), and bortezomib (Velcade) are directed not only at MM cells but also at the BM milieu and have moved rapidly from the bench to the bedside and United States Food and Drug Administration approval to treat MM.

Role of stem cell transplantation

Hematopoietic stem cell transplantation (SCT) was introduced in the treatment of multiple myeloma in the 1980s. In the autologous setting, the use of peripheral blood stem cells instead of bone marrow has markedly improved feasibility. In fit patients who have normal renal function and are younger than 65 years of age, randomized studies have shown the superiority of autologous stem cell transplantation (ASCT) compared with conventional chemotherapy. ASCT is now considered the standard of care in this population of patients. It is currently challenged, however, by the introduction of novel agents, such as thalidomide, bortezomib, and lenalidomide. The role of allogenic SCT remains controversial, even with reduced intensity conditionings. Prospective studies still are needed to evaluate the impact of both autologous and allogeneic SCT in this new era.

Suppression of abnormal karyotype predicts superior survival in multiple myeloma

Cytogenetic studies were performed as part of all diagnostic and surveillance bone marrow examinations in 956 newly diagnosed patients with multiple myeloma (MM) receiving total therapy (TT) protocols and in 1085 previously treated patients enrolled in non-TT protocols. In both groups, cytogenetic abnormalities (CA) were present in one-third at baseline and persisted in 14% prior to first and 10% prior to second transplant (TT, 5%; non-TT, 15%); post-transplant detection rates increased progressively with time, from 7% within 6 months to 21% within 24 months to 28% at relapse. According to multivariate analyses, overall survival was adversely affected by the presence of CA at baseline (hazard ratio (HR)=7.20, P<0.001) and the development of CA both prior to (HR=3.28, P<0.001) and after first transplant (HR=6.24, P<0.001), whereas suppression of CA pretransplant was favorable (HR=0.38, P<0.001). The presence of CA at relapse further distinguished patients with a short median post-relapse survival of only 11 versus 47 months in those without CA (P<0.0001). Post-relapse survival was independently adversely affected by the detection of CA both at baseline (HR=1.35, P=0.044) and relapse (HR=2.47, P<0.001). Collectively, these results underscore the importance of monitoring for CA and attest to the favorable prognostic consequences of CA suppression with effective therapy.

The allogeneic dilemma

The place of allogeneic SCT in the management of multiple myeloma remains controversial. Although it may induce long-term clinical and molecular remissions, the very high transplant-related toxicity after a myeloablative preparative regimen has limited its role to younger patients as first-line treatment option. Even with this limited indication, toxic death rate related to infections and GVHD is considered too high and this strategy has been almost abandoned. Reduced intensity conditioning (RIC) regimens look promising, as the transplant-related mortality is low even with matched unrelated donors and can be considered for older patients up to the age of 65 years. However when used in patients with a high tumor burden or with chemo-resistant disease, the immunologic effect of the graft is not sufficient to avoid relapses. Therefore, RIC allotransplantation is currently used after tumor mass reduction with high-dose therapy followed by autologous SCT. A recently published Italian study shows that this strategy induces better event-free survival than double autologous SCT due to a reduced relapse rate. The questions raised by this encouraging result are discussed in this paper.

Nonmyeloablative unrelated donor hematopoietic cell transplantation to treat patients with poor-risk, relapsed, or refractory multiple myeloma

The purpose of this study was to determine long-term outcome of unrelated donor nonmyeloablative hematopoietic cell transplantation (HCT) in patients with poor-risk multiple myeloma. A total of 24 patients were enrolled; 17 patients (71%) had chemotherapy-refractory disease, and 14 (58%) experienced disease relapse or progression after previous autologous transplantation. Thirteen patients underwent planned autologous transplantation followed 43-135 days later with unrelated transplantation, whereas 11 proceeded directly to unrelated transplantation. All 24 patients were treated with fludarabine (90 mg/m(2)) and 2 Gy of total body irradiation before HLA-matched unrelated peripheral blood stem cell transplantation. Postgrafting immunosuppression consisted of cyclosporine and mycophenolate mofetil. The median follow-up was 3 years after allografting. One patient experienced nonfatal graft rejection. The incidences of acute grades II and III and chronic graft-versus-host disease were 54%, 13%, and 75%, respectively. The 3-year nonrelapse mortality (NRM) was 21%. Complete responses were observed in 10 patients (42%); partial responses, in 4 (17%). At 3 years, overall survival (OS) and progression-free survival (PFS) rates were 61% and 33%, respectively. Patients receiving tandem autologous-unrelated transplantation had superior OS and PFS (77% and 51%) compared with patients proceeding directly to unrelated donor transplantation (44% and 11%) (PFS P value = .03). In summary, for patients with poor-risk, relapsed, or refractory multiple myeloma, cytoreductive autologous HCT followed by nonmyeloablative conditioning and unrelated HCT is an effective treatment approach, with low NRM, high complete remission rates, and prolonged disease-free survival.

A practical guide to defining high-risk myeloma for clinical trials, patient counseling and choice of therapy

Clinical outcomes for multiple myeloma (MM) are highly heterogeneous and it is now clear that pivotal genetic events are the primary harbingers of such variation. These findings have broad implications for counseling, choice of therapy and the design and interpretation of clinical investigation. Indeed, as in acute leukemias and non-hodgkins lymphoma, we believe it is no longer acceptable to consider MM a single disease entity. As such, the accurate diagnosis of MM subtypes and the adoption of common criteria for the identification and stratification of MM patients has become critical. Herein, we provide a consensus high-risk definition and offer practical guidelines for the adoption of routine diagnostic testing. Although acknowledging that more refined classifications will continue to be developed, we propose that the definition of high-risk disease (any of the t(4;14), t(14;16), t(14;20), deletion 17q13, aneuploidy or deletion chromosome 13 by metaphase cytogenetics, or plasma cell labeling index >3.0) be adopted. This classification will identify most of the 25% of MM patients for whom current therapies are inadequate and for whom investigational regimens should be vigorously pursued. Conversely, the 75% of patients remaining have more favorable outcomes using existing - albeit non-curative - therapeutic options.

