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Malard F, Neri P, Bahlis NJ, Terpos E, Moukalled N, Hungria VTM, Manier S, Mohty M. Multiple myeloma. Nat Rev Dis Primers 2024; 10:45. [PMID: 38937492 DOI: 10.1038/s41572-024-00529-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 06/29/2024]
Abstract
Multiple myeloma (MM) is a haematological lymphoid malignancy involving tumoural plasma cells and is usually characterized by the presence of a monoclonal immunoglobulin protein. MM is the second most common haematological malignancy, with an increasing global incidence. It remains incurable because most patients relapse or become refractory to treatments. MM is a genetically complex disease with high heterogeneity that develops as a multistep process, involving acquisition of genetic alterations in the tumour cells and changes in the bone marrow microenvironment. Symptomatic MM is diagnosed using the International Myeloma Working Group criteria as a bone marrow infiltration of ≥10% clonal plasma cells, and the presence of at least one myeloma-defining event, either standard CRAB features (hypercalcaemia, renal failure, anaemia and/or lytic bone lesions) or biomarkers of imminent organ damage. Younger and fit patients are considered eligible for transplant. They receive an induction, followed by consolidation with high-dose melphalan and autologous haematopoietic cell transplantation, and maintenance therapy. In older adults (ineligible for transplant), the combination of daratumumab, lenalidomide and dexamethasone is the preferred option. If relapse occurs and requires further therapy, the choice of therapy will be based on previous treatment and response and now includes immunotherapies, such as bi-specific monoclonal antibodies and chimeric antigen receptor T cell therapy.
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Affiliation(s)
- Florent Malard
- Sorbonne Université, Centre de Recherche Saint-Antoine INSERM UMRs938, Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France.
| | - Paola Neri
- Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, Canada
| | - Nizar J Bahlis
- Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, Canada
| | - Evangelos Terpos
- Department of Clinical Therapeutics, Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Nour Moukalled
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - Salomon Manier
- Department of Hematology, Lille University Hospital and INSERM UMR-S1277 and CNRS UMR9020, Lille, France
| | - Mohamad Mohty
- Sorbonne Université, Centre de Recherche Saint-Antoine INSERM UMRs938, Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France.
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2
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Aghaee M, Ledzewicz U, Robbins M, Bezman N, Jay Cho H, Moore H. Determining Optimal Combination Regimens for Patients with Multiple Myeloma. Eur J Pharm Sci 2023:106492. [PMID: 37302768 DOI: 10.1016/j.ejps.2023.106492] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 05/04/2023] [Accepted: 06/06/2023] [Indexed: 06/13/2023]
Abstract
While many novel therapies have been approved in recent years for treating patients with multiple myeloma, there is still no established curative regimen, especially for patients with high-risk disease. In this work, we use a mathematical modeling approach to determine combination therapy regimens that maximize healthy lifespan for patients with multiple myeloma. We start with a mathematical model for the underlying disease and immune dynamics, which was presented and analyzed previously. We add the effects of three therapies to the model: pomalidomide, dexamethasone, and elotuzumab. We consider multiple approaches to optimizing combinations of these therapies. We find that optimal control combined with approximation outperforms other methods, in that it can quickly produce a combination regimen that is clinically-feasible and near-optimal. Implications of this work can be used to optimize doses and advance the scheduling of drugs.
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Affiliation(s)
- Mahya Aghaee
- Laboratory for Systems Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Urszula Ledzewicz
- Institute of Mathematics, Lodz University of Technology, Lodz, Poland; Dept. of Mathematics and Statistics, Southern Illinois University Edwardsville, Edwardsville, IL, USA
| | | | - Natalie Bezman
- Oncology Research and Development, Pfizer, La Jolla, California, USA
| | - Hearn Jay Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Helen Moore
- Laboratory for Systems Medicine, College of Medicine, University of Florida, Gainesville, FL, USA.
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3
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Chen M, Jiang J, Hou J. Single-cell technologies in multiple myeloma: new insights into disease pathogenesis and translational implications. Biomark Res 2023; 11:55. [PMID: 37259170 DOI: 10.1186/s40364-023-00502-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/12/2023] [Indexed: 06/02/2023] Open
Abstract
Multiple myeloma (MM) is a hematological malignancy characterized by clonal proliferation of plasma cells. Although therapeutic advances have been made to improve clinical outcomes and to prolong patients' survival in the past two decades, MM remains largely incurable. Single-cell sequencing (SCS) is a powerful method to dissect the cellular and molecular landscape at single-cell resolution, instead of providing averaged results. The application of single-cell technologies promises to address outstanding questions in myeloma biology and has revolutionized our understanding of the inter- and intra-tumor heterogeneity, tumor microenvironment, and mechanisms of therapeutic resistance in MM. In this review, we summarize the recently developed SCS methodologies and latest MM research progress achieved by single-cell profiling, including information regarding the cancer and immune cell landscapes, tumor heterogeneities, underlying mechanisms and biomarkers associated with therapeutic response and resistance. We also discuss future directions of applying transformative SCS approaches with contribution to clinical translation.
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Affiliation(s)
- Mengping Chen
- Department of Hematology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Jinxing Jiang
- Department of Hematology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Jian Hou
- Department of Hematology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China.
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Inappropriate Expression of PD-1 and CTLA-4 Checkpoints in Myeloma Patients Is More Pronounced at Diagnosis: Implications for Time to Progression and Response to Therapeutic Checkpoint Inhibitors. Int J Mol Sci 2023; 24:ijms24065730. [PMID: 36982802 PMCID: PMC10056286 DOI: 10.3390/ijms24065730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/24/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
Multiple myeloma (MM) is a hematologic malignancy characterized by severely profound immune dysfunction. Therefore, the efficacy of drugs targeting the immune environments, such as immune checkpoint inhibitors (ICIs), is of high clinical importance. However, several clinical trials evaluating ICIs in MM in different therapeutic combinations revealed underwhelming results showing a lack of clinical efficacy and excessive side effects. The underlying mechanisms of resistance to ICIs observed in the majority of MM patients are still under investigation. Recently, we demonstrated that inappropriate expression of PD-1 and CTLA-4 on CD4 T cells in active MM is associated with adverse clinical outcomes and treatment status. The aim of the current study was to determine the usefulness of immune checkpoint expression assessment as a predictive biomarker of the response to therapeutic inhibitors. For this purpose, along with checkpoint expression estimated by flow cytometry, we evaluated the time to progression (TTP) of MM patients at different clinical stages (disease diagnosis and relapse) depending on the checkpoint expression level; the cut-off point (dividing patients into low and high expressors) was selected based on the median value. Herein, we confirmed the defective levels of regulatory PD-1, CTLA-4 receptors, and the CD69 marker activation in newly diagnosed (ND) patients, whereas relapsed/refractory patients (RR) exhibited their recovered values and reactivity. Additionally, substantially higher populations of senescent CD4+CD28− T cells were found in MM, primarily in NDMM subjects. These observations suggest the existence of two dysfunctional states in MM CD4 T cells with the predominance of immunosenescence at disease diagnosis and exhaustion at relapse, thus implying different responsiveness to the external receptor blockade depending on the disease stage. Furthermore, we found that lower CTLA-4 levels in NDMM patients or higher PD-1 expression in RRMM patients may predict early relapse. In conclusion, our study clearly showed that the checkpoint level in CD4 T cells may significantly affect the time to MM progression concerning the treatment status. Therefore, when considering novel therapies and potent combinations, it should be taken into account that blocking PD-1 rather than CTLA-4 might be a beneficial form of immunotherapy for only a proportion of RRMM patients.
