Biological relapse in multiple myeloma: Outcome and treatment strategies in a Spanish real-world setting

Recommendations regarding the best time to start treatment in patients with relapsed/refractory multiple myeloma (RRMM) after biological relapse/progression (BR) are unclear. This observational, prospective, multicenter registry aimed to evaluate the impact on time to progression (TTP) of treatment initiation at BR versus at symptomatic clinical relapse (ClinR) based on the Spanish routine practice in adult patients with RRMM. Patients had two or less previous treatment lines and at least one previous partial response. Baseline characteristics and treatment outcomes were recorded, and survival was analyzed. Of 225 patients, 110 were treated at BR (TxBR group) and 115 at ClinR (TxClinR group) according to the investigators' criteria. The proportion of patients with higher ECOG, previous noncomplete remission (CR), and second relapse were significantly higher in the TxBR group compared to the TxClinR group. TheTxClinR group showed improved outcomes, including TTP, compared to the TxBR group. Progression-free survival increased in the TxClinR group (56.2 months) compared to the TxBR group (32.5 months) (p = 0.0137), and median overall survival also increased (p = 0.0897). Median TTP was significantly longer in patients relapsing from a CR (50.4 months) and in their first relapse (38.7 months) compared to those relapsing from a non-CR response (32.9 months) and in their second relapse (25.2 months). Physicians seemed to start treatment earlier in RRMM patients with poor prognosis features. Previous responses to anti-MM treatment and the number of prior treatment lines were identified as prognosis factors, whereby relapse from CR and first relapse were associated with a longer time to progression.

A magnetic solid phase chemiluminescent immunoassay for quantification of Cystatin C in human serum

A chemiluminescent immunoassay for human serum Cystatin C (Cys C) was established using a direct-antibody sandwich model. The immunoassay kit uses magnetic separation technology, using magnetic particles as the reaction solid phase, alkaline phosphatase as the marker enzyme, and a new chemiluminescent substrate APLS as the substrate. It has the characteristics of high sensitivity and short reaction time. This product uses high-affinity antibodies, resulting in a high specificity. The established method showed good accuracy, uniformity, and stability. The limit of detection was 2.39 ng/mL. The intra-assay coefficient of variation (CV) was 3.36%-6.00%, the interassay CV was 4.12%-5.35%, and the recovery rate was 99.07%. The correlation coefficient (r) of Cys-C kit was 0.999388 ≥ 0.9900. The accuracy of the developed method was tested by automatic chemiluminescence instrument (P > 0.05). The lowest titer was 0.92500, and the highest was 1.10000. The developed method showed a good correlation with the product from Roche by comparing these two kits in 240 clinical samples from China. In total, 1392 clinical patient from China samples were measured using the reagent kit developed in this study.

Current status of drug development for patients with multiple myeloma: a review of comparison in China and the rest of world

Multiple myeloma (MM) is a highly heterogeneous malignancy. The treatment of MM has been significantly advanced in recent years. B cell maturation antigen (BCMA)-targeted immunotherapy and chimeric antigen receptor T (CAR-T) cell therapy have been approved for the treatment of relapsed and refractory MM (RRMM), which will be launched in China shortly. The CD38 (cluster of differentiation 38) antibody, daratumumab, improves the clinical outcomes both RRMM and newly diagnosed MM patients. The combination of daratumumab, bortezomib and dexamethasone achieved favorable outcomes as the first-line therapy in China. However, high-risk patients have limited benefits from these advanced therapeutics, and usually relapse early, progressing into aggressive end-stage MM. Therefore, novel therapies are sought to improve the cancer prognosis in these patients. This review furnishes an overview of the recent clinical developments of these novel drugs and compares the drug candidates under development in China to the rest of the world.

Serum soluble BCMA can be used to monitor relapse of multiple myeloma patients after chimeric antigen receptor T-cell immunotherapy

PURPOSE

Chimeric antigen receptor T-cell (CAR-T) therapy has been proven very effective in treating hematologic malignancies. Ciltacabtagene autoleucel (cilta-cel), a second-generation CAR-T cell with double B cell maturation antigen (BCMA) targeting binding domains, showed an 88% overall response rate (ORR) in patients with relapsed/refractory multiple myeloma (MM), which were carried out in our institute. This study aimed to assess the prognostic potential of soluble BCMA (sBCMA) in serum as a biomarker in MM after CAR-T therapy.