Bortezomib in Combination with Pegylated Liposomal Doxorubicin for the Treatment of Multiple Myeloma

Many novel agents and new combinations (including bortezomib, thalidomide, and lenalidomide) have been developed in recent years for the treatment of multiple myeloma (MM), creating major shifts in therapeutic management. Achieving complete response (CR)/near CR (nCR) generally serves as a reliable clinical surrogate for overall treatment outcome, ie, prolonged survival. Indeed, some newer induction regimens are yielding similar median time to disease progression effects compared with transplantation. Thus, it can be a dilemma whether a patient with CR/nCR needs to be subjected to the potential morbidity associated with transplantation after induction therapy. Combining new agents with chemotherapy-based regimens appears to offer higher overall response and CR/nCR rates than similar combinations that do not include chemotherapy. We review the preclinical and clinical rationale for combining bortezomib with pegylated liposomal doxorubicin for the treatment of MM. The synergistic interaction in sensitizing each other toward myeloma cells in vitro and their complementary in vivo activities have justified clinical studies. We summarize data for completed and ongoing phase I/II trials of this combination. To date, results have been sufficiently encouraging to initiate an international, multicenter, randomized, phase III trial comparing bortezomib with or without pegylated liposomal doxorubicin in patients with relapsed/refractory MM. The results of this trial will confirm whether the rationale for combining bortezomib with pegylated liposomal doxorubicin is validated by improved clinical outcome, ie, improved time to progression, for patients with MM.

Predictive factors for survival in myeloma patients who undergo autologous stem cell transplantation: a single-centre experience in 211 patients

High-dose therapy with autologous stem cell therapy (ASCT) has become the treatment of choice for eligible patients with myeloma. We analysed retrospectively the prognostic influence of pre-transplant characteristics and transplant modalities on response and survival in 211 myeloma patients who were transplanted in our centre between 1994 and 2004. All patients received peripheral blood stem cell support after conditioning with melphalan alone (183 patients), or melphalan and total blood irradiation (28 patients). We evaluated the influence of age, type of multiple myeloma, status prior and post ASCT, previous treatment regimens, time of ASCT from diagnosis, year of autograft, dose of re-infused CD34(+) cells, plasma cell infiltration and beta2-microglobulin at diagnosis on overall survival (OS) and event-free survival (EFS) to define patients with better prognosis. Median OS and EFS from transplantation were 50.9 and 20.1 months, respectively. Median OS from diagnosis was 68.8 months. Transplant-related mortality was 1.4%. Lower beta2-microglobulin levels, achievement of complete remission (CR) post transplant and lower plasma cell infiltration at diagnosis and transplant correlated with longer EFS and OS, whereas CR at transplant and low international prognostic index at transplant correlated with better EFS. Higher CD34(+) cell dose correlated with improved OS. We conclude that ASCT is safe and effective and the outcome is independent of age, time from diagnosis, previous treatment and conditioning regimen.

The molecular classification of multiple myeloma

To better define the molecular basis of multiple myeloma (MM), we performed unsupervised hierarchic clustering of mRNA expression profiles in CD138-enriched plasma cells from 414 newly diagnosed patients who went on to receive high-dose therapy and tandem stem cell transplants. Seven disease subtypes were validated that were strongly influenced by known genetic lesions, such as c-MAF- and MAFB-, CCND1- and CCND3-, and MMSET-activating translocations and hyperdiploidy. Indicative of the deregulation of common pathways by gene orthologs, common gene signatures were observed in cases with c-MAF and MAFB activation and CCND1 and CCND3 activation, the latter consisting of 2 subgroups, one characterized by expression of the early B-cell markers CD20 and PAX5. A low incidence of focal bone disease distinguished one and increased expression of proliferation-associated genes of another novel subgroup. Comprising varying fractions of each of the other 6 subgroups, the proliferation subgroup dominated at relapse, suggesting that this signature is linked to disease progression. Proliferation and MMSET-spike groups were characterized by significant overexpression of genes mapping to chromosome 1q, and both exhibited a poor prognosis relative to the other groups. A subset of cases with a predominating myeloid gene expression signature, excluded from the profiling analyses, had more favorable baseline characteristics and superior prognosis to those lacking this signature.

Cure of multiple myeloma -- more hype, less reality

Randomized studies have firmly established the role of autologous transplant as initial therapy in multiple myeloma (MM). Indeed, MM has emerged as the commonest indication for autologous SCT in North America. The conceptual basis for high-dose therapy is the goal of complete remission (CR) through steep reduction in tumor burden affected by single and tandem transplants. Careful analysis of the data challenges the notion of CR as a surrogate to success. Intrinsically aggressive MM, defined by known unfavorable biologic risk factors, overrides the benefit of CR. In contrast, subgroups of patients with favorable biological risk factors may achieve prolonged survival, often without ever achieving CR. Unfortunately, even with tandem transplants, there is no plateau in survival curves. To this end, sequential autologous followed by nonmyeloablative allotransplants are a novel attempt at 'curing' myeloma, but the results thus far have failed to show a definite plateau in survival. Given the improvements in supportive care and concomitant reduction in transplant-related mortality, conventional myeloablative allogeneic transplants need to be re-examined as an option in high-risk aggressive myeloma. At the same time, novel antimyeloma therapies, newer risk stratification and staging tools are transforming the treatment algorithm. We examine the changing role of transplantation in myeloma in the context of novel drug therapy, biologic risk stratification and improving supportive care while arguing that the current 'one size fits all' transplant approaches are far from a cure.