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Monoclonal Gammopathies and the Bone Marrow Microenvironment: From Bench to Bedside and Then Back Again. Hematol Rep 2023; 15:23-49. [PMID: 36648882 PMCID: PMC9844382 DOI: 10.3390/hematolrep15010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/11/2022] [Accepted: 01/03/2023] [Indexed: 01/12/2023] Open
Abstract
Multiple myeloma (MM) is an incurable hematologic malignancy characterized by a multistep evolutionary pathway, with an initial phase called monoclonal gammopathy of undetermined significance (MGUS), potentially evolving into the symptomatic disease, often preceded by an intermediate phase called "smoldering" MM (sMM). From a biological point of view, genomic alterations (translocations/deletions/mutations) are already present at the MGUS phase, thus rendering their role in disease evolution questionable. On the other hand, we currently know that changes in the bone marrow microenvironment (TME) could play a key role in MM evolution through a progressive shift towards a pro-inflammatory and immunosuppressive shape, which may drive cancer progression as well as clonal plasma cells migration, proliferation, survival, and drug resistance. Along this line, the major advancement in MM patients' survival has been achieved by the introduction of microenvironment-oriented drugs (including immunomodulatory drugs and monoclonal antibodies). In this review, we summarized the role of the different components of the TME in MM evolution from MGUS as well as potential novel therapeutic targets/opportunities.
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Roshandel E, Ghaffari-Nazari H, Mohammadian M, Salimi M, Abroun S, Mirfakhraie R, Hajifathali A. NK cell therapy in relapsed refractory multiple myeloma. Clin Immunol 2023; 246:109168. [PMID: 36415020 DOI: 10.1016/j.clim.2022.109168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 09/03/2022] [Accepted: 10/18/2022] [Indexed: 01/18/2023]
Abstract
Recent advances in adoptive cell therapy have considerably changed the paradigm of cancer immunotherapy. Although current immunotherapies could cure many patients with multiple myeloma (MM), relapsed/refractory MM (RR/MM) is still challenging in some cases. Natural killer (NK) cells are innate immune cells that exert effective cytotoxic activity against malignant cells like myeloma cells. In addition to their antitumor properties, NK cells do not induce graft versus host disease following transplantation. Therefore, they provide a promising approach to treating RR/MM patients. Currently, attempts have been made to produce large-scale and good manufacturing practices (GMP) of NK cells. Ex vivo expanded/activated NK cells derived from the own patient or allogenic donors are potential options for NK cell therapy in MM. Besides, novel cell-based products such as NK cell lines and chimeric antigen receptor (CAR)-NK cells may provide an off-the-shelf source for NK cell therapy. Here, we summarized NK cell activity in the MM microenvironment and focused on different NK cell therapy methods for MM patients.
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Affiliation(s)
- Elham Roshandel
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Haniyeh Ghaffari-Nazari
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Immunology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mozhdeh Mohammadian
- Department of Hematology and Cell Therapy, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Maryam Salimi
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeid Abroun
- Department of Hematology and Cell Therapy, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran.
| | - Reza Mirfakhraie
- Department of Medical Genetics, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Abbas Hajifathali
- Department of Immunology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
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Bertuglia G, Cani L, Larocca A, Gay F, D’Agostino M. Normalization of the Immunological Microenvironment and Sustained Minimal Residual Disease Negativity: Do We Need Both for Long-Term Control of Multiple Myeloma? Int J Mol Sci 2022; 23:15879. [PMID: 36555520 PMCID: PMC9781462 DOI: 10.3390/ijms232415879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/02/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022] Open
Abstract
Over the past two decades, the treatment landscape for multiple myeloma (MM) has progressed significantly, with the introduction of several new drug classes that have greatly improved patient outcomes. At present, it is well known how the bone marrow (BM) microenvironment (ME) exerts an immunosuppressive action leading to an exhaustion of the immune system cells and promoting the proliferation and sustenance of tumor plasma cells. Therefore, having drugs that can reconstitute a healthy BM ME can improve results in MM patients. Recent findings clearly demonstrated that achieving minimal residual disease (MRD) negativity and sustaining MRD negativity over time play a pivotal prognostic role. However, despite the achievement of MRD negativity, patients may still relapse. The understanding of immunologic changes in the BM ME during treatment, complemented by a deeper knowledge of plasma cell genomics and biology, will be critical to develop future therapies to sustain MRD negativity over time and possibly achieve an operational cure. In this review, we focus on the components of the BM ME and their role in MM, on the prognostic significance of MRD negativity and, finally, on the relative contribution of tumor plasma cell biology and BM ME to long-term disease control.
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Affiliation(s)
- Giuseppe Bertuglia
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, University of Torino, 10126 Torino, Italy
- Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Lorenzo Cani
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, University of Torino, 10126 Torino, Italy
- Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Alessandra Larocca
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, University of Torino, 10126 Torino, Italy
- Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Francesca Gay
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, University of Torino, 10126 Torino, Italy
- Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Mattia D’Agostino
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, University of Torino, 10126 Torino, Italy
- Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Torino, Italy
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Soekojo CY, Chng WJ. The Evolution Of Immune Dysfunction In Multiple Myeloma. Eur J Haematol 2022; 109:415-424. [PMID: 35880386 DOI: 10.1111/ejh.13839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/23/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This review discusses the role of immune dysfunction at the different stages of MM. METHODS Narrative review RESULTS: Multiple myeloma (MM) is a complex disease and immune dysfunction has been known to play an important role in disease pathogenesis, progression, and drug resistance. MM is known to be preceded by asymptomatic precursor states and progression from the precursor states to MM is likely related to a progressive impairment of the immune system. CONCLUSIONS An understanding of the role of the immune system in the progression of MM is important to guide the development of immunotherapeutic strategies for this disease.
