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Schinke C, Rasche L, Raab MS, Weinhold N. Impact of Clonal Heterogeneity in Multiple Myeloma. Hematol Oncol Clin North Am 2024; 38:461-476. [PMID: 38195308 DOI: 10.1016/j.hoc.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Multiple myeloma is characterized by a highly heterogeneous disease distribution within the bone marrow-containing skeletal system. In this review, we introduce the molecular mechanisms underlying clonal heterogeneity and the spatio-temporal evolution of myeloma. We discuss the clinical impact of clonal heterogeneity, which is thought to be one of the biggest obstacles to overcome therapy resistance and to achieve cure.
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Affiliation(s)
- Carolina Schinke
- Myeloma Center, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Leo Rasche
- Department of Internal Medicine 2, University Hospital of Würzburg, Würzburg, Germany; Mildred Scheel Early Career Center (MSNZ), University Hospital of Würzburg, Würzburg, Germany
| | - Marc S Raab
- Department of Internal Medicine V, Heidelberg University Clinic Hospital, Heidelberg, Germany
| | - Niels Weinhold
- Department of Internal Medicine V, Heidelberg University Clinic Hospital, Heidelberg, Germany.
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2
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Zanwar S, Ho M, Lin Y, Kapoor P, Binder M, Buadi FK, Dispenzieri A, Dingli D, Fonder A, Gertz MA, Gonsalves W, Hayman SR, Hwa Y, Hobbs M, Kourelis T, Lacy MQ, Leung N, Muchtar E, Warsame R, Jevremovic D, Kyle RA, Rajkumar SV, Kumar S. Natural history, predictors of development of extramedullary disease, and treatment outcomes for patients with extramedullary multiple myeloma. Am J Hematol 2023; 98:1540-1549. [PMID: 37421603 DOI: 10.1002/ajh.27023] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 07/10/2023]
Abstract
Extramedullary multiple myeloma (EMM) can present either at initial diagnosis (de novo) or at disease relapse (secondary) and confers an aggressive clinical course. Limited data exist for choosing the optimal therapy for EMM and this remains an area of unmet clinical need. After excluding paraskeletal multiple myeloma and primary plasma cell leukemia, we identified 204 (68%) patients with secondary EMM and 95 (32%) with de novo EMM between January 01, 2000 and 31 December, 2021. The median overall survival (OS) was 0.7 (95% CI: 0.6-0.9) years for secondary EMM and 3.6 (95%CI: 2.4-5.6) years for de novo EMM. The median progression-free survival (PFS) with initial therapy was 2.9 months (95% CI: 2.4-3.2 months) for secondary EMM and 12.9 months (95% CI: 6.7-18 months) for de novo EMM. Patients with secondary EMM treated with CAR-T therapy (n = 20) achieved a partial response (PR) or better in 75% with a median PFS of 4.9 months (3.1 months-not reached; NR). Patients with EMM treated with bispecific antibodies (n = 12) achieved a ≥ PR in 33%, with a median PFS of 2.9 months (95%CI: 2.2 months-NR). In a matched cohort, multivariate logistic regression analysis demonstrated younger age at diagnosis, 1q duplication, and t(4;14) at diagnosis of MM to be independent predictors of development of secondary EMM. Presence of EMM was independently associated with inferior OS in the matched cohorts for both de novo (HR 2.9 [95% CI: 1.6-5.4], p = .0007) and secondary EMM (HR 1.5 [95% CI: 1.1-2], p = .001).
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Affiliation(s)
- Saurabh Zanwar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew Ho
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prashant Kapoor
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Moritz Binder
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Francis K Buadi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Amie Fonder
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Yi Hwa
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Miriam Hobbs
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Martha Q Lacy
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Nephrology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rahma Warsame
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Dragan Jevremovic
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert A Kyle
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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3
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Usmani SZ, Quach H, Mateos MV, Landgren O, Leleu X, Siegel D, Weisel K, Shu X, Li C, Dimopoulos M. Final analysis of carfilzomib, dexamethasone, and daratumumab vs carfilzomib and dexamethasone in the CANDOR study. Blood Adv 2023; 7:3739-3748. [PMID: 37163358 PMCID: PMC10368773 DOI: 10.1182/bloodadvances.2023010026] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 05/12/2023] Open
Abstract
CANDOR (NCT03158688) is a phase 3, randomized, open-label trial comparing carfilzomib, daratumumab, and dexamethasone (KdD) vs carfilzomib and dexamethasone (Kd) in adults with relapsed/refectory multiple myeloma (RRMM) with 1 to 3 prior therapies. The CANDOR study met its primary end point of progression-free survival (PFS) in the primary analysis. Here, we report the final analysis of the study, including secondary end points and subgroup analyses thereof. The median follow-up was 50 months. Patients treated with KdD had higher minimal residual disease-negative (MRD-) achievement rates (28% vs 9%; odds ratio [OR], 4.22; 95% confidence interval [95% CI], 2.28-7.83) and MRD- complete response rates (22% vs 8%; OR, 3.55; 95% CI, 1.83-6.88) than those treated with Kd. Median PFS was 28.4 months for KdD vs 15.2 months for Kd (hazard ratio [HR], 0.64; 95% CI, 0.49-0.83). Median overall survival (OS) for KdD was 50.8 months vs 43.6 months for Kd (HR, 0.78 [0.60-1.03]; P = .042). Trends toward improved OS occurred in predefined subgroups, including patients refractory to lenalidomide (KdD, not reached vs Kd, 38.2 months; HR, 0.69 [0.43-1.11]) and refractory to proteasome inhibitor (KdD, 43.2 months vs Kd, 30.0 months; HR, 0.70 [0.45-1.09]), and there was significant improvement in patients with high-risk cytogenetics (KdD, 34.3 months vs Kd: 17.1 months; HR, 0.52 [0.29-0.94]). No new safety signals were identified. In summary, the final analysis of CANDOR confirmed the PFS benefit and showed a trend in OS benefit with KdD vs Kd. These findings reinforce KdD as a standard of care for RRMM, especially in clinically relevant patient subgroups. This trial was registered at www.clinicaltrials.gov as #NCT03158688.
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Affiliation(s)
| | - Hang Quach
- University of Melbourne, St Vincent’s Hospital, Melbourne, VIC, Australia
| | | | - Ola Landgren
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
| | - Xavier Leleu
- Centre Hospitalier Universitaire de Poitiers, La Miletrie/INSERM CIC 1402, Poitiers, France
| | - David Siegel
- John Theurer Cancer Center at Hackensack University Medical Center, Hackensack, NJ
| | - Katja Weisel
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Meletios Dimopoulos
- National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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4
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Zhang W, Wu C, Geng S, Wang J, Yan C, Zhang X, Zhang JJ, Wu F, Pang Y, Zhong Y, Wang J, Fu W, Huang X, Wang W, Lyu X, Huang Y, Jing H. FAM46C-mediated tumor heterogeneity predicts extramedullary metastasis and poorer survival in multiple myeloma. Aging (Albany NY) 2023; 15:3644-3677. [PMID: 37155154 PMCID: PMC10449297 DOI: 10.18632/aging.204697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 04/22/2023] [Indexed: 05/10/2023]
Abstract
Cancers originate from a single cell according to Nowell's theory of clonal evolution. The enrichment of the most aggressive clones has been developed and the heterogeneity arises for genomic instability and environmental selection. Multiple myeloma (MM) is a multiple relapse plasma cell cancer generated from bone marrow. Although there were accumulating researches in multiple myeloma pathogenesis, the heterogeneity remains poorly understood. The participants enrolled in this study were 4 EMP+ (EMP, Extramedullary plasmacytoma) and 2 EMP- primarily untreated MM patients. Single cell RNA sequencing and analysis were conducted for the single cell suspension, which was sorted by flow cytometry from peripheral blood mononuclear cells or bone marrow cells. In our research, the results of single cell RNA sequencing show that FAM46C determines MM tumor heterogeneity predicting extramedullary metastasis by influencing RNA stability. Further, we integrated and analyzed 2280 multiple myeloma samples from 7 independent datasets, which uncover that FAM46C mediated tumor heterogeneity predicts poorer survival in multiple myeloma.