Novel therapeutic strategies targeting growth factor signalling cascades in multiple myeloma

Multiple myeloma (MM) remains largely incurable despite conventional and high-dose therapies, and novel biologically based treatment approaches are urgently required. Recent studies demonstrate that various growth factors including interleukin (IL)-6, insulin-like growth factor (IGF)-1, vascular endothelial growth factor (VEGF), the tumour necrosis factor (TNF) family proteins, Wnt, and Notch family members play an important role in MM pathogenesis, and mediate tumour cell proliferation, drug resistance and migration in the bone marrow (BM) milieu. Targeting growth factors, therefore, represents a promising therapeutic strategy in MM. Novel agents inhibiting growth factor signalling cascades can target ligands, receptors, and/or downstream signalling cascade proteins in MM cells and the BM microenvironment. Combinations of these novel agents with conventional therapies may not only enhance cytotoxicity, but also avoid drug resistance and thereby improve patient outcome in MM.

Stem-cell transplantation in multiple myeloma

In patient with newly diagnosed multiple myeloma (MM), randomized studies have shown that autologous stem-cell transplantation (ASCT) is superior to conventional chemotherapy, and ASCT is now standard care, at least for younger patients. The best conditioning regimen is melphalan 200 mg/m2, and the best stem-cell source is unselected peripheral progenitor cells. Recent results of the IFM94 trial show that double ASCT is superior to single ASCT, at least in patients who do not achieve a 90% response after one transplant. By combining biologic markers (beta2-microglobulin, albumin) and genetic markers (hypodiploidy, chromosome 13 deletion) it is possible to accurately predict prognosis after ASCT. The results of allogeneic SCT remain disappointing due to a high transplant mortality. Strategies combining ASCT and reduced-intensity allogeneic SCT are currently being studied.

Vaccine strategies to treat lymphoproliferative disorders

Lymphoproliferative disorders, including follicular lymphoma (FL), multiple myeloma (MM) and chronic lymphatic leukaemia (CLL), are slowly progressive malignancies which remain incurable despite advances in therapy. Harnessing the immune system to recognise and destroy tumours is a promising new approach to treating these diseases. Dendritic cells (DC) are unique antigen-presenting cells that play a central role in the initiation and direction of immune responses. DC loaded ex vivo with tumour-associated antigens and administered as a vaccine have already shown promise in early clinical trials for a number of lymphoproliferative disorders, but the need for improvement is widely agreed. Recent advances in the understanding of basic DC biology and lessons from early clinical trials have provided exciting new insights into the generation of anti-tumour immune responses and the design of vaccine strategies. In this review we provide an overview of our current understanding of DC biology and their function in patients with lymphoproliferative disorders. We discuss the current status of clinical trials and new approaches to exploit the antigen presenting capacity of DC to design vaccines of the future.

Results of a phase I/II trial adding carmustine (300 mg/m2) to melphalan (200 mg/m2) in multiple myeloma patients undergoing autologous stem cell transplantation

Autologous stem cell transplantation (SCT) with high-dose melphalan (HDM, 200 mg/m2) is the most effective therapy for multiple myeloma. To determine the feasibility of combining carmustine (300 mg/m2) with HDM, we enrolled 49 patients with previously treated Durie-Salmon stage II/III myeloma (32M/17W, median age 53) on a phase I/II trial involving escalating doses of melphalan (160, 180, 200 mg/m2). The median beta2-microglobulin was 2.5 (0-9.3); marrow karyotypes were normal in 88%. The phase I dose-limiting toxicity was > or =grade 2 pulmonary toxicity 2 months post-SCT. Other endpoints were response rate and progression-free survival (PFS). HDM was safely escalated to 200 mg/m2; treatment-related mortality was 2% and > or =grade 2 pulmonary toxicity 10%. The complete (CR) and near complete (nCR) response rate was 49%. With a median post-SCT follow-up of 2.9 years, the PFS and overall survival (OS) post-SCT were 2.3 and 4.7 years. PFS for those with CR or nCR was 3.1 years while for those with stable disease (SD) it was 1.3 years (P=0.06). We conclude that carmustine can be combined with HDM for myeloma with minimal pulmonary toxicity and a high response rate.

Risk Stratification of Patients with Newly Diagnosed Multiple Myeloma: Optimizing Treatment Based on Pretreatment Characteristics

Marked clinical and biologic heterogeneity exists in multiple myeloma (MM). Over the years, many prognostic factors have been identified and several prognostic systems have been proposed. The integration of data from international groups including patients treated with common modalities such as chemotherapy and high-dose therapy culminated in the International Staging System. Recently, genetic information has also been shown to include powerful prognostic factors across different treatment modalities. These advances have facilitated categorization of patients into different risk groups, particularly a subset of patients at high risk with short survival times after current standard therapy. The expanding armamentarium of effective treatments in MM also means that it is now possible to select treatments for patients based on their risk categories. This review will summarize the important prognostic factors identified to date, how they can be used to identify patients at high risk, and their clinical utility in relation to treatment optimization at diagnosis.