PATIENTS AND METHODS

Serum samples (n = 44) from MM patients were collected before and after CAR-T therapy. The level of sBCMA was analyzed by enzyme-linked immunosorbent assay (ELISA). Additionally, three patients' long-term longitudinal analysis were performed.

RESULTS

Serum sBCMA level was correlated with the percentage of malignant plasma cells in bone marrow (r = 0.613). After CAR-T infusion, the sBCMA level in serum of MM patients decreased markedly (median: 508,513 pg/mL before CAR-T infusion, 89,198 pg/mL in the first month, 8448 pg/mL in the second months, and 6010 pg/mL in the third month after CAR-T infusion). In patients who obtained objective response (≥ PR), re-elevated sBCMA indicated the possibility of disease recurrence. At a cutoff 69,326.27 pg/mL, sBCMA shows high sensitivity (87.5%) and specificity (88.5%) for identifying relapse of MM after CAR-T therapy.

CONCLUSION

Our results suggested that serum sBCMA level changes in response to the clinical status of MM patients after anti-BCMA CAR-T therapy. Furthermore, sBCMA may be a auxiliary biomarker for disease monitoring in MM patients after CAR-T therapy.

Nectin-2 Expression on Malignant Plasma Cells Is Associated with Better Response to TIGIT Blockade in Multiple Myeloma

PURPOSE

T-cell immunoreceptor with Ig and ITIM domain (TIGIT) blockade could represent an alternative therapeutic option to release the immune response in patients with multiple myeloma. Here we analyzed the expression of TIGIT and its ligands poliovirus receptor (PVR) and nectin-2 in the bone marrow (BM) of patients with monoclonal gammopathies and the efficacy of TIGIT blockade activating antimyeloma immunity.

EXPERIMENTAL DESIGN

Expression levels of TIGIT and its ligands were characterized by flow cytometry and ELISA. TIGIT blockade was analyzed in in vitro functional assays with peripheral T cells. BM cells were studied with NanoString technology, real-time PCR, and ex vivo patient BM cell models.

RESULTS

TIGIT and its ligands are highly expressed in the BM of patients with multiple myeloma, suggesting that may play a role in restraining immune activation. TIGIT blockade depleted FoxP3⁺ Tregs while increasing proliferation of IFNγ-producing CD4⁺ T cells from patients with multiple myeloma. PVR ligation inhibited CD8⁺ T-cell signaling and cell proliferation which could be overcome with anti-TIGIT mAb. However, BM cells showed a remarkable heterogeneity in immune signature. Accordingly, functional ex vivo BM assays revealed that only some patients respond to checkpoint blockade. Thus, response to TIGIT blockade correlated with low frequency of TIGIT⁺ cells and high nectin-2 expression on malignant plasma cells.

CONCLUSIONS

TIGIT blockade efficiently reinvigorated peripheral T cells from patients with multiple myeloma. However, in the BM, the efficacy of blocking anti-TIGIT mAb to achieve tumor cell death may depend on the expression of TIGIT and nectin-2, becoming potential predictive biomarkers for identifying patients who may benefit from TIGIT blockade.

Distinct Clinical Features of Plasma Cell Myeloma Patients Exhibiting Dysmorphic Plasma Cells: Association with More Plasma Cells at Diagnosis

Dysmorphic plasma cells are occasionally found in bone marrow (BM) aspirates of plasma cell myeloma (PCM) patients. We retrospectively analyzed the incidences of significant dysmorphic plasma cells (SDPC) presentations and their associations with clinical features in PCM patients. Total 91 PCM patients diagnosed from January 2013 to December 2017 at author's institution were enrolled. SDPC presentation was determined as ≥ 5% (SDPC5) or ≥ 10% (SDPC10) among total PC and clinical features of PCM patients were compared with respect to SDPC presentation status. Incidence of SDPC5/SDPC10 presentation was 39.6%/18.7%. Patients with SDPC5/SDPC10 showed significantly more BM PC (P = 0.004/0.020) and higher incidences of CKS1B gains (P = 0.022/0.001) and RB1 loss (P = 0.032 for SDPC10 only) at diagnosis than those without SDPC5/SDPC10. Patients with SDPC5/SDPC10 also showed significantly greater absolute BM PC (P = 0.007/0.034 and 0.047/0.049 for 1st and 2nd follow-up, respectively) and serum M-protein (P = 0.041/0.044 and 0.039/0.049 for 1st and 2nd follow-up, respectively) reductions after chemotherapy than those without SDPC5/SDPC10. SDPC5/SDPC10 presentation was confirmed as an independent predictor of BM PC ≥ 37.7% [hazard ratio (HR) 4.649/2.613, P = 0.005/0.039]. Our present study demonstrated that SDPC presentation would be an independent predictor of more BM PC at diagnosis in PCM patients. Associations between SDPC presentation and higher incidence of CKS1B gains and RB1 loss, greater PC/serum monoclonal protein reductions after chemotherapy were also identified. Association between SDPC presentation and favorable treatment response should be evaluated in more comprehensive study.