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Affiliation(s)
- Weilong Zhang
- Department of Hematology, Biodynamic Optical Imaging Center (BIOPIC) and Lymphoma Research Center, Third Hospital, Peking University, Beijing 100084, China
| | - Chaoling Wu
- Department of Hematology, Biodynamic Optical Imaging Center (BIOPIC) and Lymphoma Research Center, Third Hospital, Peking University, Beijing 100084, China
| | - Shuang Geng
- Department of Hematology, Biodynamic Optical Imaging Center (BIOPIC) and Lymphoma Research Center, Third Hospital, Peking University, Beijing 100084, China
- Beijing Advanced Innovation Center for Genomics (ICG), School of Life Sciences, Peking-Tsinghua Center for Life Sciences, Peking University, Beijing 100084, China
| | - Jing Wang
- Department of Hematology, Biodynamic Optical Imaging Center (BIOPIC) and Lymphoma Research Center, Third Hospital, Peking University, Beijing 100084, China
| | - Changjian Yan
- Department of Hematology, Biodynamic Optical Imaging Center (BIOPIC) and Lymphoma Research Center, Third Hospital, Peking University, Beijing 100084, China
| | - Xiannian Zhang
- Department of Hematology, Biodynamic Optical Imaging Center (BIOPIC) and Lymphoma Research Center, Third Hospital, Peking University, Beijing 100084, China
- Beijing Advanced Innovation Center for Genomics (ICG), School of Life Sciences, Peking-Tsinghua Center for Life Sciences, Peking University, Beijing 100084, China
| | - Jia-jia Zhang
- Department of Hematology, Beijing Chaoyang Hospital West, Capital Medical University, Beijing 100054, China
| | - Fan Wu
- Department of Hematology, Biodynamic Optical Imaging Center (BIOPIC) and Lymphoma Research Center, Third Hospital, Peking University, Beijing 100084, China
- Beijing Advanced Innovation Center for Genomics (ICG), School of Life Sciences, Peking-Tsinghua Center for Life Sciences, Peking University, Beijing 100084, China
| | - Yuhong Pang
- Department of Hematology, Biodynamic Optical Imaging Center (BIOPIC) and Lymphoma Research Center, Third Hospital, Peking University, Beijing 100084, China
- Beijing Advanced Innovation Center for Genomics (ICG), School of Life Sciences, Peking-Tsinghua Center for Life Sciences, Peking University, Beijing 100084, China
| | - Yuping Zhong
- Department of Hematology, Beijing Chaoyang Hospital West, Capital Medical University, Beijing 100054, China
| | - Jianbin Wang
- School of Life Sciences, Tsinghua-Peking Center for Life Sciences, Tsinghua University, Beijing 100190, China
| | - Wei Fu
- Department of Hematology, Biodynamic Optical Imaging Center (BIOPIC) and Lymphoma Research Center, Third Hospital, Peking University, Beijing 100084, China
| | - Xin Huang
- Department of Hematology, Biodynamic Optical Imaging Center (BIOPIC) and Lymphoma Research Center, Third Hospital, Peking University, Beijing 100084, China
| | - Wenming Wang
- Department of Hematology, Biodynamic Optical Imaging Center (BIOPIC) and Lymphoma Research Center, Third Hospital, Peking University, Beijing 100084, China
| | - Xiaoqing Lyu
- Department of Hematology, Biodynamic Optical Imaging Center (BIOPIC) and Lymphoma Research Center, Third Hospital, Peking University, Beijing 100084, China
- Beijing Advanced Innovation Center for Genomics (ICG), School of Life Sciences, Peking-Tsinghua Center for Life Sciences, Peking University, Beijing 100084, China
| | - Yanyi Huang
- Department of Hematology, Biodynamic Optical Imaging Center (BIOPIC) and Lymphoma Research Center, Third Hospital, Peking University, Beijing 100084, China
- Beijing Advanced Innovation Center for Genomics (ICG), School of Life Sciences, Peking-Tsinghua Center for Life Sciences, Peking University, Beijing 100084, China
| | - Hongmei Jing
- Department of Hematology, Biodynamic Optical Imaging Center (BIOPIC) and Lymphoma Research Center, Third Hospital, Peking University, Beijing 100084, China
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Oben B, Cosemans C, Geerdens E, Linsen L, Vanhees K, Maes B, Theunissen K, Cruys B, Lionetti M, Arijs I, Bolli N, Froyen G, Rummens JL. The Dynamics of Nucleotide Variants in the Progression from Low-Intermediate Myeloma Precursor Conditions to Multiple Myeloma: Studying Serial Samples with a Targeted Sequencing Approach. Cancers (Basel) 2022; 14:cancers14041035. [PMID: 35205782 PMCID: PMC8870380 DOI: 10.3390/cancers14041035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/28/2022] [Accepted: 02/16/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Multiple myeloma (MM), characterized by the expansion of plasma cells in the bone marrow, is the second most common hematological malignancy. This incurable cancer is consistently preceded by non-malignant asymptomatic precursor conditions known as monoclonal gammopathy of undetermined significance (MGUS) and/or smoldering multiple myeloma (SMM). These pre-stages are relatively frequent, but only a select percentage of them will progress to MM. However, it is still not possible to individually predict when and which patients will develop MM. Therefore, this study aimed to investigate the mutational profile in the progression in serial bone marrow samples with a custom targeted sequencing panel, designed to detect variants in myeloma-related genes. Remarkably, almost all variants identified in the MM samples were also already present in the pre-stages, sometimes even many years before the progression. These results provide new important insights into the molecular mechanisms of the precursor conditions and progression to MM. Abstract Multiple myeloma (MM), or Kahler’s disease, is an incurable plasma cell (PC) cancer in the bone marrow (BM). This malignancy is preceded by one or more asymptomatic precursor conditions, monoclonal gammopathy of undetermined significance (MGUS) and/or smoldering multiple myeloma (SMM). The molecular mechanisms and exact cause of this progression are still not completely understood. In this study, the mutational profile underlying the progression from low–intermediate risk myeloma precursor conditions to MM was studied in serial BM smears. A custom capture-based sequencing platform was developed, including 81 myeloma-related genes. The clonal evolution of single nucleotide variants and short insertions and deletions was studied in serial BM smears from 21 progressed precursor patients with a median time of progression of six years. From the 21 patients, four patients had no variation in one of the 81 studied genes. Interestingly, in 16 of the 17 other patients, at least one variant present in MM was also detected in its precursor BM, even years before progression. Here, the variants were present in the pre-stage at a median of 62 months before progression to MM. Studying these paired BM samples contributes to the knowledge of the evolutionary genetic landscape and provides additional insight into the mutational behavior of mutant clones over time throughout progression.
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Affiliation(s)
- Bénedith Oben
- Laboratory Experimental Hematology, Department Clinical Biology, Jessa Hospital, 3500 Hasselt, Belgium; (C.C.); (L.L.); (J.-L.R.)
- Faculty of Medicine and Life Sciences, Hasselt University, 3500 Hasselt, Belgium; (K.V.); (I.A.); (G.F.)
- Correspondence:
| | - Charlotte Cosemans
- Laboratory Experimental Hematology, Department Clinical Biology, Jessa Hospital, 3500 Hasselt, Belgium; (C.C.); (L.L.); (J.-L.R.)
- Faculty of Medicine and Life Sciences, Hasselt University, 3500 Hasselt, Belgium; (K.V.); (I.A.); (G.F.)
- Centre for Environmental Sciences, Hasselt University, 3590 Diepenbeek, Belgium
| | - Ellen Geerdens
- Laboratory Molecular Diagnostics, Department Clinical Biology, Jessa Hospital, 3500 Hasselt, Belgium; (E.G.); (B.M.); (B.C.)
| | - Loes Linsen
- Laboratory Experimental Hematology, Department Clinical Biology, Jessa Hospital, 3500 Hasselt, Belgium; (C.C.); (L.L.); (J.-L.R.)
- Activity Center Biobanking, University Hospitals Leuven, 3000 Leuven, Belgium
- University Biobank Limburg (UBiLim), Clinical Biobank, Jessa Hospital, 3500 Hasselt, Belgium
| | - Kimberly Vanhees
- Faculty of Medicine and Life Sciences, Hasselt University, 3500 Hasselt, Belgium; (K.V.); (I.A.); (G.F.)
- University Biobank Limburg (UBiLim), Clinical Biobank, Jessa Hospital, 3500 Hasselt, Belgium
| | - Brigitte Maes
- Laboratory Molecular Diagnostics, Department Clinical Biology, Jessa Hospital, 3500 Hasselt, Belgium; (E.G.); (B.M.); (B.C.)
| | - Koen Theunissen
- Department Hematology, Jessa Hospital, 3500 Hasselt, Belgium;
| | - Bert Cruys
- Laboratory Molecular Diagnostics, Department Clinical Biology, Jessa Hospital, 3500 Hasselt, Belgium; (E.G.); (B.M.); (B.C.)
| | - Marta Lionetti
- Department Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy; (M.L.); (N.B.)
| | - Ingrid Arijs
- Faculty of Medicine and Life Sciences, Hasselt University, 3500 Hasselt, Belgium; (K.V.); (I.A.); (G.F.)
- Laboratory for Translational Genetics, Department Human Genetics, University of Leuven, 3000 Leuven, Belgium
- Belgian Inflammatory Bowel Disease Research and Development (BIRD), 1930 Zaventem, Belgium
| | - Niccolò Bolli
- Department Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy; (M.L.); (N.B.)
- Unità Operativa Complessa di Ematologia, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Guy Froyen
- Faculty of Medicine and Life Sciences, Hasselt University, 3500 Hasselt, Belgium; (K.V.); (I.A.); (G.F.)
- Laboratory Molecular Diagnostics, Department Clinical Biology, Jessa Hospital, 3500 Hasselt, Belgium; (E.G.); (B.M.); (B.C.)
| | - Jean-Luc Rummens
- Laboratory Experimental Hematology, Department Clinical Biology, Jessa Hospital, 3500 Hasselt, Belgium; (C.C.); (L.L.); (J.-L.R.)