New Approaches to Treatment for Multiple Myeloma: Durable Remission and Quality of Life as Primary Goals

New treatment approaches are changing the traditional paradigm for myeloma management. Partial or complete response with first-line therapy is now highly attainable. The focus of attention has thus shifted to obtaining the most durable remissions with the highest quality of life. A critical open question is whether more arduous and toxic therapies are justified with the intent to seek a cure. Patients with minimal symptoms at diagnosis are particularly reluctant to pursue aggressive strategies without documented long-term benefit. Conversely, patients with poor-risk molecular features, such as 13q deletion or t(4;14) translocation, can hopefully benefit from novel targeted therapies. New combinations incorporating bortezomib, thalidomide, and/or lenalidomide plus other novel agents offer the opportunity to explore therapy that is more effective and less toxic than in the past. The efficacy of single and tandem transplantation, which have documented long-term survival benefit, need to be compared with regimens integrating novel therapies. Whether true complete remission is a prerequisite for substantially improved survival is a central question in the framework of planned trials. The ultimate goal is to achieve clinical response (complete or partial) that offers the best quality remission for the longest period. Ideally, more effective induction and/or consolidation treatments will avoid concomitant toxicities and the need for maintenance therapies. Fortunately, new agents already offer longer-term disease control. The ongoing search for a cure will undoubtedly demand courage and dedication on the part of investigators and patients.

Results of autologous and allogeneic hematopoietic cell transplant therapy for multiple myeloma

We compared the results of autologous and allogeneic peripheral blood hematopoietic cell transplant (HCT) in 87 patients with multiple myeloma using myeloablative preparative regimen. Autologous transplant (n=70) led to a lower 100-day transplant-related mortality (TRM) of 4% [0-9%] compared to 18% [0-36%] in allogeneic recipients (P=0.02). More frequent complete responses were seen in allogeneic recipients (64% [37-91%] vs 34% [23-45%] in autologous recipients, P=0.09). In autologous recipients, survival at 1 year was 86% [80-95%] and, it fell to 50% [47-75%] at 4 years, whereas in allogeneic recipients, survival at 1 and 4 years remained at 64% [40-87%]. In patients surviving more than one year, 4-year survival was superior in allogeneic (100%) vs autologous recipients (58% [41-75%], P=0.02). A trend toward higher relapse was seen in autologous transplant patients (73% [55-90%] vs 37% [11-63%] in allogeneic transplant patients, P=0.1). We observed good tolerance of myeloablative conditioning regimen followed by either autologous or allogeneic transplant. Although autologous HCT is associated with lower TRM, allogeneic HCT has acceptable TRM, and is more likely to provide a sustained response. Allogeneic HCT may be suitable in younger patients, soon after diagnosis, and in those with chemosensitive disease.

Cytokines and signal transduction

Many studies have characterized the role of growth factors in multiple myeloma (MM) pathogenesis and have derived novel therapies to improve patient outcome based upon targeting cytokines and their signaling cascades both in the MM cell and in the bone-marrow (BM) microenvironment. These cytokines include interleukin 6 (IL-6), insulin-like growth factor 1 (IGF-1), vascular endothelial growth factor (VEGF), tumor necrosis factor alpha (TNF-alpha), transforming growth factor beta (TGF-beta), stromal cell-derived factor 1alpha (SDF-1alpha), IL-21, B-cell stimulating factor 3 (BSF-3) and fibroblast growth factor (FGF). These cytokines are secreted from stromal cells (SCs), endothelial cells and/or osteoclasts, and promote MM cell growth, survival and migration, as well as paracrine cytokine secretion and angiogenesis in the BM milieu. Thus inhibition of signaling cascades induced by these cytokine provides rationale for a therapeutic option for MM.

High incidence and intraclonal heterogeneity of chromosome 11 aberrations in patients with newly diagnosed multiple myeloma detected by multiprobe interphase FISH

In multiple myeloma, additional copies of chromosome 11 material, reported to confer an unfavorable prognosis, have been found in 20-45% of patients. To assess the incidence and extent of chromosome 11 aberrations, we performed interphase fluorescence in situ hybridization on CD138+ bone marrow plasma cells of 50 newly diagnosed myeloma patients, using seven locus-specific probes for chromosome 11, one for 13q14.3, and a probe set for translocation t(11;14). In 33 of 50 patients, chromosome 11 aberrations were found. Results indicated a marked intraclonal heterogeneity: in 13 patients, trisomy 11; in 10 patients, subclones with trisomy 11 and partial trisomies 11q coexisted; in 6 patients, only a partial trisomy 11q; and in 6 patients, a tetrasomy or partial tetrasomy 11. The coexistence of subclones with varying extent and copy numbers of chromosome 11 material indicates ongoing structural changes and clonal evolution. Hybridization results delineated 11q23 and 11q25 as the most frequently gained regions, which supports a relevant pathogenetic role of genes on 11q23 and 11q25. To confirm the high incidence of 11q23 gains, a further 50 patients (total n=100) were analyzed for 11q23 and 13q14.3. Myeloma with gains of 11q23 showed a low frequency of deletion 13q14.3 and may prove to be a distinct subgroup of this disease.

Reduced-intensity allogeneic stem cell transplantation in adults and children with malignant and nonmalignant diseases: end of the beginning and future challenges

During the last 10 years, multiple studies using reduced-intensity (RI) conditioning followed by allogeneic stem cell transplantation (AlloSCT) have been reported in adult and, less so, pediatric recipients. RI AlloSCT allegedly eradicates malignant cells through a graft-versus-leukemia/graft-versus-tumor effect provided by alloreactive donor T lymphocytes, natural killer cells, or both. Various studies have clearly demonstrated a graft-versus-leukemia/graft-versus-tumor effect in hematologic malignancies and solid tumors. Acute short-term toxicity, including infection and organ decompensation after myeloablative conditioning therapy, can result in a significant incidence of early transplant-related mortality. More importantly, long-term late effects-including growth retardation, infertility, and secondary malignancies-are major complications after myeloablative conditioning therapy, especially in vulnerable children, who are more susceptible to these complications. Recent results comparing RI conditioning with myeloablative conditioning followed by HLA-matched sibling AlloSCT have demonstrated a significant reduction in use of blood products, risk of infections, transplant-related mortality, length of hospitalization, and feasibility of conditioning therapy in outpatient settings. Despite the success of RI AlloSCT, large prospective randomized multicenter studies are necessary to define the appropriate patient population, optimal conditioning regimens and pretransplantation immunosuppression, role of donor lymphocyte infusions, duration of hospitalization, overall survival, cost-benefit ratio, and differences in long-term effects to evaluate the role of RI AlloSCT more fully. We review the recent experience of RI AlloSCT in adults and children with both malignant and nonmalignant diseases and discuss the challenges for the future.