Up-regulation of microRNA-497 inhibits the proliferation, migration and invasion but increases the apoptosis of multiple myeloma cells through the MAPK/ERK signaling pathway by targeting Raf-1

Multiple myeloma (MM) is a cancer that occurs in plasma cells, which fall under the category of white blood cells that are in charge of antibody production. According to previous studies, microRNA-497 (miR-497) functions as a tumor suppressor in several types of cancer, including gastric cancer and colorectal cancer. Therefore, the present study aims to investigate the effects of miR-497 on cellular function of human MM cells through the mitogen-activated protein kinase/extracellular signal-regulated kinase (MAPK/ERK) signaling pathway by targeting Raf-1. The differentially expressed genes and miRs in MM, and the relationship between the miR and gene were verified. It was found that Raf-1 was a target gene of miR-497. The data obtained from MM tissues showed increased Raf-1 level and decreased miR-497 level. MM cells were treated with mimic, inhibitor and siRNA in order to evaluate the role of miR-497, Raf-1 and MAPK/ERK in MM. The expression pattern of miR-497, Raf-1, ERK1/2, survivin, B-cell lymphoma-2 (Bcl-2) and BCL2-Associated X (Bax) as well as the extent of ERK1/2 phosphorylation were determined. Retored miR-497 and si-Raf-1 resulted in increases in the Bax expression and cell apoptosis and decreases in the expressions of Raf-1, MEK-2, survivin, Bcl-2, along with the extent of ERK1/2 phosphorylation. In addition, the biological function evaluations of MM cells revealed that miR-497 mimic or si-Raf-1 led to suppression in cell proliferation, invasion and migration. In conclusion, our results have demonstrated that miR-497 targets Raf-1 in order to inhibit the progression of MM by blocking the MAPK/ERK signaling pathway.

SAHA-induced TRAIL-sensitisation of Multiple Myeloma cells is enhanced in 3D cell culture

BACKGROUND

Multiple Myeloma (MM) is currently incurable despite many novel therapies. Tumour Necrosis Factor-Related Apoptosis-Inducing Ligand (TRAIL) is a potential anti-tumour agent although effects as a single agent are limited. In this study, we investigated whether the Histone Deacetylase (HDAC) inhibitor SAHA can enhance TRAIL-induced apoptosis and target TRAIL resistance in both suspension culture, and 3D cell culture as a model of disseminated MM lesions that form in bone.

METHODS

The effects of SAHA and/or TRAIL in 6 Multiple Myeloma cell lines were assessed in both suspension cultures and in an Alginate-based 3D cell culture model. The effect of SAHA and/or TRAIL was assessed on apoptosis by assessment of nuclear morphology using Hoechst 33342/Propidium Iodide staining. Viable cell number was assessed by CellTiter-Glo luminescence assay, Caspase-8 and -9 activities were measured by Caspase-Glo™ assay kit. TRAIL-resistant cells were generated by culture of RPMI 8226 and NCI-H929 by acute exposure to TRAIL followed by selection of TRAIL-resistant cells.

RESULTS

TRAIL significantly induced apoptosis in a dose-dependent manner in OPM-2, RPMI 8226, NCI-H929, U266, JJN-3 MM cell lines and ADC-1 plasma cell leukaemia cells. SAHA amplified TRAIL responses in all lines except OPM-2, and enhanced TRAIL responses were both via Caspase-8 and -9. SAHA treatment induced growth inhibition that further increased in the combination treatment with TRAIL in MM cells. The co-treatment of TRAIL and SAHA reduced viable cell numbers all cell lines. TRAIL responses were further potentiated by SAHA in 3D cell culture in NCI-H929, RPMI 8226 and U266 at lower TRAIL + SAHA doses than in suspension culture. However TRAIL responses in cells that had been selected for TRAIL resistance were not further enhanced by SAHA treatment.