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Affiliation(s)
- Cinnie Yentia Soekojo
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, National University Health System
| | - Wee Joo Chng
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, National University Health System
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Yi Z, Ma T, Liu J, Tie W, Li Y, Bai J, Li L, Zhang L. The yin–yang effects of immunity: From monoclonal gammopathy of undetermined significance to multiple myeloma. Front Immunol 2022; 13:925266. [PMID: 35958625 PMCID: PMC9357873 DOI: 10.3389/fimmu.2022.925266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/30/2022] [Indexed: 01/10/2023] Open
Abstract
Multiple myeloma (MM) is the third most common malignant neoplasm of the hematological system. It often develops from monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM) precursor states. In this process, the immune microenvironment interacts with the MM cells to exert yin and yang effects, promoting tumor progression on the one hand and inhibiting it on the other. Despite significant therapeutic advances, MM remains incurable, and the main reason for this may be related to the complex and variable immune microenvironment. Therefore, it is crucial to investigate the dynamic relationship between the immune microenvironment and tumors, to elucidate the molecular mechanisms of different factors in the microenvironment, and to develop novel therapeutic agents targeting the immune microenvironment of MM. In this paper, we review the latest research progress and describe the dual influences of the immune microenvironment on the development and progression of MM from the perspective of immune cells and molecules.
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Affiliation(s)
- Zhigang Yi
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, China
- Department of Pediatric Orthopedics and Pediatrics Lanzhou University Second Hospital, Lanzhou, China
| | - Tao Ma
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, China
- Department of Hematology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jia Liu
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, China
| | - Wenting Tie
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, China
| | - Yanhong Li
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, China
| | - Jun Bai
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, China
| | - Lijuan Li
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, China
- *Correspondence: Lijuan Li, ; Liansheng Zhang,
| | - Liansheng Zhang
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, China
- *Correspondence: Lijuan Li, ; Liansheng Zhang,
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Balázs K, Kocsis ZS, Ágoston P, Jorgo K, Gesztesi L, Farkas G, Székely G, Takácsi-Nagy Z, Polgár C, Sáfrány G, Jurányi Z, Lumniczky K. Prostate Cancer Survivors Present Long-Term, Residual Systemic Immune Alterations. Cancers (Basel) 2022; 14:cancers14133058. [PMID: 35804830 PMCID: PMC9264868 DOI: 10.3390/cancers14133058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/10/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary The development of cancer is very often accompanied by systemic immune alterations which can be further aggravated by major anti-cancer therapies. However, there is very little known about how long these alterations persist in patients successfully cured of cancer. The aim of our work was to investigate how cancer and radiotherapy as major anti-cancer treatment modalities impact the immune system long after the successful treatment of a tumor. We investigated prostate cancer patients treated with a special form of radiotherapy (low-dose rate brachytherapy) often used for the treatment of prostate cancer and followed a wide range of immune parameters at regular intervals up to 3 years after the start of the treatment. Our results showed that some immune alterations did not recover after the treatment of the disease, on the contrary, they persisted, and in some cases got even worse. Further studies are needed to explain the causes and the potential long-term consequences of these alterations. Abstract Background: The development of cancer and anti-tumor therapies can lead to systemic immune alterations but little is known about how long immune dysfunction persists in cancer survivors. Methods: We followed changes in the cellular immune parameters of prostate cancer patients with good prognostic criteria treated with low dose rate brachytherapy before and up to 3 years after the initiation of therapy. Results: Patients before therapy had a reduced CD4+ T cell pool and increased regulatory T cell fraction and these alterations persisted or got amplified during the 36-month follow-up. A significant decrease in the total NK cell number and a redistribution of the circulating NK cells in favor of a less functional anergic subpopulation was seen in patients before therapy but tumor regression led to the regeneration of the NK cell pool and functional integrity. The fraction of lymphoid DCs was increased in patients both before therapy and throughout the whole follow-up. Increased PDGF-AA, BB, CCL5 and CXCL5 levels were measured in patients before treatment but protein levels rapidly normalized. Conclusions: while NK cell dysfunction recovered, long-term, residual alterations persisted in the adaptive and partly in the innate immune system.
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Affiliation(s)
- Katalin Balázs
- National Public Health Center, Unit of Radiation Medicine, Department of Radiobiology and Radiohygiene, 1221 Budapest, Hungary; (K.B.); (G.S.)
- Doctoral School of Pathological Sciences, Semmelweis University, 1085 Budapest, Hungary
| | - Zsuzsa S. Kocsis
- Department of Radiobiology and Diagnostic Onco-Cytogenetics and The National Tumorbiology Laboratory, Centre of Radiotherapy, National Institute of Oncology, 1122 Budapest, Hungary; (Z.S.K.); (G.F.); (G.S.); (Z.J.)
| | - Péter Ágoston
- Centre of Radiotherapy and The National Tumorbiology Laboratory, National Institute of Oncology, 1122 Budapest, Hungary; (P.Á.); (K.J.); (L.G.); (Z.T.-N.); (C.P.)
- Department of Oncology, Semmelweis University, 1122 Budapest, Hungary
| | - Kliton Jorgo
- Centre of Radiotherapy and The National Tumorbiology Laboratory, National Institute of Oncology, 1122 Budapest, Hungary; (P.Á.); (K.J.); (L.G.); (Z.T.-N.); (C.P.)
- Department of Oncology, Semmelweis University, 1122 Budapest, Hungary
| | - László Gesztesi
- Centre of Radiotherapy and The National Tumorbiology Laboratory, National Institute of Oncology, 1122 Budapest, Hungary; (P.Á.); (K.J.); (L.G.); (Z.T.-N.); (C.P.)
| | - Gyöngyi Farkas
- Department of Radiobiology and Diagnostic Onco-Cytogenetics and The National Tumorbiology Laboratory, Centre of Radiotherapy, National Institute of Oncology, 1122 Budapest, Hungary; (Z.S.K.); (G.F.); (G.S.); (Z.J.)
| | - Gábor Székely
- Department of Radiobiology and Diagnostic Onco-Cytogenetics and The National Tumorbiology Laboratory, Centre of Radiotherapy, National Institute of Oncology, 1122 Budapest, Hungary; (Z.S.K.); (G.F.); (G.S.); (Z.J.)
| | - Zoltán Takácsi-Nagy
- Centre of Radiotherapy and The National Tumorbiology Laboratory, National Institute of Oncology, 1122 Budapest, Hungary; (P.Á.); (K.J.); (L.G.); (Z.T.-N.); (C.P.)
- Department of Oncology, Semmelweis University, 1122 Budapest, Hungary
| | - Csaba Polgár
- Centre of Radiotherapy and The National Tumorbiology Laboratory, National Institute of Oncology, 1122 Budapest, Hungary; (P.Á.); (K.J.); (L.G.); (Z.T.-N.); (C.P.)
- Department of Oncology, Semmelweis University, 1122 Budapest, Hungary
| | - Géza Sáfrány
- National Public Health Center, Unit of Radiation Medicine, Department of Radiobiology and Radiohygiene, 1221 Budapest, Hungary; (K.B.); (G.S.)
| | - Zsolt Jurányi
- Department of Radiobiology and Diagnostic Onco-Cytogenetics and The National Tumorbiology Laboratory, Centre of Radiotherapy, National Institute of Oncology, 1122 Budapest, Hungary; (Z.S.K.); (G.F.); (G.S.); (Z.J.)
| | - Katalin Lumniczky
- National Public Health Center, Unit of Radiation Medicine, Department of Radiobiology and Radiohygiene, 1221 Budapest, Hungary; (K.B.); (G.S.)