Current status of stem cell transplantation for multiple myeloma

Stem cell transplantation for myeloma has become a standard of care for newly diagnosed patients. Current evidence favors tandem transplants for those patients not achieving a complete or very good partial response (<90%) after the first transplant. Transplantation is safe and has been shown to prolong survival even in patients 65 to 70 years of age. Whether the new agents thalidomide, lenalidomide, and bortezomib will have an impact on the survival advantage of stem cell transplantation is unknown.

Outcome of unrelated transplants in patients with multiple myeloma

The outcome of patients with multiple myeloma treated with standard therapy is disappointing, with a historical median survival of 3 years. Although high-dose therapy with autologous stem cell transplant has improved treatment outcomes, cure is unlikely. Allogeneic transplant provides a tumor-free graft and a graft-versus-myeloma effect. However, only a minority of patients has a compatible sibling donor. Unrelated hematopoietic stem cell transplant is another option. We analyzed the outcome of patients who received an unrelated bone marrow transplant facilitated by the National Marrow Donor Program (NMDP). Between 1989 and 2000, 71 patients received a myeloablative unrelated transplant for multiple myeloma; 70 patients consented for this analysis. The median recipient age was 44 years. A total of 31% of patients had received a prior autologous transplant. In all, 91% of patients engrafted. The 3-year cumulative incidence estimate of relapse was 34+/-10%. The incidence of Grade II-IV GVHD was 47%. The Kaplan-Meier estimate for overall survival at 5 years was 9+/-7%. The 100-day treatment-related mortality was 42%. In multivariate analysis, only a male donor was a significant predictor for survival. Better strategies are needed to treat patients with multiple myeloma, perhaps by using less-toxic, nonmyeloablative conditioning regimens.

NY-ESO-1 is highly expressed in poor-prognosis multiple myeloma and induces spontaneous humoral and cellular immune responses

The presence of a metaphase cytogenetic abnormality (CA) is the key negative predictor of outcome in patients with multiple myeloma (MM). Gene expression profiling (GEP) of such patients showed increased expression of NY-ESO-1 compared to patients with normal cytogenetics (60% versus 31%; P = .004). NY-ESO-1 was also highly expressed in relapsing MM especially patients with CA (100% versus 60.7%; P < .001). GEP findings were confirmed at the protein level by immunostaining of marrow biopsies for NY-ESO-1. We detected spontaneous NY-ESO-1-specific antibodies by enzyme-linked immunosorbent assay in 33% of patients with NY-ESO-1+ MM, especially in CA patients (9 of 13; 70%), but in none of the NY-ESO-1- patients with MM (n = 27) or healthy donors (n = 21). Spontaneous NY-ESO-1(157-165)-specific T cells (0.2%-0.6% of CD8+ T cells) were found in the peripheral blood of NY-ESO-1+ MM with HLA-A*0201/NY-ESO-1(157-165) tetramers. These NY-ESO-1-specific T cells, when expanded, killed primary MM cells (50% lysis, effector-target [E/T] ratio, 10:1). Our data demonstrate that NY-ESO-1 is frequently expressed in MM with CA and is capable of eliciting spontaneous humoral and T-cell immunity. The pool of NY-ESO-1-specific cytotoxic T cells expands easily on NY-ESO-1 peptide stimulation and is functionally active. NY-ESO-1 should therefore be an ideal tumor target antigen for immunotherapy of patients with poor-prognosis MM.

Randomized comparison of granulocyte colony-stimulating factor versus granulocyte-macrophage colony-stimulating factor plus intensive chemotherapy for peripheral blood stem cell mobilization and autologous transplantation in multiple myeloma

Autologous peripheral blood stem cell transplantation for multiple myeloma offers higher response rates and improved survival compared with conventional chemotherapy. However, successful autografting requires effective cytoreduction and rapid hematologic reconstitution. We conducted a prospective randomized clinical trial to assess the efficacy of 2 cycles of priming chemotherapy with either granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF) for peripheral blood stem cell mobilization followed by autologous transplantation. The major study end points were the comparative utility of G-CSF versus GM-CSF, the percentage of patients achieving complete response after transplantation, and overall and progression-free survival. Priming chemotherapy included cyclophosphamide (4 g/m2), mitoxantrone (8 g/m2 every day for 2 days), and dexamethasone (20 mg/m2 every 12 hours for 2 days) followed by randomization to either G-CSF or GM-CSF daily until completion of leukapheresis. Conditioning for transplantation included cyclophosphamide (75 mg/kg every day for 2 days) plus total body irradiation (165 cGy twice daily for 3 days), and patients received maintenance immunotherapy with interferon alpha. Seventy-two patients were randomized, and 64 underwent autologous transplantation. The median age at transplantation was 52 years, and the median time from diagnosis to transplantation was 10 months; 58% of the patients had received >4 cycles of pretransplantation chemotherapy. The median number of CD34+ cells obtained after mobilization was 16.4 x 10(6)/kg in the G-CSF arm versus 12.8 x 10(6)/kg in the GM-CSF arm (P = .8). Neutrophil recovery was faster in the G-CSF group after both cycle 1 (median, 13 days with G-CSF and 16 days with GM-CSF; P < .01) and cycle 2 (median, 13 days versus 17 days in the 2 groups, respectively; P = .03). Although platelet recovery was similar after cycle 1, platelet recovery to >100000/microL was notably faster in the G-CSF group both after cycle 2 and after transplantation (P = .03). Response and overall and disease-free survival were similar in both cohorts. Overall, 23% of the patients achieved a complete response after priming chemotherapy, which improved to 33% after transplantation. An additional 47% attained a partial response after transplantation, for a total response rate of 80%. With a median follow-up of 2 years (range, 0.7-8 years), the overall survival was 88% (95% confidence interval [CI], 80%-96%) at 1 year and 65% (95% CI, 51%-79%) at 3 years. Progression-free survival was 73% (95% CI, 62%-84%) at 1 year and 40% (95% CI, 26%-54%) at 3 years. Relapse or progressive disease was the most common cause of death (25 [83%] of 30 deaths). We conclude that mobilization with chemotherapy plus G-CSF versus GM-CSF results in similar CD34+ progenitor collections, even in patients exposed to multiple cycles of alkylator-based chemotherapy. Earlier neutrophil and platelet recovery was seen with G-CSF priming. Two cycles of priming chemotherapy plus autologous transplantation yields survival rates similar to those in published reports, including those using tandem transplantation.