- Faculty of Medicine and Life Sciences, Hasselt University, 3500 Hasselt, Belgium; (K.V.); (I.A.); (G.F.)
- University Biobank Limburg (UBiLim), Clinical Biobank, Jessa Hospital, 3500 Hasselt, Belgium
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Mann H, Katiyar V, Varga C, Comenzo RL. Smoldering multiple myeloma - Past, present, and future. Blood Rev 2021; 52:100869. [PMID: 34312016 DOI: 10.1016/j.blre.2021.100869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/13/2021] [Accepted: 07/15/2021] [Indexed: 02/06/2023]
Abstract
Smoldering multiple myeloma (SMM) routinely precedes the development of multiple myeloma. While some patients experience aggressive disease, others have more indolent courses akin to those with monoclonal gammopathy of undetermined significance. Much effort has been made to understand the pathobiological basis of this heterogeneity. Scientific advancements have led to the emergence of various clinical and genomic markers of relevance, translating into evolution of disease definitions over time. More recently, the interest in manipulation of biological pathways has intensified in a bid to stall or halt disease progression. Studies with lenalidomide have exemplified the promise of early intervention, whereas numerous therapeutic approaches remain the subject of ongoing clinical investigation. This review summarizes the historic progress made in defining SMM as a distinct clinicopathologic entity, provides a critical appraisal of the evidence guiding risk assessment, and suggests a pragmatic approach to its modern-day management. Finally, an overview of developments on the horizon is also provided.
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Affiliation(s)
- Hashim Mann
- Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA; The John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA.
| | - Vatsala Katiyar
- Division of Hematology/Oncology, Brown Cancer Center, University of Louisville, Louisville, KY, USA
| | - Cindy Varga
- Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA; The John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA
| | - Raymond L Comenzo
- Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA; The John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA
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7
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Mondala PK, Vora AA, Zhou T, Lazzari E, Ladel L, Luo X, Kim Y, Costello C, MacLeod AR, Jamieson CHM, Crews LA. Selective antisense oligonucleotide inhibition of human IRF4 prevents malignant myeloma regeneration via cell cycle disruption. Cell Stem Cell 2021; 28:623-636.e9. [PMID: 33476575 DOI: 10.1016/j.stem.2020.12.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 10/22/2020] [Accepted: 12/21/2020] [Indexed: 12/22/2022]
Abstract
In multiple myeloma, inflammatory and anti-viral pathways promote disease progression and cancer stem cell generation. Using diverse pre-clinical models, we investigated the role of interferon regulatory factor 4 (IRF4) in myeloma progenitor regeneration. In a patient-derived xenograft model that recapitulates IRF4 pathway activation in human myeloma, we test the effects of IRF4 antisense oligonucleotides (ASOs) and identify a lead agent for clinical development (ION251). IRF4 overexpression expands myeloma progenitors, while IRF4 ASOs impair myeloma cell survival and reduce IRF4 and c-MYC expression. IRF4 ASO monotherapy impedes tumor formation and myeloma dissemination in xenograft models, improving animal survival. Moreover, IRF4 ASOs eradicate myeloma progenitors and malignant plasma cells while sparing normal human hematopoietic stem cell development. Mechanistically, IRF4 inhibition disrupts cell cycle progression, downregulates stem cell and cell adhesion transcript expression, and promotes sensitivity to myeloma drugs. These findings will enable rapid clinical development of selective IRF4 inhibitors to prevent myeloma progenitor-driven relapse.
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Affiliation(s)
- Phoebe K Mondala
- Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Ashni A Vora
- Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | | | - Elisa Lazzari
- Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Luisa Ladel
- Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Xiaolin Luo
- Ionis Pharmaceuticals, Carlsbad, CA 92008, USA
| | | | - Caitlin Costello
- Moores Cancer Center at University of California, San Diego, La Jolla, CA 92093, USA; Division of Blood and Marrow Transplantation, Department of Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | | | - Catriona H M Jamieson
- Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92093, USA; Moores Cancer Center at University of California, San Diego, La Jolla, CA 92093, USA.
| | - Leslie A Crews
- Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92093, USA; Moores Cancer Center at University of California, San Diego, La Jolla, CA 92093, USA.
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8
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Biran N, Vesole DH, Donato ML, Ip A, Kaur G, Goldberg S, Siegel DS. Treatment of Smoldering Myeloma: Problems With Study Design as well as Biological and Clinical Implications. J Clin Oncol 2020; 38:1367-1368. [PMID: 32160077 DOI: 10.1200/jco.19.02972] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Noa Biran
- Noa Biran, MD; David H. Vesole, MD, PhD; Michele L. Donato, MD; Andrew Ip, MD; Gurbakhash Kaur, MD; Stuart Goldberg, MD; and David S. Siegel, MD, PhD; John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ
| | - David H Vesole
- Noa Biran, MD; David H. Vesole, MD, PhD; Michele L. Donato, MD; Andrew Ip, MD; Gurbakhash Kaur, MD; Stuart Goldberg, MD; and David S. Siegel, MD, PhD; John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ
| | - Michele L Donato
- Noa Biran, MD; David H. Vesole, MD, PhD; Michele L. Donato, MD; Andrew Ip, MD; Gurbakhash Kaur, MD; Stuart Goldberg, MD; and David S. Siegel, MD, PhD; John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ
| | - Andrew Ip
- Noa Biran, MD; David H. Vesole, MD, PhD; Michele L. Donato, MD; Andrew Ip, MD; Gurbakhash Kaur, MD; Stuart Goldberg, MD; and David S. Siegel, MD, PhD; John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ
| | - Gurbakhash Kaur
- Noa Biran, MD; David H. Vesole, MD, PhD; Michele L. Donato, MD; Andrew Ip, MD; Gurbakhash Kaur, MD; Stuart Goldberg, MD; and David S. Siegel, MD, PhD; John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ
| | - Stuart Goldberg
- Noa Biran, MD; David H. Vesole, MD, PhD; Michele L. Donato, MD; Andrew Ip, MD; Gurbakhash Kaur, MD; Stuart Goldberg, MD; and David S. Siegel, MD, PhD; John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ
| | - David S Siegel
- Noa Biran, MD; David H. Vesole, MD, PhD; Michele L. Donato, MD; Andrew Ip, MD; Gurbakhash Kaur, MD; Stuart Goldberg, MD; and David S. Siegel, MD, PhD; John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ
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9
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Zang M, Guo J, Liu L, Jin F, Feng X, An G, Qin X, Wu Y, Lei Q, Meng B, Zhu Y, Guan Y, Deng S, Hao M, Xu Y, Zou D, Wu M, Qiu L, Zhou W. Cdc37 suppression induces plasma cell immaturation and bortezomib resistance in multiple myeloma via Xbp1s. Oncogenesis 2020; 9:31. [PMID: 32139666 PMCID: PMC7058164 DOI: 10.1038/s41389-020-0216-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 02/13/2020] [Indexed: 12/20/2022] Open
Abstract
Multiple myeloma (MM) is the second most prevalent hematologic malignancy. Although the use of bortezomib (BTZ) significantly improves MM therapy, intrinsic and acquired drug resistance to BTZ remains a major clinical problem. In this study, we find that Cdc37, a key co-chaperone of Hsp90, is downregulated in relapsed MM patients, especially after BTZ treatment, suggesting a link between Cdc37 and BTZ resistance. Suppression of Cdc37 or inhibition of Cdc37/Hsp90 association induces plasma cell dedifferentiation, quiescence of MM cells, and BTZ resistance in MM. Furthermore, we discover that Cdc37 expression correlates positively with Xbp1s, a critical transcription factor for plasma cell differentiation in MM samples. Depletion/inhibition of Cdc37 downregulates Xbp1s, while overexpression of Xbp1s in MM cell lines partially rescues plasma immaturation and BTZ resistance. It is suggested that Xbp1s may act as a key downstream effector of Cdc37. Experiments with a mouse model also demonstrate that Cdc37 inhibition promotes plasma cell immaturation, confers BTZ resistance, and increases MM progression in vivo. Together, we identify a critical factor and a new signaling mechanism that regulate plasma cell immaturation and BTZ resistance in MM cells. Our findings may constitute a novel strategy that overcomes BTZ resistance in MM therapy.