- Correspondence: or ; Tel.: +36-1-4822011
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The Role of T Cell Immunity in Monoclonal Gammopathy and Multiple Myeloma: From Immunopathogenesis to Novel Therapeutic Approaches. Int J Mol Sci 2022; 23:ijms23095242. [PMID: 35563634 PMCID: PMC9104275 DOI: 10.3390/ijms23095242] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 02/01/2023] Open
Abstract
Multiple Myeloma (MM) is a malignant growth of clonal plasma cells, typically arising from asymptomatic precursor conditions, namely monoclonal gammopathy of undetermined significance (MGUS) and smoldering MM (SMM). Profound immunological dysfunctions and cytokine deregulation are known to characterize the evolution of the disease, allowing immune escape and proliferation of neoplastic plasma cells. In the past decades, several studies have shown that the immune system can recognize MGUS and MM clonal cells, suggesting that anti-myeloma T cell immunity could be harnessed for therapeutic purposes. In line with this notion, chimeric antigen receptor T cell (CAR-T) therapy is emerging as a novel treatment in MM, especially in the relapsed/refractory disease setting. In this review, we focus on the pivotal contribution of T cell impairment in the immunopathogenesis of plasma cell dyscrasias and, in particular, in the disease progression from MGUS to SMM and MM, highlighting the potentials of T cell-based immunotherapeutic approaches in these settings.
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12
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The Leading Role of the Immune Microenvironment in Multiple Myeloma: A New Target with a Great Prognostic and Clinical Value. J Clin Med 2022; 11:jcm11092513. [PMID: 35566637 PMCID: PMC9105926 DOI: 10.3390/jcm11092513] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 02/04/2023] Open
Abstract
Multiple myeloma (MM) is a plasma cell (PC) malignancy whose development flourishes in the bone marrow microenvironment (BMME). The BMME components’ immunoediting may foster MM progression by favoring initial immunotolerance and subsequent tumor cell escape from immune surveillance. In this dynamic process, immune effector cells are silenced and become progressively anergic, thus contributing to explaining the mechanisms of drug resistance in unresponsive and relapsed MM patients. Besides traditional treatments, several new strategies seek to re-establish the immunological balance in the BMME, especially in already-treated MM patients, by targeting key components of the immunoediting process. Immune checkpoints, such as CXCR4, T cell immunoreceptor with immunoglobulin and ITIM domains (TIGIT), PD-1, and CTLA-4, have been identified as common immunotolerance steps for immunotherapy. B-cell maturation antigen (BCMA), expressed on MMPCs, is a target for CAR-T cell therapy, antibody-(Ab) drug conjugates (ADCs), and bispecific mAbs. Approved anti-CD38 (daratumumab, isatuximab), anti-VLA4 (natalizumab), and anti-SLAMF7 (elotuzumab) mAbs interfere with immunoediting pathways. New experimental drugs currently being evaluated (CD137 blockers, MSC-derived microvesicle blockers, CSF-1/CSF-1R system blockers, and Th17/IL-17/IL-17R blockers) or already approved (denosumab and bisphosphonates) may help slow down immune escape and disease progression. Thus, the identification of deregulated mechanisms may identify novel immunotherapeutic approaches to improve MM patients’ outcomes.
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13
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Satcher RL, Zhang XHF. Evolving cancer-niche interactions and therapeutic targets during bone metastasis. Nat Rev Cancer 2022; 22:85-101. [PMID: 34611349 DOI: 10.1038/s41568-021-00406-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 12/14/2022]
Abstract
Many cancer types metastasize to bone. This propensity may be a product of genetic traits of the primary tumour in some cancers. Upon arrival, cancer cells establish interactions with various bone-resident cells during the process of colonization. These interactions, to a large degree, dictate cancer cell fates at multiple steps of the metastatic cascade, from single cells to overt metastases. The bone microenvironment may even influence cancer cells to subsequently spread to multiple other organs. Therefore, it is imperative to spatiotemporally delineate the evolving cancer-bone crosstalk during bone colonization. In this Review, we provide a summary of the bone microenvironment and its impact on bone metastasis. On the basis of the microscopic anatomy, we tentatively define a roadmap of the journey of cancer cells through bone relative to various microenvironment components, including the potential of bone to function as a launch pad for secondary metastasis. Finally, we examine common and distinct features of bone metastasis from various cancer types. Our goal is to stimulate future studies leading to the development of a broader scope of potent therapies.
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Affiliation(s)
- Robert L Satcher
- Department of Orthopedic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiang H-F Zhang
- Lester and Sue Smith Breast Center, Baylor College of Medicine, Houston, TX, USA.
- Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA.
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX, USA.
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14
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Adoptive Cellular Therapy for Multiple Myeloma Using CAR- and TCR-Transgenic T Cells: Response and Resistance. Cells 2022; 11:cells11030410. [PMID: 35159220 PMCID: PMC8834324 DOI: 10.3390/cells11030410] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 12/15/2022] Open
Abstract
Despite the substantial improvement of therapeutic approaches, multiple myeloma (MM) remains mostly incurable. However, immunotherapeutic and especially T cell-based approaches pioneered the therapeutic landscape for relapsed and refractory disease recently. Targeting B-cell maturation antigen (BCMA) on myeloma cells has been demonstrated to be highly effective not only by antibody-derived constructs but also by adoptive cellular therapies. Chimeric antigen receptor (CAR)-transgenic T cells lead to deep, albeit mostly not durable responses with manageable side-effects in intensively pretreated patients. The spectrum of adoptive T cell-transfer covers synthetic CARs with diverse specificities as well as currently less well-established T cell receptor (TCR)-based personalized strategies. In this review, we want to focus on treatment characteristics including efficacy and safety of CAR- and TCR-transgenic T cells in MM as well as the future potential these novel therapies may have. ACT with transgenic T cells has only entered clinical trials and various engineering strategies for optimization of T cell responses are necessary to overcome therapy resistance mechanisms. We want to outline the current success in engineering CAR- and TCR-T cells, but also discuss challenges including resistance mechanisms of MM for evading T cell therapy and point out possible novel strategies.