Prognostic factors for survival after autologous transplantation: a single centre experience in 133 multiple myeloma patients

Autologous stem cell transplantation (ASCT) has an established role in the treatment of symptomatic multiple myeloma (MM). Our aim was to analyse the impact of selected prognostic parameters on the survival of patients with MM after ASCT. The new International Staging System (ISS) was also evaluated. A total of 133 MM patients were transplanted in our centre between 1995 and 2002. Following ASCT, 35% of patients were in complete remission (CR) and 60% were in partial remission (PR). The median progression-free (PFS) and overall (OS) survival from transplantation were 29.5 and 68.8 months, respectively. Transplant-related mortality (TRM) was 3%. On multivariate analysis, factors associated with significantly shorter OS were lack of CR after transplant (P = 0.002, hazard ratio (HR): 3.1), stage 3 according to ISS (P = 0.001, HR: 3.0) and age at transplant over 60 years (P = 0.035, HR: 2.0). The status of disease before ASCT did not significantly affect PFS and OS after transplantation. We conclude that ASCT is a safe and effective procedure in MM patients, associated with low TRM. The survival after ASCT was dependent on response after ASCT, stage according to ISS and age.

Prognostic and biologic significance of chromosomal imbalances assessed by comparative genomic hybridization in multiple myeloma

Cytogenetic abnormalities, evaluated either by karyotype or by fluorescence in situ hybridization (FISH), are considered the most important prognostic factor in multiple myeloma (MM). However, there is no information about the prognostic impact of genomic changes detected by comparative genomic hybridization (CGH). We have analyzed the frequency and prognostic impact of genetic changes as detected by CGH and evaluated the relationship between these chromosomal imbalances and IGH translocation, analyzed by FISH, in 74 patients with newly diagnosed MM. Genomic changes were identified in 51 (69%) of the 74 MM patients. The most recurrent abnormalities among the cases with genomic changes were gains on chromosome regions 1q (45%), 5q (24%), 9q (24%), 11q (22%), 15q (22%), 3q (16%), and 7q (14%), while losses mainly involved chromosomes 13 (39%), 16q (18%), 6q (10%), and 8p (10%). Remarkably, the 6 patients with gains on 11q had IGH translocations. Multivariate analysis selected chromosomal losses, 11q gains, age, and type of treatment (conventional chemotherapy vs autologous transplantation) as independent parameters for predicting survival. Genomic losses retained the prognostic value irrespective of treatment approach. According to these results, losses of chromosomal material evaluated by CGH represent a powerful prognostic factor in MM patients. (Blood. 2004;104:2661-2666)

Relation between harvest success and outcome after autologous peripheral blood stem cell transplantation in multiple myeloma

We studied the prognostic influence of pretransplant characteristics on response and survival in 104 consecutive patients with multiple myeloma receiving uniform pretransplant treatment consisting of VAD regimen, stem cell mobilisation, harvesting, and conditioning with melphalan 200 mg/m2. At the time of peripheral blood stem cell transplantation (PBSCT), 11% of patients were in complete remission (CR), and 63% in partial remission (PR). We evaluated the influence of age, sex, pretransplant response, number of harvested CD34+ cells, number of infused CD34+ cells, splitting part of the harvest for succeeding transplants on overall (OS) and progression-free survival (PFS) times. Following PBSCT, 31% of the patients were in CR and 57% in PR. Median OS and PFS from transplantation were 67 and 36 months, respectively. Transplant-related mortality was 0%. The number of harvested CD34+ cells was the only variable that was prognostic for OS in univariate and multivariate analyses. None of the variables was prognostic for PFS, although pretransplant response was nearly significant. The procedure of splitting and saving part of the harvest thus reducing the number of cells in the graft had no influence on outcome measured as OS or PFS.

Molecular monitoring of minimal residual disease in patients with multiple myeloma

Improvement of transplantation strategies and a multitude of emerging novel therapies result in a better treatment outcome in patients with multiple myeloma (MM). This gives rise to the need for sensitive methods to detect minimal residual disease (MRD) in MM. Qualitative molecular monitoring using allele-specific oligonucleotide PCR for the immunoglobulin heavy chain (IgH) is well established to detect clonotypic cells after therapy or in stem cell harvests. Recently, real-time IgH PCR or limiting dilution based PCR assays offer the possibility to quantify the amount of residual tumour cells. In this review, different qualitative and quantitative IgH PCR techniques will be discussed as well as the current clinical role of molecular monitoring of MRD in patients with MM.