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Affiliation(s)
- Meirong Zang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China.,Department of Hematology, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jiaojiao Guo
- Cancer Research Institute, School of Basic Medical Science Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education; Key Laboratory of Carcinogenesis, National Health and Family Planning Commission, Central South University, Hunan, China
| | - Lanting Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Fengyan Jin
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Xiangling Feng
- Xiang Ya School of Public Health, Central South University, Changsha, Hunan, China
| | - Gang An
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Xiaoqi Qin
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Yangbowen Wu
- Xiang Ya School of Public Health, Central South University, Changsha, Hunan, China
| | - Qian Lei
- Cancer Research Institute, School of Basic Medical Science Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education; Key Laboratory of Carcinogenesis, National Health and Family Planning Commission, Central South University, Hunan, China
| | - Bin Meng
- Cancer Research Institute, School of Basic Medical Science Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education; Key Laboratory of Carcinogenesis, National Health and Family Planning Commission, Central South University, Hunan, China
| | - Yinghong Zhu
- Cancer Research Institute, School of Basic Medical Science Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education; Key Laboratory of Carcinogenesis, National Health and Family Planning Commission, Central South University, Hunan, China
| | - Yongjun Guan
- Cancer Research Institute, School of Basic Medical Science Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education; Key Laboratory of Carcinogenesis, National Health and Family Planning Commission, Central South University, Hunan, China
| | - Shuhui Deng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Mu Hao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Yan Xu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Dehui Zou
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Minghua Wu
- Cancer Research Institute, School of Basic Medical Science Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education; Key Laboratory of Carcinogenesis, National Health and Family Planning Commission, Central South University, Hunan, China
| | - Lugui Qiu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China.
| | - Wen Zhou
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China. .,Cancer Research Institute, School of Basic Medical Science Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education; Key Laboratory of Carcinogenesis, National Health and Family Planning Commission, Central South University, Hunan, China.
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10
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Liu H, Yang Y, Jiang J, Wang X, Zhang C, Jiang Y, Hong L, Huang H. Coexistence Of A Huge Venous Thromboembolism And Bleeding Tendency In Cytokine Release Syndrome During CAR-T Therapy. Onco Targets Ther 2019; 12:8955-8960. [PMID: 31802905 PMCID: PMC6826178 DOI: 10.2147/ott.s223697] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/10/2019] [Indexed: 01/16/2023] Open
Abstract
Chimeric antigen receptor (CAR)-modified T cell therapy is increasingly administered for hematological malignancies. Cytokine release syndrome (CRS) is a common and severe complication of CAR-T therapy. In the present case, a 62-year-old male patient was diagnosed with relapsed and refractory multiple myeloma (RRMM). Treated with CART-CD19/BCMA therapy, his symptoms remitted, during which occasional but severe CRS associated with coagulation disorder still appeared, as evidenced by the coexistence of a huge thrombosis and bleeding tendency. Through the First Generation Sequencing, we extracted genomic DNA from the patient’s peripheral blood to analyze the distribution of polymorphism at the –572C/G site of the promoter of IL-6 gene. The results showed that the genotype of –572C/G promoter polymorphism was CC, indicating that high level of IL-6 and –572C/G polymorphism might be associated with the risk of thrombotic disorders. We concluded that immediate diagnosis and appropriate treatment of coagulopathy could reduce CRS-related mortality.
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Affiliation(s)
- Haiyan Liu
- Department of Hematology, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, People's Republic of China
| | - Ye Yang
- School of Integrative Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu 210023, People's Republic of China
| | - Jie Jiang
- Department of Hematology, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, People's Republic of China
| | - Xinfeng Wang
- Department of Hematology, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, People's Republic of China
| | - Chenlu Zhang
- Department of Hematology, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, People's Republic of China
| | - Yijing Jiang
- Department of Hematology, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, People's Republic of China
| | - Lemin Hong
- Department of Hematology, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, People's Republic of China
| | - Hongming Huang
- Department of Hematology, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, People's Republic of China
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11
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Cytogenetic intraclonal heterogeneity of plasma cell dyscrasia in AL amyloidosis as compared with multiple myeloma. Blood Adv 2019; 2:2607-2618. [PMID: 30327369 DOI: 10.1182/bloodadvances.2018023200] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 08/31/2018] [Indexed: 01/13/2023] Open
Abstract
Analysis of intraclonal heterogeneity has yielded insights into the clonal evolution of hematologic malignancies. We compared the clonal and subclonal compositions of the underlying plasma cell dyscrasia in 544 systemic light chain amyloidosis (PC-AL) patients with 519 patients with monoclonal gammopathy of undetermined significance (MGUS), smoldering multiple myeloma (SMM), or symptomatic MM; ie, PC-non-AL patients). Using interphase fluorescence in situ hybridization, subclones were stringently defined as clone size below two thirds of the largest clone and an absolute difference of ≥30%. Subclones were found less frequently in the PC-AL group, at 199 (36.6%) of 544 as compared with 267 (51.4%) of 519 in the PC-non-AL group (P < .001), and were not associated with the stage of plasma cell dyscrasia in either entity. In both groups, translocation t(11;14), other immunoglobulin heavy chain translocations, and hyperdiploidy were typically found as main clones, whereas gain of 1q21 and deletions of 8p21, 13q14, and 17p13 were frequently found as subclones. There were no shifts in the subclone/main clone ratio depending on the MGUS, SMM, or MM stage of plasma cell dyscrasia. In multivariate analysis, t(11;14) was associated with lower rates of subclone formation and hyperdiploidy with higher rates. PC-AL itself lost statistical significance, demonstrating that the lower subclone frequency in AL is a reflection of its exceptionally high t(11;14) frequency. In summary, the subclone patterns in PC-AL and PC-non-AL are closely related, implying that subclone formation depends on the main cytogenetic categories and is independent of disease entity and stage.
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12
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Biran N, Rowley SD, Vesole DH, Zhang S, Donato ML, Skarbnik AP, Richter J, Pecora A, Siegel DS. A phase I/II study of escalating doses of thalidomide in conjunction with bortezomib and high-dose melphalan as a conditioning regimen for autologous stem cell transplantation in patients with multiple myeloma. Bone Marrow Transplant 2019; 54:1881-1891. [PMID: 31101891 DOI: 10.1038/s41409-019-0534-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 02/27/2019] [Accepted: 04/12/2019] [Indexed: 11/09/2022]
Abstract
A regimen of escalating doses of thalidomide, in combination with bortezomib and high-dose melphalan (mel/vel/thal), was evaluated as a conditioning regimen for autologous stem cell transplantation (ASCT) in multiple myeloma (MM) patients with a prior transplant who had relapsed or achieved less than a complete remission following a prior ASCT. Thalidomide was dose escalated starting from 600 mg to 1000 mg on days -5 to -1 in a 3 × 3 design, bortezomib was administered at 1.6 mg/m2 intravenously on days -4 and -1 and melphalan 200 mg/m2 was administered on day -2. No dose-limiting toxicity was seen in the phase I portion of the trial. An additional 20 patients were enrolled at the maximum tolerated dose of thalidomide of 1000 mg daily. The overall response rate was 69% with 38% complete remission. Median PFS and OS were 9.3 and 65.4 months, respectively, with a median follow-up of 17.8 months. The most common grade 3-4 adverse events (AEs) were neutropenic fever (58.6%), mucositis (6.9%), and diarrhea (6.9%). Serious AEs included somnolence (13.8%) and tumor lysis syndrome (3.4%). The addition of high-dose thalidomide to bortezomib and melphalan as conditioning for salvage ASCT was well tolerated and was an effective conditioning regimen.
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Affiliation(s)
- Noa Biran
- John Theurer Cancer Center at Hackensack Meridian, Seton Hall University School of Medicine, Hackensack, NJ, USA.
| | - Scott D Rowley
- John Theurer Cancer Center at Hackensack Meridian, Seton Hall University School of Medicine, Hackensack, NJ, USA
| | - David H Vesole
- John Theurer Cancer Center at Hackensack Meridian, Seton Hall University School of Medicine, Hackensack, NJ, USA
| | - Shijia Zhang
- University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Michele L Donato
- John Theurer Cancer Center at Hackensack Meridian, Seton Hall University School of Medicine, Hackensack, NJ, USA
| | | | - Joshua Richter
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andrew Pecora
- John Theurer Cancer Center at Hackensack Meridian, Seton Hall University School of Medicine, Hackensack, NJ, USA
| | - David S Siegel
- John Theurer Cancer Center at Hackensack Meridian, Seton Hall University School of Medicine, Hackensack, NJ, USA
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13
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Dzobo K, Senthebane DA, Thomford NE, Rowe A, Dandara C, Parker MI. Not Everyone Fits the Mold: Intratumor and Intertumor Heterogeneity and Innovative Cancer Drug Design and Development. OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2019; 22:17-34. [PMID: 29356626 DOI: 10.1089/omi.2017.0174] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Disruptive innovations in medicine are game-changing in nature and bring about radical shifts in the way we understand human diseases, their treatment, and/or prevention. Yet, disruptive innovations in cancer drug design and development are still limited. Therapies that cure all cancer patients are in short supply or do not exist at all. Chief among the causes of this predicament is drug resistance, a mechanism that is much more dynamic than previously understood. Drug resistance has limited the initial success experienced with biomarker-guided targeted therapies as well. A major contributor to drug resistance is intratumor heterogeneity. For example, within solid tumors, there are distinct subclones of cancer cells, presenting profound complexity to cancer treatment. Well-known contributors to intratumor heterogeneity are genomic instability, the microenvironment, cellular genotype, cell plasticity, and stochastic processes. This expert review explains that for oncology drug design and development to be more innovative, we need to take into account intratumor heterogeneity. Initially thought to be the preserve of cancer cells, recent evidence points to the highly heterogeneous nature and diverse locations of stromal cells, such as cancer-associated fibroblasts (CAFs) and cancer-associated macrophages (CAMs). Distinct subpopulations of CAFs and CAMs are now known to be located immediately adjacent and distant from cancer cells, with different subpopulations exerting different effects on cancer cells. Disruptive innovation and precision medicine in clinical oncology do not have to be a distant reality, but can potentially be achieved by targeting these spatially separated and exclusive cancer cell subclones and CAF subtypes. Finally, we emphasize that disruptive innovations in drug discovery and development will likely come from drugs whose effect is not necessarily tumor shrinkage.
