Risk groups of myeloma patients by histologic pattern and proliferative activity

The impact of bone marrow fibrosis and JAK2 expression on clinical outcomes in patients with newly diagnosed multiple myeloma treated with immunomodulatory agents and/or proteasome inhibitors

We determined the impact of bone marrow fibrosis (BMF) on the clinical outcomes of newly diagnosed multiple myeloma (NDMM) patients in the current era of myeloma therapy. A total of 393 MM patients were included in the final analysis. The median followup was 83 months (range: 3.9 to 212 months). BMF was noted in 122 (48.2%) evaluable patients. Median progression free survival (PFS) in patients without BMF was 30.2 (95% CI: 24.7-38.0) months, and 21.1 (95% CI: 18.8-27.5) months in patients with BMF present (P = .024). Median overall survival (OS) was 61.2 (95% CI: 51.5-81.2) months in patients without BMF, and 45.1 (95% CI: 38.7-57.0) months in patients with BMF (P = .0048). A subset of 99 patients had their bone marrow biopsies stained for JAK1 and JAK2 by immunohistochemistry. Of these samples 67 (67.7%) patients had detectable JAK2 expression predominantly noted on bone marrow megakaryocytes. JAK2 expression correlated with myeloma disease stage (P = .0071). Our study represents the largest dataset to date examining the association of BMF with prognosis in the era of novel therapies and widespread use of hematopoietic stem cell transplant (HSCT). Our data suggest that MM patients with BMF (particularly those with extensive BMF) have a poorer prognosis even when treated with immunomodulatory agents and proteasome inhibitors.

Proliferation and Angiogenesis Using Immunohistochemistry in Prognosticating Multiple Myeloma

Multiple myeloma is a neoplasm of plasma cells characterised by the presence of M protein in serum and urine. Angiogenesis and proliferation play a major role in the pathogenesis of various neoplasms. The study evaluated proliferation and angiogenesis in 48 cases of myeloma, and correlated it with morphological and clinical parameters. The histomorphological features like plasma cell morphology, percentage of plasma cells and pattern of infiltration were studied in the bone marrow aspirate and trephine biopsy. Angiogenesis was assessed by calculating the microvessel density (MVD) using immunohistochemistry for CD34. Proliferation was assessed using Ki67 and CD38 highlighted the plasma cells. The mean Ki67 % was found to be significantly higher (19.6 % range 2-40 %) in poorly differentiated morphology compared to well differentiated morphology (4.06 % range 0.2-20 %) (p = 0.003). The mean MVD in the well differentiated morphology was 10.6 (range 1.2-47.4) compared to 20.3 (range 6.9-39.6) in the poorly differentiated morphology (p = 0.04). The mean MVD was 5.7 (range 1.2-12.8) in the interstitial pattern of infiltration compared to 20.04 (2.9-47.4) in the diffuse pattern (p < 0.0001). The mean MVD was 6.4 in cases with serum albumin >3.5 gm/dl compared to 13.3 in cases with serum albumin <3.5 gm/dl (p = 0.009). Both the Ki67 and MVD showed an increasing trend with the clinical staging. Thus the study of proliferation and angiogenesis in bone marrow biopsy is useful for prognosticating patients with multiple myeloma.

Pancytopenia in Multiple Myeloma- An Enigma: Our Experience from Tertiary Care Hospital

INTRODUCTION

Multiple myeloma is a plasma cell neoplasm that is characterized by clonal proliferation of malignant plasma cell in the bone marrow along with M-protein in the serum and/or urine. Pancytopenia as a initial presentation of multiple myeloma is quite unusual. We are presenting a case series having pancytopenia as the presenting complaint.

MATERIALS AND METHODS

A retrospective study was conducted for a period of 30 months, wherein all the cases of multiple myeloma presenting with pancytopenia were included. The complete blood picture, peripheral smear examination, bone marrow aspirate & protein electrophoresis of all the cases were reviewed & analysed.

RESULTS

During the study period, 10 cases presented with pancytopenia with a mean age of 66.3 years (range: 59-72 years) at presentation with male: female ratio being 8:2. Fatigue and weakness was the most common symptom (100%) & average ESR was 104 mm/hour. High-resolution serum electrophoresis, showed a dense, sharp to wide M band in the gamma globulin region. Bone marrow plasma cell percentage was increased with an average of 63.1%. Bone marrow biopsy correlation was obtained in 100% cases.

CONCLUSION

Diagnosing multiple myeloma, presenting as pancytopenia requires a high degree of suspicion to avoid delay in initiation of treatment.

Significance of bone marrow fibrosis in multiple myeloma

AIMS

The aim of the current study was to asses the frequency of increased fibrosis in myeloma and to find its correlation with other bone marrow parameters and survival.

METHODS

Forty-four multiple myeloma patients diagnosed between 2001 and 2005 were included in the present study. A detailed study of the bone marrow aspiration smears and trephine biopsy was done. Bone marrow fibrosis was graded and correlated with other parameters like plasma cell morphology, pattern of infiltration, mitotic activity and also with the survival of the patients.