Multiple myeloma

Multiple myeloma is a malignant disease of plasma cells that manifests as one or more of lytic bone lesions, monoclonal protein in the blood or urine, and disease in the bone marrow. Treatment for myeloma has changed beyond recognition in the past decade, and now includes state of the art supportive treatment and infusional chemotherapy courses, followed for younger patients by high-dose melphalan and an autologous transplant. Patients younger than 70 years can now expect a doubling of median survival to 5 years, a 20% chance of surviving longer than 10 years, and a 50% chance of attaining complete morphological and biochemical remission. Bisphosphonate control of bone disease is essential. Exploitation of the understanding of the biology of myeloma has led to the development of biological treatments, such as thalidomide, CC-5013, and bortezomib, which target the myeloma cell and the bone-marrow microenvironment, which plays a crucial part in the disease's pathogenesis. These treatments will hold the key to future success.

Multiple myeloma

High-dose therapy with stem cell transplantation (SCT) and novel targeted therapies (thalidomide, its more potent analogues, and bortezomib) represent two approaches for overcoming resistance of multiple myeloma (MM) cells to conventional therapies. While it is now clear that dose-intensification improves the outcome in younger patients, long-term remissions are obtained in a minority of patients. Therefore, the impact of novel agents as part of front-line therapy is the objective of ongoing trials. Gene expression profiling (GEP) will help to improve the management of MM not only by identifying prognostic subgroups but also by defining molecular pathways that are associated with these subgroups and that are possible targets for future therapies. In Section I, Dr. John Shaughnessy describes recent data obtained with GEP of CD138-purified plasma cells from patients with MM. His group has already shown that overexpression of the Wnt signaling inhibitor DKK1 by MM plasma cells blocks osteoblast differentiation and contributes to the development of osteolytic bone lesions. Recent data allow identification of four subgroups of MM in which GEP is highly correlated not only with different clinical characteristics and outcome but also with different cytogenetic abnormalities. In addition, abnormal expression of only three genes (RAN, ZHX-2, CHC1L) is associated with rapid relapses. In the context of intensive therapy with tandem autotransplantations, this model appears to be more powerful than current prognostic models based on standard biologic variables and cytogenetics. Understanding why the dysregulation of these three genes is associated with a more aggressive behavior of the disease will help to define new therapeutic strategies. In Section II, Dr. Jean-Luc Harousseau presents recent results achieved with tandem autologous SCT (ASCT) and with reduced intensity conditioning (RIC) allogeneic SCT. ASCT is now considered as the standard of care in patients up to 65 years of age. The IFM (Intergroupe Francophone du Myelome) has recently shown that double ASCT is superior to single ASCT. Current results of three other randomized trials confirm that double ASCT is superior, at least in terms of event-free survival. However, patients with poor prognostic features do poorly even after tandem ASCT. Strategies to further improve the outcome of ASCT include more intensive therapies and the use of novel agents such as thalidomide and immunomodulatory analogs (IMiDs) or bortezomib. Results of allogeneic SCT remain disappointing in MM even with T cell-depleted grafts. Preliminary results of a strategy combining ASCT to reduce tumor burden and RIC allogeneic SCT are encouraging, although the follow-up is still short. However, again, patients with chromosome 13 deletions have poor results with RIC. Longer follow-up of ongoing multicentric studies will help to clarify the indications of RIC. In Section III, Dr. Paul Richardson summarizes current knowledge of novel targeted therapies in MM. A better understanding of interactions between MM cells and bone marrow stromal cells and of the signaling cascades whereby cytokines mediate proliferation, survival, drug resistance and migration of MM cells provide the rationale for testing novel agents in relapsed/refractory MM. Increased angiogenesis coupled with the known anti-angiogenesis activity of thalidomide justified its use in refractory MM. The remarkable responses initially achieved prompted a number of clinical studies in different indications and the development of more potent IMIDs. Among them CC-5013 (Revlimid) has been tested in Phase I/II studies and a randomized Phase III study has just been completed. Blockade of NF-kappa B using the proteasome inhibitor bortezomib (Velcade) may mediate anti-MM activity by inhibiting interleukin (IL)-6 production in stromal cells and other mechanisms of action have been shown in preclinical studies. Based on the promising results of the Phase II trial, a large randomized trial of bortezomib versus dexamethasone has been completed. Studies of bortezomib combined with other drugs are ongoing. Arsenic trioxide has a number of properties showing that it targets MM cells interacting with the microenvironment. Clinical studies are ongoing as well. Other agents in MM have already been or will probably be translated soon from the bench to the bedside.

Relationship between elevated FX expression and increased production of GDP-L-fucose, a common donor substrate for fucosylation in human hepatocellular carcinoma and hepatoma cell lines