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Affiliation(s)
- Kevin Dzobo
- 1 International Centre for Genetic Engineering and Biotechnology (ICGEB) , Cape Town, South Africa .,2 Division of Medical Biochemistry, Department of Integrative Biomedical Sciences, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town , Cape Town, South Africa
| | - Dimakatso Alice Senthebane
- 1 International Centre for Genetic Engineering and Biotechnology (ICGEB) , Cape Town, South Africa .,2 Division of Medical Biochemistry, Department of Integrative Biomedical Sciences, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town , Cape Town, South Africa
| | - Nicholas Ekow Thomford
- 3 Pharmacogenetics Research Group, Division of Human Genetics, Department of Pathology, Faculty of Health Sciences, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town , Cape Town, South Africa
| | - Arielle Rowe
- 1 International Centre for Genetic Engineering and Biotechnology (ICGEB) , Cape Town, South Africa
| | - Collet Dandara
- 3 Pharmacogenetics Research Group, Division of Human Genetics, Department of Pathology, Faculty of Health Sciences, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town , Cape Town, South Africa
| | - M Iqbal Parker
- 2 Division of Medical Biochemistry, Department of Integrative Biomedical Sciences, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town , Cape Town, South Africa
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14
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Duek A, Trakhtenbrot L, Amariglio N, Benyamini N, Zilbershats I, Ganzel C, Shevetz O, Leiba R, Rozic G, Nagler A, Leiba M. Newly diagnosed multiple myeloma patients carrying monoallelic deletion of the whole locus of immunoglobulin heavy chain gene have a better prognosis compared to those with t(4;14) and t(14;16). Genes Chromosomes Cancer 2019; 58:516-520. [PMID: 30675954 DOI: 10.1002/gcc.22738] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 01/20/2019] [Accepted: 01/21/2019] [Indexed: 11/08/2022] Open
Abstract
The current study evaluated the prognostic significance of the monoallelic deletion of the whole locus of the immunoglobulin heavy-chain (w_del(IGH)) gene compared to translocations t(4;14) and t(14;16) among newly diagnosed multiple myeloma (MM) patients. We retrospectively analyzed clinical (age, gender, and staging) and laboratory data at diagnosis and the overall survival (OS) of 255 newly diagnosed MM patients carrying w_del(IGH) or translocations t(4;14) or t(14;16). Bone marrow samples were examined by morphological and sequential interphase fluorescense in situ hybridization analyses. Among 255 patients, 117 (45.8%) had w_del(IGH), 99 (38.8%) had t(4;14), and 39 (15.3%) had t(14;16). Mean age was 61.6 ± 11.6 years. Groups did not differ significantly in age, gender, or lactate dehydrogenase levels. Patients in the w_del(IGH) group presented more frequently at International Staging System stage I than at stage II/III. Patients in the w_del(IGH) group had significantly fewer additional chromosomal aberrations (1.58) than the other two groups (2.3 and 2.13 in the del(IGH), t(14;16) and t(4;14) groups, respectively, P < 0.0001). Furthermore, the w_del(IGH) group had significantly longer estimated median OS (9.47 years) compared to those with translocations t(14;16) (3.02 years, P = 0.002) or t(4;14) (4.18 years, P = 0.001), respectively. These findings suggest a potential prognostic significance of monoallelic deletion of IGH among these patients. Additional studies are needed to better understand the nature and mechanism of this prognostic factor.
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Affiliation(s)
- Adrian Duek
- Division of Hematology and Bone Marrow Transplantation, The Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Luba Trakhtenbrot
- Division of Hematology and Bone Marrow Transplantation, The Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel-Aviv University, Israel.,Cancer Research Center, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Ninette Amariglio
- Division of Hematology and Bone Marrow Transplantation, The Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel-Aviv University, Israel.,Cancer Research Center, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Noam Benyamini
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | | | - Chezi Ganzel
- Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Olga Shevetz
- Department of Hematology, Kaplan Medical Center, Rehovot, Israel
| | | | - Gabriela Rozic
- Division of Hematology and Bone Marrow Transplantation, The Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel-Aviv University, Israel.,Department of Molecular Biology, Ariel University, Ariel, Israel
| | - Arnon Nagler
- Division of Hematology and Bone Marrow Transplantation, The Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Merav Leiba
- Division of Hematology and Bone Marrow Transplantation, The Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel-Aviv University, Israel.,Division of Hematology, Assuta Ashdod University Hospital, and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
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15
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De Smedt E, Lui H, Maes K, De Veirman K, Menu E, Vanderkerken K, De Bruyne E. The Epigenome in Multiple Myeloma: Impact on Tumor Cell Plasticity and Drug Response. Front Oncol 2018; 8:566. [PMID: 30619733 PMCID: PMC6297718 DOI: 10.3389/fonc.2018.00566] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/13/2018] [Indexed: 01/19/2023] Open
Abstract
Multiple myeloma (MM) is a clonal plasma cell malignancy that develops primarily in the bone marrow (BM), where reciprocal interactions with the BM niche foster MM cell survival, growth, and drug resistance. MM cells furthermore reshape the BM to their own needs by affecting the different BM stromal cell types resulting in angiogenesis, bone destruction, and immune suppression. Despite recent advances in treatment modalities, MM remains most often incurable due to the development of drug resistance to all standard of care agents. This underscores the unmet need for these heavily treated relapsed/refractory patients. Disruptions in epigenetic regulation are a well-known hallmark of cancer cells, contributing to both cancer onset and progression. In MM, sequencing and gene expression profiling studies have also identified numerous epigenetic defects, including locus-specific DNA hypermethylation of cancer-related and B cell specific genes, genome-wide DNA hypomethylation and genetic defects, copy number variations and/or abnormal expression patterns of various chromatin modifying enzymes. Importantly, these so-called epimutations contribute to genomic instability, disease progression, and a worse outcome. Moreover, the frequency of mutations observed in genes encoding for histone methyltransferases and DNA methylation modifiers increases following treatment, indicating a role in the emergence of drug resistance. In support of this, accumulating evidence also suggest a role for the epigenetic machinery in MM cell plasticity, driving the differentiation of the malignant cells to a less mature and drug resistant state. This review discusses the current state of knowledge on the role of epigenetics in MM, with a focus on deregulated histone methylation modifiers and the impact on MM cell plasticity and drug resistance. We also provide insight into the potential of epigenetic modulating agents to enhance clinical drug responses and avoid disease relapse.
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Affiliation(s)
- Eva De Smedt
- Department of Hematology and Immunology-Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Hui Lui
- Department of Hematology and Immunology-Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Ken Maes
- Department of Hematology and Immunology-Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Kim De Veirman
- Department of Hematology and Immunology-Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Eline Menu
- Department of Hematology and Immunology-Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Karin Vanderkerken
- Department of Hematology and Immunology-Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Elke De Bruyne
- Department of Hematology and Immunology-Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
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16
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Ramakrishnan V, Mager DE. Pharmacodynamic Models of Differential Bortezomib Signaling Across Several Cell Lines of Multiple Myeloma. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2018; 8:146-157. [PMID: 30516019 PMCID: PMC6430155 DOI: 10.1002/psp4.12358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 09/18/2018] [Indexed: 12/28/2022]
Abstract
The heterogeneous polyclonal nature of multiple myeloma complicates the identification of protein biomarkers predictive of drug response. In this study, a pharmacodynamic systems modeling approach was used to link in vitro bortezomib exposure and myeloma cell death. The exposure‐response was integrated through a network of important protein biomarker dynamics activated by bortezomib in four myeloma cell lines. The pharmacodynamic models reasonably characterized the protein and myeloma cell dynamics simultaneously following bortezomib (20 nM) treatment. The models were used to identify differences in pathway dynamics across cell lines from model‐estimated protein biomarker turnover parameters and global sensitivity analyses. Additionally, a statistical correlation analysis between drug sensitivity and model‐fitted protein activation profiles (i.e., cumulative area under the protein expression‐time curves) supported the identification of shared biomarkers associated with sensitivity differences among the cell lines. Both types of analysis identified similar important proteins associated with bortezomib pharmacodynamics, such as phosphorylated Nuclear Factor kappa‐light‐chain‐enhancer of activated B cells (pNFkappaB), phosphorylated protein kinase B (pAKT), and caspase‐8 (Cas 8).