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15
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Heider M, Nickel K, Högner M, Bassermann F. Multiple Myeloma: Molecular Pathogenesis and Disease Evolution. Oncol Res Treat 2021; 44:672-681. [PMID: 34749378 DOI: 10.1159/000520312] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/12/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Multiple myeloma is the second most common hematologic malignancy, which to date remains incurable despite advances in treatment strategies including the use of novel substances such as proteasome inhibitors, immunomodulatory drugs, and monoclonal antibodies. SUMMARY The bone marrow-based disease is preceded by the 2 sequential premalignant conditions: monoclonal gammo-pathy of undetermined significance and smoldering myeloma. Plasma cell leukemia and extramedullary disease occur, when malignant clones lose their dependency on the bone marrow. Key genetic features of these plasma cell dyscrasias include chromosomal aberrations such as translocations and hyperdiploidy, which occur during error-prone physiologic processes in B-cell development. Next-generation sequencing studies have identified mutations in major oncogenic pathways and tumor suppressors, which contribute to the pathogenesis of multiple myeloma and have revealed insights into the clonal evolution of the disease, particularly along different lines of therapy. More recently, the importance of epigenetic alterations and the role of the bone marrow microenvironment, including immune and osteogenic cells, have become evident. Key Messages: We herein review the current knowledge of the pathogenesis of multiple myeloma, which is crucial for the development of novel targeted therapeutic strategies. These can contribute to the endeavor to make multiple myeloma a curable disease.
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Affiliation(s)
- Michael Heider
- Department of Medicine III, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,TranslaTUM, Center for Translational Cancer Research, Technical University of Munich, Munich, Germany
| | - Katharina Nickel
- Department of Medicine III, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Marion Högner
- Department of Medicine III, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Florian Bassermann
- Department of Medicine III, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,TranslaTUM, Center for Translational Cancer Research, Technical University of Munich, Munich, Germany
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16
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Regulatory T-Cells and Multiple Myeloma: Implications in Tumor Immune Biology and Treatment. J Clin Med 2021; 10:jcm10194588. [PMID: 34640606 PMCID: PMC8509132 DOI: 10.3390/jcm10194588] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/23/2021] [Accepted: 09/27/2021] [Indexed: 01/10/2023] Open
Abstract
Multiple myeloma (MM) is associated with both cellular and humoral immune deficiencies and, despite significant advances in treatment, remains an incurable disease. Regulatory T-cells (Tregs) represent a critical subset of CD4 T-cells, characterized by CD4 + CD25+ Forkhead box P3+ (FoxP3+) phenotype, able to control peripheral tolerance and responses to foreign and tumor antigens. Tregs are elevated in various types of cancer, including hematological malignancies; in MM, data regarding Tregs function and numbers and their correlation with survival parameters are controversial. Advances in cancer biology have shown that the tumor microenvironment plays an important role in tumor progression. In MM, the highly immunosuppressive nature of the bone marrow microenvironment has been significantly elucidated in the past decade and it is now well acknowledged that targeting only the tumor clone may not be able to cure MM. Tregs within the tumor microenvironment might play a significant role in the suppression of antitumor immune responses against cancer cells and are considered to predict poor outcome in cancer patients; nonetheless the exact prognostic significance of this cell subpopulation in malignancies is still a matter of debate. In this review, we discuss the role of Tregs as an essential cell population of the MM immune microenvironment.
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17
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Deregulated Expression of Immune Checkpoints on Circulating CD4 T Cells May Complicate Clinical Outcome and Response to Treatment with Checkpoint Inhibitors in Multiple Myeloma Patients. Int J Mol Sci 2021; 22:ijms22179298. [PMID: 34502204 PMCID: PMC8431347 DOI: 10.3390/ijms22179298] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/20/2021] [Accepted: 08/24/2021] [Indexed: 12/29/2022] Open
Abstract
Unlike solid-tumor patients, a disappointingly small subset of multiple myeloma (MM) patients treated with checkpoint inhibitors derive clinical benefits, suggesting differential participation of inhibitory receptors involved in the development of T-cell-mediated immunosuppression. In fact, T cells in MM patients have recently been shown to display features of immunosenescence and exhaustion involved in immune response inhibition. Therefore, we aimed to identify the dominant inhibitory pathway in MM patients to achieve its effective control by therapeutic interventions. By flow cytometry, we examined peripheral blood (PB) CD4 T cell characteristics assigned to senescence or exhaustion, considering PD-1, CTLA-4, and BTLA checkpoint expression, as well as secretory effector function, i.e., capacity for IFN-γ and IL-17 secretion. Analyses were performed in a total of 40 active myeloma patients (newly diagnosed and treated) and 20 healthy controls. At the single-cell level, we found a loss of studied checkpoints’ expression on MM CD4 T cells (both effector (Teff) and regulatory (Treg) cells) primarily at diagnosis; the checkpoint deficit in MM relapse was not significant. Nonetheless, PD-1 was the only checkpoint distributed on an increased proportion of T cells in all MM patients irrespective of disease phase, and its expression on CD4 Teff cells correlated with adverse clinical courses. Among patients, the relative defect in secretory effector function of CD4 T cells was more pronounced at myeloma relapse (as seen in declined Th1/Treg and Th17/Treg cell rates). Although the contribution of PD-1 to MM clinical outcomes is suggestive, our study clearly indicated that the inappropriate expression of immune checkpoints (associated with dysfunctionality of CD4 T cells and disease clinical phase) might be responsible for the sub-optimal clinical response to therapeutic checkpoint inhibitors in MM.
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18
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Wang Y, Feng W, Liu P. Genotype-immunophenotype analysis reveals the immunogenomic subtype and prognosis of multiple myeloma. Carcinogenesis 2021; 41:1746-1754. [PMID: 32278317 DOI: 10.1093/carcin/bgaa037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 03/22/2020] [Accepted: 04/10/2020] [Indexed: 01/28/2023] Open
Abstract
Immune dysfunction plays an important role in tumour development, recurrence, therapeutic responses and overall survival (OS). Multiple myeloma (MM) is a clonal B-cell malignancy which characterized by anti-tumoural immune dysfunction. In this study, we analysed 28 tumour-immune-related pathways and calculated the immune pathway score through published microarray data from the Gene Expression Omnibus (GEO) data portal. A training set of 345 patients and a validation set of 214 patients with primary MM were chosen. We performed least absolute shrinkage and selection operator (LASSO) analysis to identify prognostic factors. Then, we used cluster analysis to divide patients into three immunogenomic subtypes, which named abnormal immune activated type, common type and anti-myeloma immune activated type. Log‑rank tests showed that anti-myeloma immune activated type had the best prognosis and abnormal immune activated type had the shortest OS (P = 0.000) and event-free survival (EFS) (P = 0.000). Multivariate Cox also indicated that the immunogenomic subtype was an independent predictor of OS (P = 0.001) and EFS (P = 0.000). We also analysed the characteristics and the immune-response patterns of different subtypes. Then, we established a mathematical model to classify patients in the validation set. In the validation set, patients with different immunogenomic subtypes also had a significantly different OS (P = 0.001) and EFS (P = 0.005). Our study explored tumour-immune-related pathways at a multi-dimensional level and found the immunogenomic subtype of MM. Potential mechanisms on the genetic level of how tumour-immunity influences the prognosis and therapeutic responses are provided. The immunogenomic subtype may be feasible for deciding clinical treatment in the future.