The levels of fucosylated glycoproteins in various cancers and inflammatory processes have been a subject of intense study. The level of fucosyltransferases and intracellular GDP-L-fucose, a sugar nucleotide and a common donor substrate for all fucosyltransferases, may regulate the level of fucosylated glycoproteins. This study reports on the determination of GDP-L-fucose levels in human hepatocellular carcinoma (HCC) and surrounding tissues, using a recently established high-throughput assay system. Levels of GDP-L-fucose in HCC tissues were significantly increased compared with adjacent nontumor tissues or normal livers. The mean +/- SD for GDP-L-fucose level was 3.6 +/- 0.2 micro mol/mg in control liver, 4.6 +/- 0.9 micro mol/mg in adjacent noninvolved liver tissues (chronic hepatitis, 4.4 +/- 0.7 micro mol/mg; liver cirrhosis, 4.8 +/- 0.9 micro mol/mg), and 7.1 +/- 2.5 micro mol/mg in HCC tissues. The level of GDP-L-fucose in HCC decreased in proportion with tumor size (r = -0.675, P = 0.0002). When expression of the series of genes responsible for GDP-L-fucose synthesis was investigated, the gene expression of FX was found to be increased in 70% (7 of 10) of the HCC tissues examined compared with that in their surrounding tissues. The levels of GDP-L-fucose were positively correlated with the expression of FX mRNA (r = 0.599, P = 0.0074). The levels of FX gene expression in some human hepatoma and hepatocyte cell lines were determined. FX mRNA production was strongly increased in HepG2 and Chang liver, moderately increased in Hep3B and HLF, and, in HLE, was similar to that of a normal human liver tissue. To investigate the effect of GDP-L-fucose on core fucosylation, FX cDNA was transfected into Hep3B cells, which express a relatively low level of GDP-L-fucose:N-acetyl-beta-D-glucosaminide alpha1-6 fucosyltransferase (alpha1-6 FucT) and FX mRNA. Transfection of this gene caused an increase in GDP-L-fucose levels as well as the extent of fucosylation on glycoproteins, including alpha-fetoprotein, as judged by reactivity to lectins. Collectively, the results herein suggest that the high level of fucosylation in HCC is dependent on a high expression of FX followed by increases in GDP-L-fucose, as well as an enhancement in alpha1-6 FucT expression. Thus, an elevation in GDP-L-fucose levels and the up-regulation of FX expression represent potential markers for HCC.

Beneficial effect of high-dose chemotherapy in multiple myeloma patients with unfavorable prognostic features

It has been established that high-dose chemotherapy (HDT) improves the therapeutic outcome of patients with multiple myeloma (MM) as compared with standard-dose therapy (SDT); however, little is known about the impact of HDT on different prognostic groups of MM patients. We therefore compared the survival times of 77 patients with previously untreated MM who were enrolled in HDT regimens with those of 64 similar patients <65 years old, who would be eligible for HDT but were treated by SDT. Overall, HDT was superior to SDT with respect to achievement of complete remissions (28% versus 2%; P <0.0001) and improvement of progression-free survival (PFS) (30.2 versus 21.2 months; P = 0.01) as well as overall survival (OS) (median 54.9 versus 49.4 months; P = 0.048). According to the chromosome 13q14 status as determined by fluorescence in situ hybridization and serum levels of beta(2)-microglobulin (beta(2)M), MM patients were separated into a standard-risk group (normal chromosome 13q14 and beta(2)M </=4 mg/l) and a high-risk group (deletion of chromosome 13q14 and/or beta(2)M >4 mg/l). Among patients of the high-risk group, both PFS (26.4 versus 10.7 months; P = 0.004) and OS times (40 versus 23 months; P = 0.05) were longer in patients receiving HDT compared with patients treated by SDT. In the standard-risk group, PFS and OS times were not significantly different between HDT patients and SDT patients. Results of this retrospective analysis suggest that the beneficial effects of HDT are greater in MM patients with high-risk features than in patients with absence of such poor prognostic indicators.

Survival after relapse following tandem autotransplants in multiple myeloma patients: the University of Arkansas total therapy I experience

Despite the superiority of high-dose (compared with standard) treatment in multiple myeloma, relapses still occur. We evaluated relapse patterns, salvage treatments employed and outcome in patients given tandem transplants on our total therapy I protocol. We focused on 146 patients (of 231 enrolled) who received tandem autotransplants < or =12 months apart and survived > or =2 months after the second transplant. With a median follow-up of 9 years after enrollment, 31 (21%) patients remain in complete or stable partial remission. Ninety-five (65%) patients received therapy for relapsing myeloma. The median time from the first transplant to relapse was 2.9 years. The median overall survival from relapse was 2.4 years. In one-quarter (23/95) of cases, the postrelapse interval exceeded the interval from the first transplant to relapse. On multivariate analysis, the presence of any cytogenetic abnormalities [P<0.001, Hazard Ratio (HR): 3.84] and beta-2 microglobulin levels >4 mg/l at relapse (P<0.001, HR: 2.87) were significant for poor survival after relapse. The median survival after relapse was 5.1, 1.3 and 0.7 years in patients with none (44%), one (46%) and two (10%) poor-risk factors, respectively. In conclusion, a sizeable fraction of myeloma patients relapsing after tandem autotransplants without poor-risk features enjoyed meaningful survival prolongation when appropriately treated.

T-cell receptor excision circles: a novel prognostic parameter for the outcome of transplantation in multiple myeloma patients

This study investigated whether T-cell receptor excision circles (TRECs) are a prognostic marker for the outcome of myeloma patients undergoing a tandem autologous peripheral blood stem cell transplantation (PBSCT). Twenty-five patients were enrolled. Samples were obtained at study enrollment, after conventional therapy, between first and second transplantation and 3, 6, 12 and 24 months after the second PBSCT. TRECs were quantified using real-time polymerase chain reaction. A high variation in TREC levels was found at diagnosis (median TREC level 136/10(5) peripheral blood mononuclear cells (PBMCs); range 1-1729), suggesting individual differences in thymic output of naive T cells. Patients with more than 136 TRECs/10(5) P BMCs at diagnosis had a statistically significant better overall survival (P=0.05) and event-free survival (P=0.045), whereas low TREC levels correlated with a higher incidence of infectious complications. Median TREC values were lowest after the first PBSCT (52/10(5) PBMCs) and reached the baseline 12 months after the second transplantation. Patients with high TREC levels after the second PBSCT had a significantly higher probability of being in complete or partial remission 30 months after the second PBSCT. TREC levels were not correlated with beta2-microglobulin and C-reactive protein levels at diagnosis. These data suggest that TRECs could be a relevant prognostic factor for patients who receive high-dose chemotherapy and autologous PBSCT.