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Affiliation(s)
- Vidya Ramakrishnan
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, New York, USA
| | - Donald E Mager
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, New York, USA
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17
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Laganà A, Beno I, Melnekoff D, Leshchenko V, Madduri D, Ramdas D, Sanchez L, Niglio S, Perumal D, Kidd BA, Miotto R, Shaknovich R, Chari A, Cho HJ, Barlogie B, Jagannath S, Dudley JT, Parekh S. Precision Medicine for Relapsed Multiple Myeloma on the Basis of an Integrative Multiomics Approach. JCO Precis Oncol 2018; 2018. [PMID: 30706044 PMCID: PMC6350920 DOI: 10.1200/po.18.00019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Purpose Multiple myeloma (MM) is a malignancy of plasma cells, with a median survival of 6 years. Despite recent therapeutic advancements, relapse remains mostly inevitable, and the disease is fatal in the majority of patients. A major challenge in the treatment of patients with relapsed MM is the timely identification of treatment options in a personalized manner. Current approaches in precision oncology aim at matching specific DNA mutations to drugs, but incorporation of genome-wide RNA profiles has not yet been clinically assessed. Methods We have developed a novel computational platform for precision medicine of relapsed and/or refractory MM on the basis of DNA and RNA sequencing. Our approach expands on the traditional DNA-based approaches by integrating somatic mutations and copy number alterations with RNA-based drug repurposing and pathway analysis. We tested our approach in a pilot precision medicine clinical trial with 64 patients with relapsed and/or refractory MM. Results We generated treatment recommendations in 63 of 64 patients. Twenty-six patients had treatment implemented, and 21 were assessable. Of these, 11 received a drug that was based on RNA findings, eight received a drug that was based on DNA, and two received a drug that was based on both RNA and DNA. Sixteen of the 21 evaluable patients had a clinical response (ie, reduction of disease marker ≥ 25%), giving a clinical benefit rate of 76% and an overall response rate of 66%, with five patients having ongoing responses at the end of the trial. The median duration of response was 131 days. Conclusion Our results show that a comprehensive sequencing approach can identify viable options in patients with relapsed and/or refractory myeloma, and they represent proof of principle of how RNA sequencing can contribute beyond DNA mutation analysis to the development of a reliable drug recommendation tool.
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Affiliation(s)
- Alessandro Laganà
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
| | - Itai Beno
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
| | - David Melnekoff
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
| | - Violetta Leshchenko
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
| | - Deepu Madduri
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
| | - Dennis Ramdas
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
| | - Larysa Sanchez
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
| | - Scot Niglio
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
| | - Deepak Perumal
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
| | - Brian A Kidd
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
| | - Riccardo Miotto
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
| | - Rita Shaknovich
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
| | - Ajai Chari
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
| | - Hearn Jay Cho
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
| | - Bart Barlogie
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
| | - Sundar Jagannath
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
| | - Joel T Dudley
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
| | - Samir Parekh
- , and , Icahn School of Medicine at Mount Sinai, New York, NY; and , Cancer Genetics, Rutherford, NJ
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18
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Jung SH, Ahn SY, Choi HW, Shin MG, Lee SS, Yang DH, Ahn JS, Kim YK, Kim HJ, Lee JJ. STAT3 expression is associated with poor survival in non-elderly adult patients with newly diagnosed multiple myeloma. Blood Res 2017; 52:293-299. [PMID: 29333406 PMCID: PMC5762740 DOI: 10.5045/br.2017.52.4.293] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 06/28/2017] [Accepted: 07/08/2017] [Indexed: 12/22/2022] Open
Abstract
Background Signal transducer and activator of transcription 3 (STAT3) is not only a key signaling molecule in the regulation of growth but is also involved in malignant transformation. We investigated the prognostic significance of STAT3 expression in 94 non-elderly adult patients (aged 38 to 65 yr) with newly diagnosed multiple myeloma (MM). Methods Tumor cell-specific phosphotyrosine-STAT3 (PY-STAT3) expression at the time of diagnosis was evaluated with dual immunohistochemical (IHC) staining for PY-STAT3 and CD138. Results PY-STAT3 positivity was detected in 10 patients (10.6%), including three who showed strong expression. PY-STAT3-positive patients had higher serum C-reactive protein and calcium levels at diagnosis than did PY-STAT3-negative patients. PY-STAT3 positivity had predictive value for poor progression-free survival (PFS; P=0.001) and overall survival (OS; P=0.003). Among the 60 patients who received frontline autologous stem cell transplantation, PY-STAT3-positive patients had poorer PFS than did PY-STAT3-negative patients (4.2 vs. 19.2 mo, respectively; P=0.013). Multivariate analysis identified PY-STAT3 expression as an independent prognostic factor for PFS (relative risk [RR]=2.706, P=0.014) and OS (RR=3.091, P=0.044). Conclusion These data show that PY-STAT3 positivity, as determined using dual IHC, is a marker of poor prognosis in non-elderly adult patients with MM.
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Affiliation(s)
- Sung-Hoon Jung
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Seo-Yeon Ahn
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Hyun-Woo Choi
- Department of Laboratory Medicine, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Myung-Geun Shin
- Department of Laboratory Medicine, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Seung-Shin Lee
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Deok-Hwan Yang
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Jae-Sook Ahn
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Yeo-Kyeoung Kim
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Hyeoung-Joon Kim
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Je-Jung Lee
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
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19
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Lazzari E, Mondala PK, Santos ND, Miller AC, Pineda G, Jiang Q, Leu H, Ali SA, Ganesan AP, Wu CN, Costello C, Minden M, Chiaramonte R, Stewart AK, Crews LA, Jamieson CHM. Alu-dependent RNA editing of GLI1 promotes malignant regeneration in multiple myeloma. Nat Commun 2017; 8:1922. [PMID: 29203771 PMCID: PMC5715072 DOI: 10.1038/s41467-017-01890-w] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 10/24/2017] [Indexed: 12/12/2022] Open
Abstract
Despite novel therapies, relapse of multiple myeloma (MM) is virtually inevitable. Amplification of chromosome 1q, which harbors the inflammation-responsive RNA editase adenosine deaminase acting on RNA (ADAR)1 gene, occurs in 30–50% of MM patients and portends a poor prognosis. Since adenosine-to-inosine RNA editing has recently emerged as a driver of cancer progression, genomic amplification combined with inflammatory cytokine activation of ADAR1 could stimulate MM progression and therapeutic resistance. Here, we report that high ADAR1 RNA expression correlates with reduced patient survival rates in the MMRF CoMMpass data set. Expression of wild-type, but not mutant, ADAR1 enhances Alu-dependent editing and transcriptional activity of GLI1, a Hedgehog (Hh) pathway transcriptional activator and self-renewal agonist, and promotes immunomodulatory drug resistance in vitro. Finally, ADAR1 knockdown reduces regeneration of high-risk MM in serially transplantable patient-derived xenografts. These data demonstrate that ADAR1 promotes malignant regeneration of MM and if selectively inhibited may obviate progression and relapse. The treatment of multiple myeloma is challenging due to high relapse rates. Here the authors show that expression of ADAR1 correlates with poor patient outcomes, and that ADAR1-mediated editing of GLI1 is a mechanism relevant in the context of multiple myeloma progression and drug resistance.
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Affiliation(s)
- Elisa Lazzari
- Division of Regenerative Medicine, Department of Medicine, Moores Cancer Center, University of California, San Diego, La Jolla, CA, 92037, USA
| | - Phoebe K Mondala
- Division of Regenerative Medicine, Department of Medicine, Moores Cancer Center, University of California, San Diego, La Jolla, CA, 92037, USA
| | - Nathaniel Delos Santos
- Division of Regenerative Medicine, Department of Medicine, Moores Cancer Center, University of California, San Diego, La Jolla, CA, 92037, USA
| | - Amber C Miller
- Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Gabriel Pineda
- Division of Regenerative Medicine, Department of Medicine, Moores Cancer Center, University of California, San Diego, La Jolla, CA, 92037, USA.,Department of Health Sciences, School of Health and Human Services at National University, San Diego, CA, 92123, USA
| | - Qingfei Jiang
- Division of Regenerative Medicine, Department of Medicine, Moores Cancer Center, University of California, San Diego, La Jolla, CA, 92037, USA
| | - Heather Leu
- Division of Regenerative Medicine, Department of Medicine, Moores Cancer Center, University of California, San Diego, La Jolla, CA, 92037, USA
| | - Shawn A Ali
- Division of Regenerative Medicine, Department of Medicine, Moores Cancer Center, University of California, San Diego, La Jolla, CA, 92037, USA
| | - Anusha-Preethi Ganesan
- Division of Regenerative Medicine, Department of Medicine, Moores Cancer Center, University of California, San Diego, La Jolla, CA, 92037, USA
| | - Christina N Wu
- Division of Regenerative Medicine, Department of Medicine, Moores Cancer Center, University of California, San Diego, La Jolla, CA, 92037, USA
| | - Caitlin Costello
- Department of Medicine, Moores Cancer Center at University of California, San Diego, La Jolla, CA, 92093, USA
| | - Mark Minden
- Princess Margaret Hospital, University Health Network, Toronto, ON, Canada, M5G 2M9
| | | | - A Keith Stewart
- Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Leslie A Crews
- Division of Regenerative Medicine, Department of Medicine, Moores Cancer Center, University of California, San Diego, La Jolla, CA, 92037, USA.
| | - Catriona H M Jamieson
- Division of Regenerative Medicine, Department of Medicine, Moores Cancer Center, University of California, San Diego, La Jolla, CA, 92037, USA. .,Department of Medicine, Moores Cancer Center at University of California, San Diego, La Jolla, CA, 92093, USA.