RESULTS

Increased fibrosis was seen in nine cases (20.5%). It was observed that plasma cell burden in the marrow was under-estimated in the aspirate smears compared with the trephine biopsy in patients with increased fibrosis. Increased marrow fibrosis correlated significantly with poorly differentiated plasma cell morphology (p = 0.020) and mitotic activity (p = 0.003), which by themselves are established prognostic markers for survival in multiple myeloma. Patients with increased fibrosis of the marrow also had a median survival time of just 11 months.

CONCLUSIONS

A bone marrow trephine biopsy is essential in all cases of myeloma at diagnosis, as it helps identify a subset of myeloma patients with increased marrow fibrosis and poorer prognosis.

Proliferative activity of plasma cells is the most relevant prognostic factor in elderly multiple myeloma patients

Although multiple myeloma (MM) is predominantly a disease of the elderly, few studies have focused on the identification of prognostic factors in this group of patients. Four hundred twenty five MM patients >65 years were uniformly treated with chemotherapy (MP or VCMP/VBAD). Multivariate analysis identified 4 factors with independent unfavorable prognostic influence: high percentage of S-phase bone marrow plasma cells (>2.5%); elevated beta(2) microglobulin (B2M) (>4 mg/L); age >80 years old; and LDH serum levels (above normal limit). The S-phase value was the most powerful independent prognostic factor to discriminate subgroups of patients with different prognosis. Thus, 3 main risk categories could be identified according to S-phase values: </=1%, 1-3% and >3%, with median survivals of 34, 22 and 12 months, respectively (p < 0.0001). Our study also proved the value for elderly patients of the recently developed International Score System (ISS) based on B2M and albumin. Furthermore, the number of S-phase cells helped to subdivide the ISS III Group identifying a subset of patients with very poor prognosis defined by an additional high S-phase, who displayed a median survival of only 8 months. These results demonstrate that elderly patients can be accurately classified according to prognosis, which may be particularly valuable when comparing the efficacy of new treatment strategies. Moreover, our results underline the high prognostic value of proliferative activity of PC, a parameter that should be considered in routine laboratory investigations of MM.

Evaluation of argyrophilic nucleolar organiser regions (AgNORs) in multiple myeloma

AIM

To investigate the prognostic value of argyrophylic nucleolar organiser regions (AgNORs) in multiple myeloma.

METHODS

Bone marrow aspirates from 55 newly diagnosed patients with multiple myeloma were stained with the one step AgNO3 technique. The mean number of AgNORs in each plasma cell nucleus (AgNOR count) was tested for a possible correlation with other clinical and laboratory variables at presentation (clinical stage, substage, heavy and light chain isotype, haemoglobin concentration, platelet count, marrow infiltration rate, degree of skeletal lesions, M protein concentration, plasma cell morphology, and serum concentrations of calcium, albumin, lactate dehydrogenase, C reactive protein, and beta 2 microglobulin) and with outcome (response to first line treatment, first remission duration, and overall survival).

RESULTS

A significant association between mean (SD) AgNOR count was found only for clinical stage (stage I, 3.09 (1.19); stage II, 3.80 (1.53); stage III, 5.28 (1.79); p < 0.005) and, from all stage determinants, only for M protein concentration (high, 5.92 (1.80); low, 4.01 (1.92); p < 0.001). There was a linear relation between AgNOR count and serum M protein concentration for patients with both IgG (r = 0.450; p < 0.01) and IgA (r = 0.768; p < 0.002) producing multiple myeloma.

CONCLUSIONS

Unlike previous investigations, no clear prognostic value for the AgNOR count was found in multiple myeloma. Instead, the results indicate that the AgNOR count might be an index for M protein synthesis rate. This is consistent with other findings in tissues with low proliferative potential and high protein synthetic activity, and calls for a cautious interpretation of AgNORs in malignancies with similar features.

Prognostic relevance of AgNORs in tumor pathology

The importance of the analysis of the silver-stained nucleolar organizer regions (AgNORs) for prognostic purposes in tumor pathology has been reviewed. Current available data from the literature demonstrate that the evaluation of the quantity of interphase AgNORs is an independent prognostic factor in several types of human tumors. Results of our investigations indicate that AgNORs are the most powerful variable predicting survival in patients with pharyngeal carcinoma, multiple myeloma, male breast and prostate carcinoma. The combination of AgNOR counts and histologic pattern allows the stratification of patients with multiple myeloma, pharyngeal and prostate carcinoma into low- and high-risk groups, which could benefit from different therapy. Moreover, AgNOR analysis predicts response to treatment in adult patients with acute myelogenous leukemia, and appears as an independent prognostic factor in a prospective study on renal cell carcinoma. Therefore, AgNOR analysis is a really important prognostic factor for several human neoplasias. The experimental and theoretical justifications for AgNORs as a prognostic factor are also reviewed, in particular the strict correlation between AgNOR quantity and tumor cell doubling time. Lastly, the lack of prognostic significance of AgNOR analysis in some circumstances is critically discussed.