CONCLUSIONS

SAHA is a potent sensitizer of TRAIL responses in both TRAIL sensitive and resistant cell lines, in both suspension and 3D culture, however SAHA did not sensitise TRAIL-sensitive cell populations that had been selected for TRAIL-resistance from initially TRAIL-sensitive populations. SAHA may increase TRAIL sensitivity in insensitive cells, but not in cells that have specifically been selected for acquired TRAIL-resistance.

Immune checkpoint blockade: the role of PD-1-PD-L axis in lymphoid malignancies

The co-inhibitory receptor programmed cell death (PD)-1, expressed by immune effector cells, is credited with a protective role for normal tissue during immune responses, by limiting the extent of effector activation. Its presently known ligands, programmed death ligands (PD-Ls) 1 and 2, are expressed by a variety of cells including cancer cells, suggesting a role for these molecules as an immune evasion mechanism. Blocking of the PD-1-PD-L signaling axis has recently been shown to be effective and was clinically approved in relapsed/refractory tumors such as malignant melanoma and lung cancer, but also classical Hodgkin’s lymphoma. A plethora of trials exploring PD-1 blockade in cancer are ongoing. Here, we review the role of PD-1 signaling in lymphoid malignancies, and the latest results of trials investigating PD-1 or PD-L1 blocking agents in this group of diseases. Early phase studies proved very promising, leading to the clinical approval of a PD-1 blocking agent in Hodgkin’s lymphoma, and Phase III clinical studies are either planned or ongoing in most lymphoid malignancies.

Abnormal repression of SHP-1, SHP-2 and SOCS-1 transcription sustains the activation of the JAK/STAT3 pathway and the progression of the disease in multiple myeloma

Sustained activation of JAK/STAT3 signaling pathway is classically described in Multiple Myeloma (MM). One explanation could be the silencing of the JAK/STAT suppressor genes, through the hypermethylation of SHP-1 and SOCS-1, previously demonstrated in MM cell lines or in whole bone marrow aspirates. The link between such suppressor gene silencing and the degree of bone marrow invasion or the treatment response has not been evaluated in depth. Using real-time RT-PCR, we studied the expression profile of three JAK/STAT suppressor genes: SHP-1, SHP-2 and SOCS-1 in plasma cells freshly isolated from the bone marrows of MM patients and healthy controls. Our data demonstrated an abnormal repression of such genes in malignant plasma cells and revealed a significant correlation between such defects and the sustained activation of the JAK/STAT3 pathway during MM. The repressed expression of SHP-1 and SHP-2 correlated significantly with a high initial degree of bone marrow infiltration but was, unexpectedly, associated with a better response to the induction therapy. Collectively, our data provide new evidences that substantiate the contribution of JAK/STAT suppressor genes in the pathogenesis of MM. They also highlight the possibility that the decreased gene expression of SHP-1 and SHP-2 could be of interest as a new predictive factor of a favorable treatment response, and suggest new potential mechanisms of action of the therapeutic molecules. Whether such defect helps the progression of the disease from monoclonal gammopathy of unknown significance to MM remains, however, to be determined.

Observational study of multiple myeloma in Latin America

Relatively little is known about the outcomes of multiple myeloma in Latin America, a world region where incorporation of novel agents is generally slow. In the current retrospective-prospective study, we aimed to describe the patterns of care and treatment results in five Latin American countries. Between April 2007 and October 2009, patients who had been diagnosed from January 2005 to December 2007 were registered at 23 institutions from Argentina, Brazil, Chile, Mexico, and Peru. We divided patients into two cohorts, according to transplantation eligibility, and analyzed them with regard to first-line treatment and overall survival (OS). We analyzed a total of 852 patients, 46.9 % of whom were female. The median follow-up was 62 months. Among transplantation-ineligible patients (N = 461), the mean age was 67.4 years, approximately one third of patients received a thalidomide-based treatment in the first line, and the median OS was 43.0 months. Transplantation-eligible patients (N = 391) had a mean age of 54.7 years and a median OS of 73.6 months. Autologous transplantation was performed in 58.6 % of the patients for whom this procedure was initially planned and in only 26.9 % of the overall patients. Our long-term results reflect the contemporary literature for patients with multiple myeloma treated with autologous transplantation and thalidomide-based regimens in clinical trials and observational studies. However, further efforts are needed to approve and incorporate novel agents in Latin American countries, as well as to increase access to transplantation, in order to achieve the expected improvements in patient outcomes.