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20
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The non-canonical poly(A) polymerase FAM46C acts as an onco-suppressor in multiple myeloma. Nat Commun 2017; 8:619. [PMID: 28931820 PMCID: PMC5606997 DOI: 10.1038/s41467-017-00578-5] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 07/11/2017] [Indexed: 12/17/2022] Open
Abstract
FAM46C is one of the most frequently mutated genes in multiple myeloma. Here, using a combination of in vitro and in vivo approaches, we demonstrate that FAM46C encodes an active non-canonical poly(A) polymerase which enhances mRNA stability and gene expression. Reintroduction of active FAM46C into multiple myeloma cell lines, but not its catalytically-inactive mutant, leads to broad polyadenylation and stabilization of mRNAs strongly enriched with those encoding endoplasmic reticulum-targeted proteins and induces cell death. Moreover, silencing of FAM46C in multiple myeloma cells expressing WT protein enhance cell proliferation. Finally, using a FAM46C-FLAG knock-in mouse strain, we show that the FAM46C protein is strongly induced during activation of primary splenocytes and that B lymphocytes isolated from newly generated FAM46C KO mice proliferate faster than those isolated from their WT littermates. Concluding, our data clearly indicate that FAM46C works as an onco-suppressor, with the specificity for B-lymphocyte lineage from which multiple myeloma originates. FAM46C is one of the most frequently mutated genes in multiple myeloma (MM), but its molecular function remains unknown. Here the authors show that FAM46C is a poly(A) polymerase and that loss of function of FAM46C drives multiple myeloma through the destabilisation of ER response transcripts.
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21
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Landgren O, Iskander K. Modern multiple myeloma therapy: deep, sustained treatment response and good clinical outcomes. J Intern Med 2017; 281:365-382. [PMID: 28205262 DOI: 10.1111/joim.12590] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In the USA at the beginning of this century, the average overall survival in patients with multiple myeloma was about 3 years. Around that time, three drugs (bortezomib, lenalidomide and thalidomide) were introduced for the treatment of multiple myeloma and, in 2012, carfilzomib received accelerated approval by the US Food and Drug Administration (FDA). Driven by access to better drugs, median overall survival in younger patients (aged <50 years) was >10 years by 2014. The FDA approved 14 new drugs for the treatment of cancer in 2015; four of these were approved for the treatment of myeloma (panobinostat, daratumumab, elotuzumab and ixazomib). In 2015 and 2016, expanded label indications were approved by the FDA for lenalidomide and carfilzomib, respectively. The recent increase in approved, highly effective combination therapies for patients with multiple myeloma has led the way to redefining the goals of therapy. Here, we review and provide a clinical perspective on the treatment goals and management of multiple myeloma in the era of modern therapy. Recent meta-analyses show that minimal residual disease (MRD) negativity is associated with longer progression-free and overall survival in patients with multiple myeloma. With the use of modern combination therapy, large proportions (>60-70%) of newly diagnosed multiple myeloma patients achieve complete responses and MRD negativity. Modern combination therapies induce rapid, deep and sustainable responses (including MRD negativity), supporting a treatment paradigm shift away from palliative two-drug combinations towards the use of modern, potent, three- or four-drug combination regimens in early lines of therapy. Data support the use of modern therapy upfront rather than reserving it for later stages of the disease. As survival time increases with modern combination therapies, development of early reliable surrogate end-points for survival, such as MRD negativity, are needed for expedited read-out of future randomized clinical trials.
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Affiliation(s)
- O Landgren
- Myeloma Service, Division of Hematology Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - K Iskander
- Department of Clinical Development, Amgen, Thousand Oaks, CA, USA
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22
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Offidani M, Corvatta L, Bringhen S, Gentili S, Troia R, Maracci L, Larocca A, Gay F, Leoni P, Boccadoro M. Salvage therapy in first relapse: a retrospective study in a large patient population with multiple myeloma. Eur J Haematol 2017; 98:289-295. [DOI: 10.1111/ejh.12834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2016] [Indexed: 12/29/2022]
Affiliation(s)
- Massimo Offidani
- Clinica di Ematologia Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona; Ancona Italy
| | - Laura Corvatta
- Clinica di Ematologia Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona; Ancona Italy
| | - Sara Bringhen
- Myeloma Unit; Division of Hematology; University of Torino; Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino; Torino Italy
| | - Silvia Gentili
- Clinica di Ematologia Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona; Ancona Italy
| | - Rossella Troia
- Myeloma Unit; Division of Hematology; University of Torino; Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino; Torino Italy
| | - Laura Maracci
- Clinica di Ematologia Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona; Ancona Italy
| | - Alessandra Larocca
- Myeloma Unit; Division of Hematology; University of Torino; Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino; Torino Italy
| | - Francesca Gay
- Myeloma Unit; Division of Hematology; University of Torino; Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino; Torino Italy
| | - Pietro Leoni
- Clinica di Ematologia Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona; Ancona Italy
| | - Mario Boccadoro
- Myeloma Unit; Division of Hematology; University of Torino; Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino; Torino Italy
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23
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Terragna C, Remondini D, Martello M, Zamagni E, Pantani L, Patriarca F, Pezzi A, Levi G, Offidani M, Proserpio I, De Sabbata G, Tacchetti P, Cangialosi C, Ciambelli F, Viganò CV, Dico FA, Santacroce B, Borsi E, Brioli A, Marzocchi G, Castellani G, Martinelli G, Palumbo A, Cavo M. The genetic and genomic background of multiple myeloma patients achieving complete response after induction therapy with bortezomib, thalidomide and dexamethasone (VTD). Oncotarget 2016; 7:9666-79. [PMID: 26575327 PMCID: PMC4891075 DOI: 10.18632/oncotarget.5718] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/27/2015] [Indexed: 11/25/2022] Open
Abstract
The prime focus of the current therapeutic strategy for Multiple Myeloma (MM) is to obtain an early and deep tumour burden reduction, up to the level of complete response (CR). To date, no description of the characteristics of the plasma cells (PC) prone to achieve CR has been reported. This study aimed at the molecular characterization of PC obtained at baseline from MM patients in CR after bortezomib-thalidomide-dexamethasone (VTD) first line therapy. One hundred and eighteen MM primary tumours obtained from homogeneously treated patients were profiled both for gene expression and for single nucleotide polymorphism genotype. Genomic results were used to obtain a predictor of sensitivity to VTD induction therapy, as well as to describe both the transcription and the genomic profile of PC derived from MM with subsequent optimal response to primary induction therapy. By analysing the gene profiles of CR patients, we identified a 5-gene signature predicting CR with an overall median accuracy of 75% (range: 72%–85%). In addition, we highlighted the differential expression of a series of genes, whose deregulation might explain patients' sensitivity to VTD therapy. We also showed that a small copy number loss, covering 606Kb on chromosome 1p22.1 was the most significantly associated with CR patients.
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Affiliation(s)
- Carolina Terragna
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Daniel Remondini
- Department of Physics and Astronomy (DIFA), Bologna University, Bologna, Italy
| | - Marina Martello
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Elena Zamagni
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Lucia Pantani
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | | | - Annalisa Pezzi
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Giuseppe Levi
- Department of Physics and Astronomy (DIFA), Bologna University, Bologna, Italy
| | - Massimo Offidani
- Clinica di Ematologia, A.O.U. Ospedali Riuniti di Ancona, Ancona, Italy
| | - Ilaria Proserpio
- U.O Oncologia Medica, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | | | - Paola Tacchetti
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Clotilde Cangialosi
- Hematology Division UTMO, Azienda "Ospedali Riuniti Villa Sofia-Cervello" Presidio Ospedaliero V.Cervello, Palermo, Italy
| | | | | | - Flores Angela Dico
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Barbara Santacroce
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Enrica Borsi
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Annamaria Brioli
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Giulia Marzocchi
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Gastone Castellani
- Department of Physics and Astronomy (DIFA), Bologna University, Bologna, Italy
| | - Giovanni Martinelli
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Antonio Palumbo
- Myeloma Unit, Division of Hematology, University of Torino, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Michele Cavo
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
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24
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A Phase I/II Study of Escalating Doses of Bortezomib in Conjunction with High-Dose Melphalan as a Conditioning Regimen for Salvage Autologous Peripheral Blood Stem Cell Transplantation in Patients with Multiple Myeloma. Biol Blood Marrow Transplant 2016; 22:2165-2171. [PMID: 27590107 DOI: 10.1016/j.bbmt.2016.08.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 08/18/2016] [Indexed: 01/01/2023]
Abstract
Escalating doses of bortezomib with high-dose melphalan was evaluated as as a conditioning regimen for autologous stem cell transplantation (ASCT) in patients with relapsed or refractory multiple myeloma (MM). MM patients with less than a partial remission (PR) (or 50% reduction) compared to their pretransplantation paraprotein parameters after a prior ASCT with melphalan conditioning, or who were in relapse after a prior autologous transplantation, were eligible for study. Bortezomib was dose escalated in steps of 1, 1.3, and 1.6 mg/m2 (3 × 3 design) on days -4 and -1 before transplantation with melphalan 200 mg/m2 given on day -2. Thirty-two patients were enrolled: 12 in the phase I dose escalation phase and an additional 20 in phase II to gain additional experience with the regimen. Twenty-four (75%) patients were Durie Salmon stage III, and 12 (37.5%) had >2 prior lines of therapy. The overall response rate (≥PR) was 44% with 22% complete remission. Two-year overall survival and progression-free survival were 76% and 39%, respectively, with a median follow-up of 31.7 months. The most common grade 3 and 4 nonhematologic adverse events were neutropenic fever (25%), nausea (18.8%), and mucositis (9.4%). Serious adverse events included intensive care unit admission (9.4%), seizure (3.1%), prolonged diarrhea (3.1%), and Guillain-Barre syndrome (3.1%). Two patients (6%) died of sepsis. There was no emergent peripheral neuropathy nor increase in any pre-existing peripheral neuropathy. The addition of bortezomib to melphalan as conditioning for salvage ASCT was well tolerated. More importantly, it can provide durable remission for patients who have a suboptimal response to prior single-agent melphalan conditioning for ASCT, without requiring a reduction in the dose of melphalan. Larger randomized prospective studies to determine the effect of combination conditioning are being conducted.