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Affiliation(s)
- Yue Wang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wanjing Feng
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Peng Liu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
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19
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Innao V, Allegra A, Ginaldi L, Pioggia G, De Martinis M, Musolino C, Gangemi S. Reviewing the Significance of Vitamin D Substitution in Monoclonal Gammopathies. Int J Mol Sci 2021; 22:4922. [PMID: 34066482 PMCID: PMC8124934 DOI: 10.3390/ijms22094922] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 11/25/2022] Open
Abstract
Vitamin D is a steroid hormone that is essential for bone mineral metabolism and it has several other effects in the body, including anti-cancer actions. Vitamin D causes a reduction in cell growth by interrupting the cell cycle. Moreover, the active form of vitamin D, i.e., 1,25-dihydroxyvitamin D, exerts various effects via its interaction with the vitamin D receptor on the innate and adaptive immune system, which could be relevant in the onset of tumors. Multiple myeloma is a treatable but incurable malignancy characterized by the growth of clonal plasma cells in protective niches in the bone marrow. In patients affected by multiple myeloma, vitamin D deficiency is commonly correlated with an advanced stage of the disease, greater risk of progression, the development of pathological fractures, and a worse prognosis. Changes in the vitamin D receptor often contribute to the occurrence and progress of deficiencies, which can be overcome by supplementation with vitamin D or analogues. However, in spite of the findings available in the literature, there is no clear standard of care and clinical practice varies. Further research is needed to better understand how vitamin D influences outcomes in patients with monoclonal gammopathies.
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Affiliation(s)
- Vanessa Innao
- Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, Division of Haematology, University of Messina, 98125 Messina, Italy; (V.I.); (C.M.)
| | - Alessandro Allegra
- Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, Division of Haematology, University of Messina, 98125 Messina, Italy; (V.I.); (C.M.)
| | - Lia Ginaldi
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (L.G.); (M.D.M.)
- Allergy and Clinical Immunology Unit, Center for the Diagnosis and Treatment of Osteoporosis, AUSL 04 Teramo, 64100 Teramo, Italy
| | - Giovanni Pioggia
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), 98164 Messina, Italy;
| | - Massimo De Martinis
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (L.G.); (M.D.M.)
- Allergy and Clinical Immunology Unit, Center for the Diagnosis and Treatment of Osteoporosis, AUSL 04 Teramo, 64100 Teramo, Italy
| | - Caterina Musolino
- Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, Division of Haematology, University of Messina, 98125 Messina, Italy; (V.I.); (C.M.)
| | - Sebastiano Gangemi
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, University of Messina, 98125 Messina, Italy;
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20
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D'Souza C, Prince HM, Neeson PJ. Understanding the Role of T-Cells in the Antimyeloma Effect of Immunomodulatory Drugs. Front Immunol 2021; 12:632399. [PMID: 33746969 PMCID: PMC7973099 DOI: 10.3389/fimmu.2021.632399] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 02/15/2021] [Indexed: 12/12/2022] Open
Abstract
Immunomodulatory drugs (IMiDs) are effective treatments for patients with multiple myeloma. IMiDs have pleotropic effects including targeting the myeloma cells directly, and improving the anti-myeloma immune response. In the absence of myeloma cells, lenalidomide and pomalidomide induce CD4+ T cell secretion of IL-2 and indirect activation of Natural Killer (NK) cells. In the context of T cell receptor ligation, IMiDs enhance T cell proliferation, cytokine release and Th1 responses, both in vivo and in vitro. Furthermore, combination treatment of IMiDs and myeloma-targeting monoclonal antibodies eg. daratumumab (anti-CD38) and elotuzumab (anti-SLAMF7), checkpoint inhibitors, or bispecific T cell engagers showed synergistic effects, mainly via enhanced T and NK cell dependent cellular toxicity and T cell proliferation. Conversely, the corticosteroid dexamethasone can impair the immune modulatory effects of IMiDs, indicating that careful choice of myeloma drugs in combination with IMiDs is key for the best anti-myeloma therapeutic efficacy. This review presents an overview of the role for T cells in the overall anti-myeloma effects of immunomodulatory drugs.
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Affiliation(s)
- Criselle D'Souza
- Cancer Immunology Program, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - H Miles Prince
- Cancer Immunology Program, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.,Clinical Hematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Paul J Neeson
- Cancer Immunology Program, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
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21
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Joshua DE, Vuckovic S, Favaloro J, Lau KHA, Yang S, Bryant CE, Gibson J, Ho PJ. Treg and Oligoclonal Expansion of Terminal Effector CD8 + T Cell as Key Players in Multiple Myeloma. Front Immunol 2021; 12:620596. [PMID: 33708212 PMCID: PMC7940512 DOI: 10.3389/fimmu.2021.620596] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/12/2021] [Indexed: 12/13/2022] Open
Abstract
The classical paradigm of host-tumor interaction, i.e. elimination, equilibrium, and escape (EEE), is reflected in the clinical behavior of myeloma which progresses from the premalignant condition, Monoclonal Gammopathy of Unknown Significance (MGUS). Despite the role of other immune cells, CD4+ regulatory T cells (Treg) and cytotoxic CD8+ T cells have emerged as the dominant effectors of host control of the myeloma clone. Progression from MGUS to myeloma is associated with alterations in Tregs and terminal effector CD8+ T cells (TTE). These changes involve CD39 and CD69 expression, affecting the adenosine pathway and residency in the bone marrow (BM) microenvironment, together with oligoclonal expansion within CD8+ TTE cells. In this mini-review article, in the context of earlier data, we summarize our recent understanding of Treg involvement in the adenosine pathway, the significance of oligoclonal expansion within CD8+ TTE cells and BM-residency of CD8+ TTE cells in MGUS and newly diagnosed multiple myeloma patients.