The Prognostic Significance of Beta2 Microglobulin in Patients with Hemophagocytic Lymphohistiocytosis

Objective. To determine the prognostic significance of beta2 microglobulin (β₂-m) concentrations in patients with hemophagocytic lymphohistiocytosis (HLH), a rare disorder caused by pathologic activation of the immune system. Patients and Methods. The study population consisted of 74 patients diagnosed with HLH and 35 healthy controls. Serum β₂-m levels were measured using a latex agglutination photometric immunoassay. Results. Median serum β₂-m levels were significantly higher in HLH patients than in healthy controls (4.05 versus 1.5 mg/L; P < 0.001) and were significantly higher in patients with lymphoma associated hemophagocytic syndrome (LAHS) than in patients with benign disease-associated HLH (4.2 versus 3.3 mg/L; P < 0.001). Higher serum β₂-m levels were positively correlated with LAHS (P = 0.005), abnormal lactate dehydrogenase concentrations (P = 0.009), and hypoalbuminemia (P = 0.003). ROC analysis showed that overall survival (OS) was significantly shorter in LAHS patients with serum β₂-m levels ≥4.03 mg/L compared to <4.03 mg/L (P < 0.001). Moreover, multivariate analysis showed that serum β₂-m level was an independent prognostic of OS (P = 0.034) in patients with LAHS. Conclusion. High serum β₂-m levels and LAHS were associated with markedly poorer OS in patients with HLH. Serum β₂-m concentration was a powerful and independent prognostic factor for OS in patients with LAHS.

Inhibitory effect of epirubicin-loaded lipid microbubbles with conjugated anti-ABCG2 antibody combined with therapeutic ultrasound on multiple myeloma cancer stem cells

Ultrasound-targeted microbubble destruction (UTMD) technique is thought to improve the chemotherapeutic agent delivery from microbubbles (MBs) in tumor tissues and reduce the side effects in non-tumor tissues. Multiple myeloma (MM) is a bone marrow cancer and remains to be an incurable disease. In this study, we used the UTMD technique to investigate the inhibitory effect of our developed novel reagent on MM cancer stem cells (CD138(-)CD34(-)MM CSCs) that are MM cells with CD138(-)CD34(-) phenotypes, responsible for MM-initiating potential, drug resistance and eventual relapse. The preparatory steps of novel reagent was first epirubicin (EPI)-loaded in the lipid MBs that was consisted of 1,2-distearoyl-sn-glycero-3-phosphoethanolamine-N-[methoxy(polyethylene glycol)-2000]-biotin, dipalmitoyl-phosphatidylglycerol and 25-NBD-cholesterol, then anti-ABCG2 monoclonal antibody (mAb) was conjugated onto the MB surface to form EPI-MBs+mAb. CD138(-)CD34(-)MM CSCs were isolated from human MM RPMI 8226 cell line by the magnetic associated cell sorting method. The results showed that the attenuated proliferation, migration and invasion ability, and increased apoptosis were observed when MM CSCs were incubated with a various agents. EPI-MBs+mAb combined with therapeutic ultrasound significantly promoted the MM CSC apoptosis compared with EPI, EPI-MBs alone or EPI-MBs+mAb without ultrasound exposure. These results suggest that the developed EPI-MBs+mAb combined with therapeutic ultrasound remarkably induced MM CSC apoptosis in vitro.

Logic-Based and Cellular Pharmacodynamic Modeling of Bortezomib Responses in U266 Human Myeloma Cells

Systems models of biological networks show promise for informing drug target selection/qualification, identifying lead compounds and factors regulating disease progression, rationalizing combinatorial regimens, and explaining sources of intersubject variability and adverse drug reactions. However, most models of biological systems are qualitative and are not easily coupled with dynamical models of drug exposure-response relationships. In this proof-of-concept study, logic-based modeling of signal transduction pathways in U266 multiple myeloma (MM) cells is used to guide the development of a simple dynamical model linking bortezomib exposure to cellular outcomes. Bortezomib is a commonly used first-line agent in MM treatment; however, knowledge of the signal transduction pathways regulating bortezomib-mediated cell cytotoxicity is incomplete. A Boolean network model of 66 nodes was constructed that includes major survival and apoptotic pathways and was updated using responses to several chemical probes. Simulated responses to bortezomib were in good agreement with experimental data, and a reduction algorithm was used to identify key signaling proteins. Bortezomib-mediated apoptosis was not associated with suppression of nuclear factor κB (NFκB) protein inhibition in this cell line, which contradicts a major hypothesis of bortezomib pharmacodynamics. A pharmacodynamic model was developed that included three critical proteins (phospho-NFκB, BclxL, and cleaved poly (ADP ribose) polymerase). Model-fitted protein dynamics and cell proliferation profiles agreed with experimental data, and the model-predicted IC50 (3.5 nM) is comparable to the experimental value (1.5 nM). The cell-based pharmacodynamic model successfully links bortezomib exposure to MM cellular proliferation via protein dynamics, and this model may show utility in exploring bortezomib-based combination regimens.