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25
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Zang M, Zou D, Yu Z, Li F, Yi S, Ai X, Qin X, Feng X, Zhou W, Xu Y, Li Z, Hao M, Sui W, Deng S, Acharya C, Zhao Y, Ru K, Qiu L, An G. Detection of recurrent cytogenetic aberrations in multiple myeloma: a comparison between MLPA and iFISH. Oncotarget 2016; 6:34276-87. [PMID: 26416457 PMCID: PMC4741451 DOI: 10.18632/oncotarget.5371] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 09/04/2015] [Indexed: 11/25/2022] Open
Abstract
Multiple myeloma (MM) is a genetically heterogeneous disease with diverse clinical characteristics and outcomes. Recently, multiplex ligation-dependent probe amplification (MLPA) has emerged as an effective and robust method for the detection of cytogenetic aberrations in MM patients. In the present study, MLPA analysis was applied to analyze cytogenetics of CD138 tumor cells of 59 MM samples, and its result was compared, retrospectively, with the interphase fluorescence in situ hybridization (iFISH) data. We firstly established the normal range of each of the 42 diagnostic probes using healthy donor samples. A total of 151 aberrations were detected in 59 patient samples, and 49/59 cases (83.1%) harbored at least one copy number variation. Overall, 0–7 aberrations were detected per case using MLPA, indicating the heterogeneity and complexity of MM cytogenetics. We showed the high efficiency of MLPA and the high congruency of the two methods to assess cytogenetic aberrations. Considering that MLPA analysis is not reliable when the aberration only exits in a small population of tumor cells, it is essential to use both MLPA and iFISH as complementary techniques for the diagnosis of MM.
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Affiliation(s)
- Meirong Zang
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Dehui Zou
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Zhen Yu
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Fei Li
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shuhua Yi
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Xiaofei Ai
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Xiaoqi Qin
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Xiaoyan Feng
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China.,LeBow Institute for Myeloma Therapeutics and Jerome Lipper Center for Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Wen Zhou
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China.,Cancer Research Institute, Key Laboratory of Carcinogenesis of Ministry of Health and Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Central South University, Changsha, China
| | - Yan Xu
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Zengjun Li
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Mu Hao
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Weiwei Sui
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Shuhui Deng
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Chirag Acharya
- LeBow Institute for Myeloma Therapeutics and Jerome Lipper Center for Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Yaozhong Zhao
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Kun Ru
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Lugui Qiu
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Gang An
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China.,LeBow Institute for Myeloma Therapeutics and Jerome Lipper Center for Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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Leiba M, Duek A, Amariglio N, Avigdor A, Benyamini N, Hardan I, Zilbershats I, Ganzel C, Shevetz O, Novikov I, Cohen Y, Ishoev G, Rozic G, Nagler A, Trakhtenbrot L. Translocation t(11;14) in newly diagnosed patients with multiple myeloma: Is it always favorable? Genes Chromosomes Cancer 2016; 55:710-8. [DOI: 10.1002/gcc.22372] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 05/02/2016] [Accepted: 05/03/2016] [Indexed: 12/20/2022] Open
Affiliation(s)
- Merav Leiba
- Division of Hematology and Bone Marrow Transplantation; and the Cancer Research Center, The Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University; Tel Aviv Israel
| | - Adrian Duek
- Division of Hematology and Bone Marrow Transplantation; and the Cancer Research Center, The Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University; Tel Aviv Israel
| | - Ninette Amariglio
- Division of Hematology and Bone Marrow Transplantation; and the Cancer Research Center, The Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University; Tel Aviv Israel
| | - Abraham Avigdor
- Division of Hematology and Bone Marrow Transplantation; and the Cancer Research Center, The Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University; Tel Aviv Israel
| | - Noam Benyamini
- Department of Hematology and Bone Marrow Transplantation; Rambam Health Care Campus; Haifa Israel
| | - Izhar Hardan
- Department of Hematology; Meir Medical Center; Kfar Saba Israel
| | | | - Chezi Ganzel
- Department of Hematology; Shaare Zedek Medical Center; Jerusalem Israel
| | - Olga Shevetz
- Department of Hematology; Kaplan Medical Center; Rehovot Israel
| | - Ilya Novikov
- Biostatistical Unit; Gertner Institute of Epidemiology and Health Policy Research; Ramat Gan Israel
| | - Yossi Cohen
- Department of Hematology; Laniyado Hospital; Netanya Israel
| | - Galina Ishoev
- Division of Hematology and Bone Marrow Transplantation; and the Cancer Research Center, The Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University; Tel Aviv Israel
| | - Gabriela Rozic
- Division of Hematology and Bone Marrow Transplantation; and the Cancer Research Center, The Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University; Tel Aviv Israel
| | - Arnon Nagler
- Division of Hematology and Bone Marrow Transplantation; and the Cancer Research Center, The Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University; Tel Aviv Israel
| | - Luba Trakhtenbrot
- Division of Hematology and Bone Marrow Transplantation; and the Cancer Research Center, The Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University; Tel Aviv Israel
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Musto P, Montefusco V. Are maintenance and continuous therapies indicated for every patient with multiple myeloma? Expert Rev Hematol 2016; 9:743-51. [DOI: 10.1080/17474086.2016.1196127] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Robinson SR, Oliver AW, Chevassut TJ, Newbury SF. The 3' to 5' Exoribonuclease DIS3: From Structure and Mechanisms to Biological Functions and Role in Human Disease. Biomolecules 2015; 5:1515-39. [PMID: 26193331 PMCID: PMC4598762 DOI: 10.3390/biom5031515] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 07/01/2015] [Accepted: 07/06/2015] [Indexed: 12/03/2022] Open
Abstract
DIS3 is a conserved exoribonuclease and catalytic subunit of the exosome, a protein complex involved in the 3' to 5' degradation and processing of both nuclear and cytoplasmic RNA species. Recently, aberrant expression of DIS3 has been found to be implicated in a range of different cancers. Perhaps most striking is the finding that DIS3 is recurrently mutated in 11% of multiple myeloma patients. Much work has been done to elucidate the structural and biochemical characteristics of DIS3, including the mechanistic details of its role as an effector of RNA decay pathways. Nevertheless, we do not understand how DIS3 mutations can lead to cancer. There are a number of studies that pertain to the function of DIS3 at the organismal level. Mutant phenotypes in S. pombe, S. cerevisiae and Drosophila suggest DIS3 homologues have a common role in cell-cycle progression and microtubule assembly. DIS3 has also recently been implicated in antibody diversification of mouse B-cells. This article aims to review current knowledge of the structure, mechanisms and functions of DIS3 as well as highlighting the genetic patterns observed within myeloma patients, in order to yield insight into the putative role of DIS3 mutations in oncogenesis.
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Affiliation(s)
- Sophie R Robinson
- Medical Research Building, Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton BN1 9PS, UK.
| | - Antony W Oliver
- Genome Damage and Stability Centre, School of Life Sciences, University of Sussex, Falmer, Brighton BN1 9RQ, UK.
| | - Timothy J Chevassut
- Medical Research Building, Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton BN1 9PS, UK.
| | - Sarah F Newbury
- Medical Research Building, Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton BN1 9PS, UK.
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Is there any complimentary role of F-18 NaF PET/CT in detecting of osseous involvement of multiple myeloma? A comparative study for F-18 FDG PET/CT and F-18 FDG NaF PET/CT. Ann Hematol 2015; 94:1567-75. [DOI: 10.1007/s00277-015-2410-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 05/24/2015] [Indexed: 02/07/2023]
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