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Affiliation(s)
- Douglas E Joshua
- Institute of Haematology, NSW Health Pathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Slavica Vuckovic
- Institute of Haematology, NSW Health Pathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - James Favaloro
- Institute of Haematology, NSW Health Pathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Ka Hei Aleks Lau
- School of Life Sciences, University of Technology Sydney, Ultimo, NSW, Australia
| | - Shihong Yang
- Institute of Haematology, NSW Health Pathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Christian E Bryant
- Institute of Haematology, NSW Health Pathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - John Gibson
- Institute of Haematology, NSW Health Pathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Phoebe Joy Ho
- Institute of Haematology, NSW Health Pathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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22
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Hematopoietic versus Solid Cancers and T Cell Dysfunction: Looking for Similarities and Distinctions. Cancers (Basel) 2021; 13:cancers13020284. [PMID: 33466674 PMCID: PMC7828769 DOI: 10.3390/cancers13020284] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/24/2020] [Accepted: 01/08/2021] [Indexed: 12/22/2022] Open
Abstract
Simple Summary Dysfunction of the immune T cell compartment occurs in many hematopoietic as well as solid cancers and hampers successful application of new immunotherapeutic approaches. A complete understanding of T cell dysfunction might improve the outcome of such therapies, but an overview in the various cancers is still lacking. We aim to map areas of similarities and differences in solid versus hematopoietic malignancies, providing a high-level rather than a detailed perspective on T cell dysfunction in those tumors. Abstract Cancer cells escape, suppress and exploit the host immune system to sustain themselves, and the tumor microenvironment (TME) actively dampens T cell function by various mechanisms. Over the last years, new immunotherapeutic approaches, such as adoptive chimeric antigen receptor (CAR) T cell therapy and immune checkpoint inhibitors, have been successfully applied for refractory malignancies that could only be treated in a palliative manner previously. Engaging the anti-tumor activity of the immune system, including CAR T cell therapy to target the CD19 B cell antigen, proved to be effective in acute lymphocytic leukemia. In low-grade hematopoietic B cell malignancies, such as chronic lymphocytic leukemia, clinical outcomes have been tempered by cancer-induced T cell dysfunction characterized in part by a state of metabolic lethargy. In multiple myeloma, novel antigens such as BCMA and CD38 are being explored for CAR T cells. In solid cancers, T cell-based immunotherapies have been applied successfully to melanoma and lung cancers, whereas application in e.g., breast cancer lags behind and is modestly effective as yet. The main hurdles for CAR T cell immunotherapy in solid tumors are the lack of suitable antigens, anatomical inaccessibility, and T cell anergy due to immunosuppressive TME. Given the wide range of success and failure of immunotherapies in various cancer types, it is crucial to comprehend the underlying similarities and distinctions in T cell dysfunction. Hence, this review aims at comparing selected, distinct B cell-derived versus solid cancer types and at describing means by which malignant cells and TME might dampen T cell anti-tumor activity, with special focus on immunometabolism. Drawing a meaningful parallel between the efficacy of immunotherapy and the extent of T cell dysfunction will shed light on areas where we can improve immune function to battle cancer.
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23
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Ninkovic S, Quach H. Shaping the Treatment Paradigm Based on the Current Understanding of the Pathobiology of Multiple Myeloma: An Overview. Cancers (Basel) 2020; 12:E3488. [PMID: 33238653 PMCID: PMC7700434 DOI: 10.3390/cancers12113488] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/11/2020] [Accepted: 11/19/2020] [Indexed: 02/06/2023] Open
Abstract
Multiple myeloma is an incurable malignancy which despite progressive improvements in overall survival over the last decade remains characterised by recurrent relapse with progressively shorter duration of response and treatment-free intervals with each subsequent treatment. Efforts to unravel the complex and heterogeneous genomic alterations, the marked dysregulation of the immune system and the multifarious interplay between malignant plasma cells and those of the tumour microenvironment have not only led to improved understanding of myelomagenesis and disease progression but have facilitated the rapid development of novel therapeutics including immunotherapies and small molecules bringing us a step closer to therapies that no doubt will extend survival. Novel therapeutic combinations both in the upfront and relapsed setting as well as novel methods to assess response and guide management are rapidly transforming the management of myeloma.
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Affiliation(s)
- Slavisa Ninkovic
- Department of Haematology, St. Vincent’s Hospital Melbourne, Fitzroy, VIC 3065, Australia;
- Faculty of Medicine, University of Melbourne, Fitzroy, VIC 3065, Australia
| | - Hang Quach
- Department of Haematology, St. Vincent’s Hospital Melbourne, Fitzroy, VIC 3065, Australia;
- Faculty of Medicine, University of Melbourne, Fitzroy, VIC 3065, Australia
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24
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Papadimitriou K, Tsakirakis N, Malandrakis P, Vitsos P, Metousis A, Orologas-Stavrou N, Ntanasis-Stathopoulos I, Kanellias N, Eleutherakis-Papaiakovou E, Pothos P, Fotiou D, Gavriatopoulou M, Kastritis E, Dimopoulos MA, Terpos E, Tsitsilonis OE, Kostopoulos IV. Deep Phenotyping Reveals Distinct Immune Signatures Correlating with Prognostication, Treatment Responses, and MRD Status in Multiple Myeloma. Cancers (Basel) 2020; 12:E3245. [PMID: 33158030 PMCID: PMC7692501 DOI: 10.3390/cancers12113245] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/16/2020] [Accepted: 10/29/2020] [Indexed: 12/16/2022] Open
Abstract
Despite recent advances, Multiple Myeloma (MM) remains an incurable disease with apparent heterogeneity that may explain patients' variable clinical outcomes. While the phenotypic, (epi)genetic, and molecular characteristics of myeloma cells have been thoroughly examined, there is limited information regarding the role of the bone marrow (BM) microenvironment in the natural history of the disease. In the present study, we performed deep phenotyping of 32 distinct immune cell subsets in a cohort of 94 MM patients to reveal unique immune profiles in both BM and peripheral blood (PB) that characterize distinct prognostic groups, responses to induction treatment, and minimal residual disease (MRD) status. Our data show that PB cells do not reflect the BM microenvironment and that the two sites should be studied independently. Adverse ISS stage and high-risk cytogenetics were correlated with distinct immune profiles; most importantly, BM signatures comprised decreased tumor-associated macrophages (TAMs) and erythroblasts, whereas the unique Treg signatures in PB could discriminate those patients achieving complete remission after VRd induction therapy. Moreover, MRD negative status was correlated with a more experienced CD4- and CD8-mediated immunity phenotype in both BM and PB, thus highlighting a critical role of by-stander cells linked to MRD biology.
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Affiliation(s)
- Konstantinos Papadimitriou
- Department of Biology, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (K.P.); (N.T.); (P.V.); (A.M.); (N.O.-S.); (P.P.)
| | - Nikolaos Tsakirakis
- Department of Biology, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (K.P.); (N.T.); (P.V.); (A.M.); (N.O.-S.); (P.P.)
| | - Panagiotis Malandrakis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Panagiotis Vitsos
- Department of Biology, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (K.P.); (N.T.); (P.V.); (A.M.); (N.O.-S.); (P.P.)
| | - Andreas Metousis
- Department of Biology, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (K.P.); (N.T.); (P.V.); (A.M.); (N.O.-S.); (P.P.)
| | - Nikolaos Orologas-Stavrou
- Department of Biology, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (K.P.); (N.T.); (P.V.); (A.M.); (N.O.-S.); (P.P.)
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Nikolaos Kanellias
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Evangelos Eleutherakis-Papaiakovou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Panagiotis Pothos
- Department of Biology, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (K.P.); (N.T.); (P.V.); (A.M.); (N.O.-S.); (P.P.)
| | - Despina Fotiou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Meletios-Athanasios Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Ourania E. Tsitsilonis
- Department of Biology, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (K.P.); (N.T.); (P.V.); (A.M.); (N.O.-S.); (P.P.)
| | - Ioannis V. Kostopoulos
- Department of Biology, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (K.P.); (N.T.); (P.V.); (A.M.); (N.O.-S.); (P.P.)