High density of tryptase-positive mast cells in patients with multiple myeloma: correlation with parameters of disease activity

Multiple myeloma (MM) is a plasma cell neoplasm characterized by bone marrow infiltration from malignant plasma cells. Mast cells play an important role in inflammation and angiogenesis in malignant diseases. The aim of the study was to evaluate the mast cell density in bone marrow of untreated MM patients with markers of disease activity such as serum interleukin-6 (IL-6), B2M, and C-reactive protein (CRP), the grade of bone marrow infiltration, and the levels of produced paraprotein. We studied 86 newly diagnosed MM patients (46 males, 40 females, mean age 59 ± 13.7 years). Thirty of them reached plateau phase after chemotherapy and 20 healthy volunteers. According to the criteria of International Staging System (ISS) staging system, 23 patients had stage I, 30 had stage II, and 33 had stage III. The serum concentrations of CRP, B2M, and IL-6, and the mast cell density (MCD) values were significantly higher in MM patients' group (1.6 ± 1.8, 4.3 ± 2.9, 7.1 ± 5.1, and 9 ± 4.8), in comparison with those found in control group (0.4 ± 0.1, 1.5 ± 0.6, 1.1 ± 0.5, and 1.9 ± 0.7; p < 0.001 in all the cases). Significant differences were found between the grade of infiltration in bone marrow, and the paraprotein values in patients' serum before and after chemotherapy. Furthermore, there was a significant correlation between the MCD values and the prognostic markers CRP (r = 0.452, p < 0.0001), IL-6 (r = 0.475, p < 0.0001), bone marrow infiltration (r = 0.333, p < 0.0002), and serum paraprotein levels(r = 0.221, p < 0.04). High MCD values strengthen the hypothesis that mast cells participate in the pathogenesis of disease progression and may be used as an indicator of the disease activity.

The prognostic role of bone turnover markers in multiple myeloma patients: The impact of their assay. A systematic review and meta-analysis

BACKGROUND

Multiple myeloma (MM) is characterized by the progressive destruction of bone tissue due to the uncontrolled proliferation of the immunoglobulins. The detection of bone turnover markers (BTMs) may represent a non-invasive method to assess the bone involvement and to predict the risk of bone morbidity. This systematic review evaluates clinical utility of changes in BTMs levels in MM patients and their prognostic role.

METHODS

We searched Medline, Embase, WOS and Scopus. All eligible articles were examined and the risk of bias was evaluated. Results about PICP, PINP, ICTP, OC, CTX, NTX, RANKL and OPG were extracted. Weighted mean difference, risk ratio and hazard ratio were pooled.

RESULTS

Thirty studies and more than 2500 patients were included in this systematic review. The majority of them (50%) used ELISA to quantify BTMs, 10 of them used RIA and only 4 did not report the information regarding the type of immunoassays. In MM patients, the concentration of NTX and ICTP increased, instead the concentrations of BAP and OC lowered when compared to healthy subjects. High levels of ICTP were predictive of bone events (RR 1.18) and they were associated to poor survival (HR 1.08). Most of the included studies were considered at high risk of bias, in fact the reporting of the results was often incomplete. Between-studies heterogeneity was high.

CONCLUSIONS

BTMs measurement may be very useful in the management of MM patients, especially to evaluate the bone disease progression. They could help clinicians to identify patients at high risk of bone events and to opt for more appropriate therapy; nevertheless their high biological and analytical variability limit their implementation in clinical practice.

Response evaluation and monitoring of multiple myeloma

Monitoring multiple myeloma (MM) is essential during the evaluation of response to each therapy line, after transplantation and at the time of relapse or progression in all patients. An initial complete workup, including appropriate protein studies in serum and urine is mandatory. The use of uniform criteria is particularly important in the context of clinical trials. Complete remission (CR) definition, the goal for the majority of patients, is now in constant evolution, with immunophenotypic and molecular minimal residual disease measurement in bone marrow as well as imaging techniques. Identification of relapse/progression with traditional and novel techniques for eventual prompt intervention with rescue treatment is a current issue of debate.

