Investigative Tools for Diagnosis and Management

Clinical utility and implementation of gene-expression profiling in myeloma: current status and challenges

SUMMARY Multiple myeloma, a neoplasm of terminally differentiated plasma cell, is the second most frequent hematological malignancy after non-Hodgkin’s lymphoma. Gene-expression profiling is a powerful and sensitive tool that can detect global transcriptional changes in cells. This technology has been applied in myeloma studies in the last decade in diverse areas such as understanding molecular pathogenesis, role of microenvironment, molecular heterogeneity, prognosis prediction and identification of novel therapeutic targets. In this review, we will briefly retrace the achievements and consider the future perspectives of gene-expression profiling in multiple myeloma research.

Oral characteristics of a patient with Ekman-Westborg-Julin trait: a case history

This article presents the case of a Japanese woman who had Ekman-Westborg-Julin trait. She had general macrodontia with multituberculism, evagination of the premolar, single conical roots, shovel-shaped incisors, enamel hypoplasia, impacted tooth, dental crowding, and an open bite. The oral and general characteristics of this patient are described and include the histological and radiographic findings of the mandibular third molars. We suggest that the distinctive oral features with macrodontia of the permanent teeth, multituberculism, evagination, single conical roots, and impaction of the tooth could be defined as the Ekman-Westborg-Julin trait.

Immunoglobulin D multiple myeloma: response to therapy, survival, and prognostic factors in 75 patients

BACKGROUND

To analyze the clinical features, outcomes including efficacy of treatment, and prognostic factors of patients with immunoglobulin D multiple myeloma (IgD MM).

DESIGN AND METHODS

Seventy-five patients diagnosed with IgD MM were selected from the Korean Myeloma Registry database (www.myeloma.or.kr).

RESULTS

Median age was 57 years and the main presenting features were bone pain (77%). Renal function impairment and hypercalcemia were present in 40 (53%) and 20 (27%) patients. Sixty-seven patients (89%) had lambda light chains. Forty-eight patients (64%) were of stage III by International Staging System. Twenty-six patients (53%) had chromosomal abnormalities mostly by conventional cytogenetics. Thirty-nine patients (54%) were treated with vincristine, adriamycin, and dexamethasone chemotherapy; the overall response rate (ORR) of 56%. Sixteen patients (22%) received first-line chemotherapy including new drugs (bortezomib or thalidomide), with an ORR of 81%. At a median follow-up time of 28.6 months, median overall survival (OS) was 18.5 months. Age, extramedullary plasmacytoma, del(13) or hypoploidy, serum β(2) microglobulin level, and platelet count were significant prognostic factors for OS.

CONCLUSIONS

IgD MM is an aggressive disease that is usually detected at an advanced stage. Despite a positive initial response, survival after relapse was dismal. Intensive treatment strategies before and following stem cell transplantation may improve outcomes in younger patients.

Oligoclonal bands and immunoglobulin isotype switch during monitoring of patients with multiple myeloma and autologous hematopoietic cell transplantation: a 16-year experience

BACKGROUND

Over the last 20 years, high dose therapy followed by hemopoietic stem cell transplantation has been employed in patients with multiple myeloma (MM). During 16 years of follow-up, the degree of tumor response and survival in 238 patients with autologous stem cell transplantation (ASCT) and changes in the serum protein electrophoretic pattern were analyzed.

METHODS

Agarose gel electrophoresis with densitometric analysis and immunofixation were performed to evaluate serum monoclonal protein. IgM, IgA, IgG and beta(2)-microglobulin (beta2M) were quantitated. Urine protein electrophoresis with IF was performed on cellulose acetate gel using colloidal silver staining without concentrating.

RESULTS

After 34 months of follow-up (range 1-160 months), eight patients (3.4%) showed a distinct monoclonal protein band that was different from their original isotype switch. This was observed to be a transient phenomenon (22.2 months). Thirty-seven patients (15.5%) developed oligoclonal bands (OB) between the first and the twentieth month after ASCT (mean 4.4 months), which persisted for 7.9 months (1-36 months). The mean overall survival time was statistically different (p<0.05) between the group with OB and the group without them. Mean values of serum albumin, beta2M, and non-involved immunoglobulins did not show statistical differences.

CONCLUSIONS

The occurrence of OB could be a potential favorable prognostic marker after transplantation due to the prolonged survival observed. Close follow-up of anomalous protein bands, either in serum or urine, is essential due to the additional difficulty in interpretation when the therapeutic response and evolution are evaluated.

Multiple myeloma

Multiple myeloma is characterised by clonal proliferation of malignant plasma cells, and mounting evidence indicates that the bone marrow microenvironment of tumour cells has a pivotal role in myeloma pathogenesis. This knowledge has already expanded treatment options for patients with multiple myeloma. Prototypic drugs thalidomide, bortezomib, and lenalidomide have each been approved for the treatment of this disease by targeting both multiple myeloma cells and the bone marrow microenvironment. Although benefit was first shown in relapsed and refractory disease, improved overall response, duration of response, and progression-free and overall survival can be achieved when these drugs are part of first-line regimens. This treatment framework promises to improve outcome not only for patients with multiple myeloma, but also with other haematological malignancies and solid tumours.