A triclonal gammopathy in a relapsing multiple myeloma patient, detected by immunosubtraction method

Multiple myeloma (MM) is a plasma cell dyscrasia characterized by the malignant proliferation of a plasma cell clone that produces a monoclonal immunoglobulin. Diagnosis and management of patients with monoclonal gammopathies depend on accurate identification and characterization of monoclonal proteins. We present a 67-year-old male patient with anaemia, weakness and weight loss for six months. His physical examination was normal with no fever, and no bone lesions were present in the imaging studies. Laboratory investigations revealed low haemoglobin and albumin concentrations with high total protein and beta 2-microglobulin concentrations. Capillary zone electrophoresis with immunosubtraction method revealed a triclonal pattern of M-protein (IgG κ + IgG λ + IgA κ) which was not prominent with immunofixation electrophoresis. After bone marrow biopsy, MM with triclonal gammopathy was diagnosed and autologous stem cell transplantation was performed. Six months later, again a triclonal M-protein was detected by immunosubtraction method, and a relapse was confirmed with a second bone marrow biopsy. The occurrence of monoclonal and biclonal gammopathies can often be seen upon diagnosis in plasma cell dyscrasias and lymphoproliferative disorders, but triclonal paraproteins are very rare and their clinical significance is unknown. In this particular patient, triclonality was detected by an alternative method called immunosubtraction by capillary electrophoresis. The patient was resistant to therapy suggesting that more than one monoclonal M protein may be a negative prognostic factor, and with new technologies and methods, the number of patients with different monoclonal patterns may increase.

Second autologous transplant as salvage therapy in multiple myeloma

High-dose chemotherapy followed by autologous haematopoetic stem cell transplantation (ASCT) is a standard frontline therapy for multiple myeloma (MM). Unfortunately, there are no randomized clinical studies examining the role of a second ASCT in patients who relapse after the initial autotransplant. Analysing all available retrospective studies, it seems that salvage ASCT can safely be performed in most patients with an overall treatment-related mortality rate <5%. Approximately 65% of patients will achieve an objective response and progression-free and overall survival will be around 12 months and 32 months, respectively. Retrospective data suggest that patients with a progression-free survival of ≥18 months after initial ASCT are most likely to benefit from a salvage autotransplant. However, patients with a <12-month duration of response after initial ASCT should not be considered for a second autograft in the relapsed setting because this group will probably only experience ASCT-related toxicity without any clinical benefit. Quality of response after initial ASCT and number of therapies preceding salvage ASCT may also have a predictive value. Importantly, these findings need to be verified by randomized clinical trials in order to firmly integrate salvage ASCT into a global therapeutic concept for myeloma patients including optimized induction, consolidation, and maintenance approaches.

Increased numbers of T helper 17 cells and the correlation with clinicopathological characteristics in multiple myeloma

OBJECTIVE

T helper 17 (Th17) cells play important roles in adaptive immunity and are involved in several inflammatory and autoimmune diseases, but little is known about their role in tumour immunity. The current study investigated the involvement of Th17 cells in multiple myeloma.

METHODS

Flow cytometry was used to investigate the frequencies of Th17 cells in peripheral blood mononuclear cells from 30 patients with multiple myeloma and from 14 healthy control subjects. The concentrations of Th17-associated cytokines (interleukin [IL]-6, IL-17, IL-1β and IL-23) were measured by enzyme-linked immunosorbent assay.

RESULTS

There was a significantly increased proportion of Th17 cells, and increased plasma concentrations of Th17-associated cytokines, in patients with multiple myeloma compared with healthy controls. There was a significant relationship between the proportion of Th17 cells and clinical tumour stage, serum lactate dehydrogenase concentration and serum creatinine concentration.

CONCLUSIONS

Th17 cells might be important therapeutic targets in multiple myeloma and could facilitate a better outcome for tumour immunotherapy.

Treatment of spinal epidural compression due to hematological malignancies: a single institution's retrospective experience

PURPOSE

To analyze the neurological and mechanical outcomes in 44 consecutive patients treated for a hematological malignancy with epidural localization to assess the place of surgery in the treatment of this pathology.

METHODS

Clinical records, CT and MRI scans of 44 patients with epidural localizations of multiple myeloma or lymphoma treated between 1990 and 2005 were analyzed retrospectively. Neurological status, epiduritis and osteolysis volumes, vertebral collapse, and spinal canal compromise were assessed. The neurological outcome was graded according to Frankel and the mechanical outcome was evaluated on the rate of vertebral collapse.

RESULTS

Surgery was performed in 11 patients (25 %) for neurological (n = 9) or mechanical (n = 2) reasons. In five cases, a concomitant biopsy was performed because the etiology of the epiduritis was unknown. Fifteen patients (34.1 %) presented with a neurological deficit secondary to an acute vertebral collapse (n = 4), an epiduritis (n = 7), or both (n = 4). Whatever the treatment (surgical or not), a complete recovery (Frankel E) occurred in 14/15 (93.3 %) after a mean delay of 12 weeks (range 2-24 weeks). During the follow-up, seven collapses occurred. We estimated that a threshold of 30 % of osteolysis was associated with a significant risk of vertebral collapse (P = 0.005).

CONCLUSIONS

Hematological malignancies with epidural localization must be treated first medically, even in patients with neurological symptoms. Surgery should be considered only in the cases of acute vertebral collapse, medical treatment failure, or to prevent acute collapse in patients with vertebral osteolysis of more than 30 %.

Physical activity participation and barriers for people with multiple myeloma

PURPOSE

This study aims to examine, for people treated for multiple myeloma, (1) differences between prediagnosis and postdiagnosis levels of physical activity, (2) perceived barriers and likelihood of attending a physical activity program, and (3) factors that influence whether or not respondents are meeting physical activity guidelines.

METHODS

This was a quantitative cross-sectional study; data were gathered from a larger Australian population-wide survey. Respondents completed the survey in hard copy, online, or over the telephone. Demographic and clinical variables included age, gender, locality, time since diagnosis, and marital status. The Godin Leisure-Time Questionnaire measured physical activity; barriers and likelihood of participating in a physical activity program were assessed using a five-point Likert scale. Data were analyzed using descriptive, bivariate, and multivariate analyses.

RESULTS

Of the 229 respondents, 53.1 % were male, 42 % aged 60-69 years, and 75.7 % were married or in a de facto relationship. Participation in physical activity declined significantly from prediagnosis levels. Fatigue, injuries, and pain were the strongest perceived barriers to participation; 41 % reported they were likely to attend an exercise program if offered. Respondents who were sufficiently active before diagnosis were 4.79 times more likely to be sufficiently active posttreatment.

CONCLUSIONS

People with multiple myeloma reported very low levels of physical activity across all levels of intensity; however, they were interested in attending a physical activity program. To increase physical activity among people with multiple myeloma, interventions should target perceived barriers with a particular focus on those who were not physically active prior to diagnosis.

Impact of the treatment-free interval on health-related quality of life in patients with multiple myeloma: a UK cross-sectional survey

BACKGROUND

While the impact of various treatments on myeloma patients' health-related quality of life (HRQL) has been reported, the impact of a treatment-free interval (TFI) is currently unclear. The aims of this study were to assess if (1) a TFI is associated with a better HRQL vs. other treatment phases and (2) the length of the TFI influences HRQL.

METHODS

A cross-sectional postal survey was conducted in the UK. The survey was sent to 605 multiple myeloma patients via the charity Myeloma UK and asked patients to rate their HRQL using the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30), EORTC QLQ-MY20 and the EQ-5D. The results were analysed using ordinary least squares regression.

RESULTS

Surveys of 402 (67 %) were returned; 370 (61 %) were considered eligible for analysis. Results demonstrated that being in a first TFI relative to other treatment phases and experiencing a longer TFI were significantly associated with better HRQL as assessed by various domains of the QLQ-C30, MY20 and EQ-5D.

CONCLUSION

Patients enjoy better HRQL when in their first TFI, and the length of the TFI also positively impacts on HRQL This information may be important for patients and their physicians making treatment decisions and has implications for treatment protocols incorporating extended therapy.

Nuclear remodeling as a mechanism for genomic instability in cancer

This chapter focuses on the three-dimensional organization of the nucleus in normal, early genomically unstable, and tumor cells. A cause-consequence relationship is discussed between nuclear alterations and the resulting genomic rearrangements. Examples are presented from studies on conditional Myc deregulation, experimental tumorigenesis in mouse plasmacytoma, nuclear remodeling in Hodgkin's lymphoma, and in adult glioblastoma. A model of nuclear remodeling is proposed for cancer progression in multiple myeloma. Current models of nuclear remodeling are described, including our model of altered nuclear architecture and the onset of genomic instability.