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Alrasheed N, Lee L, Ghorani E, Henry JY, Conde L, Chin M, Galas-Filipowicz D, Furness AJS, Chavda SJ, Richards H, De-Silva D, Cohen OC, Patel D, Brooks A, Rodriguez-Justo M, Pule M, Herrero J, Quezada SA, Yong KL. Marrow-Infiltrating Regulatory T Cells Correlate with the Presence of Dysfunctional CD4 +PD-1 + Cells and Inferior Survival in Patients with Newly Diagnosed Multiple Myeloma. Clin Cancer Res 2020; 26:3443-3454. [PMID: 32220887 DOI: 10.1158/1078-0432.ccr-19-1714] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 12/21/2019] [Accepted: 03/24/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Immune dysregulation is described in multiple myeloma. While preclinical models suggest a role for altered T-cell immunity in disease progression, the contribution of immune dysfunction to clinical outcomes remains unclear. We aimed to characterize marrow-infiltrating T cells in newly diagnosed patients and explore associations with outcomes of first-line therapy. EXPERIMENTAL DESIGN We undertook detailed characterization of T cells from bone marrow (BM) samples, focusing on immune checkpoints and features of immune dysfunction, correlating with clinical features and progression-free survival. RESULTS We found that patients with multiple myeloma had greater abundance of BM regulatory T cells (Tregs) which, in turn, expressed higher levels of the activation marker CD25 compared with healthy donors. Patients with higher frequencies of Tregs had shorter PFS and a distinct Treg immune checkpoint profile (increased PD-1, LAG-3) compared with patients with lower frequencies of Tregs. Analysis of CD4 and CD8 effectors revealed that low CD4effector (CD4eff):Treg ratio and increased frequency of PD-1-expressing CD4eff cells were independent predictors of early relapse over and above conventional risk factors, such as genetic risk and depth of response. Ex vivo functional analysis and RNA sequencing revealed that CD4 and CD8 cells from patients with greater abundance of CD4effPD-1+ cells displayed transcriptional and secretory features of dysfunction. CONCLUSIONS BM-infiltrating T-cell subsets, specifically Tregs and PD-1-expressing CD4 effectors, negatively influence clinical outcomes in newly diagnosed patients. Pending confirmation in larger cohorts and further mechanistic work, these immune parameters may inform new risk models, and present potential targets for immunotherapeutic strategies.
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Affiliation(s)
- Nouf Alrasheed
- Research Department of Haematology, University College London Cancer Institute, London, United Kingdom
| | - Lydia Lee
- Research Department of Haematology, University College London Cancer Institute, London, United Kingdom
| | - Ehsan Ghorani
- Research Department of Haematology, University College London Cancer Institute, London, United Kingdom
- Cancer Immunology Unit, Research Department of Haematology, University College London Cancer Institute, London, United Kingdom
| | - Jake Y Henry
- Research Department of Haematology, University College London Cancer Institute, London, United Kingdom
- Cancer Immunology Unit, Research Department of Haematology, University College London Cancer Institute, London, United Kingdom
| | - Lucia Conde
- Bill Lyons Informatics Centre, University College London Cancer Institute, London, United Kingdom
| | - Melody Chin
- Research Department of Haematology, University College London Cancer Institute, London, United Kingdom
| | - Daria Galas-Filipowicz
- Research Department of Haematology, University College London Cancer Institute, London, United Kingdom
| | - Andrew J S Furness
- Research Department of Haematology, University College London Cancer Institute, London, United Kingdom
- Cancer Immunology Unit, Research Department of Haematology, University College London Cancer Institute, London, United Kingdom
| | - Selina J Chavda
- Research Department of Haematology, University College London Cancer Institute, London, United Kingdom
| | - Huw Richards
- Research Department of Haematology, University College London Cancer Institute, London, United Kingdom
| | - Dunnya De-Silva
- Research Department of Haematology, University College London Cancer Institute, London, United Kingdom
| | - Oliver C Cohen
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Dominic Patel
- Department of Histopathology, University College London, London, United Kingdom
| | - Anthony Brooks
- Institute of Child Health, University College London, London, United Kingdom
| | | | - Martin Pule
- Research Department of Haematology, University College London Cancer Institute, London, United Kingdom
| | - Javier Herrero
- Bill Lyons Informatics Centre, University College London Cancer Institute, London, United Kingdom
| | - Sergio A Quezada
- Research Department of Haematology, University College London Cancer Institute, London, United Kingdom.
- Cancer Immunology Unit, Research Department of Haematology, University College London Cancer Institute, London, United Kingdom
| | - Kwee L Yong
- Research Department of Haematology, University College London Cancer Institute, London, United Kingdom.
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26
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Role of the Bone Marrow Milieu in Multiple Myeloma Progression and Therapeutic Resistance. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e752-e768. [PMID: 32651110 DOI: 10.1016/j.clml.2020.05.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/22/2020] [Accepted: 05/29/2020] [Indexed: 01/10/2023]
Abstract
Multiple myeloma (MM) is a cancer of the plasma cells within the bone marrow (BM). Studies have shown that the cellular and noncellular components of the BM milieu, such as cytokines and exosomes, play an integral role in MM pathogenesis and progression by mediating drug resistance and inducing MM proliferation. Moreover, the BM microenvironment of patients with MM facilitates cancer tolerance and immune evasion through the expansion of regulatory immune cells, inhibition of antitumor effector cells, and disruption of the antigen presentation machinery. These are of special relevance, especially in the current era of cancer immunotherapy. An improved understanding of the supportive role of the MM BM microenvironment will allow for the development of future therapies targeting MM in the context of the BM milieu to elicit deeper and more durable responses. In the present review, we have discussed our current understanding of the role of the BM microenvironment in MM progression and resistance to therapy and discuss novel potential approaches to alter its pro-MM function.
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Leblay N, Maity R, Hasan F, Neri P. Deregulation of Adaptive T Cell Immunity in Multiple Myeloma: Insights Into Mechanisms and Therapeutic Opportunities. Front Oncol 2020; 10:636. [PMID: 32432039 PMCID: PMC7214816 DOI: 10.3389/fonc.2020.00636] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 04/06/2020] [Indexed: 12/16/2022] Open
Abstract
Immunotherapy has recently emerged as a promising treatment option for multiple myeloma (MM) patients. Profound immune dysfunction and evasion of immune surveillance are known to characterize MM evolution and disease progression. Along with genomic changes observed in malignant plasma cells, the bone marrow (BM) milieu creates a protective environment sustained by the complex interaction of BM stromal cells (BMSCs) and malignant cells that using bidirectional connections and cytokines released stimulate disease progression, drug resistance and enable immune escape. Local immune suppression and T-cell exhaustion are important mediating factors of clinical outcomes and responses to immune-based approaches. Thus, further characterization of the defects present in the immune system of MM patients is essential to develop novel therapies and to repurpose the existing ones. This review seeks to provide insights into the mechanisms that promote tumor escape, cause inadequate T-cell stimulation and impaired cytotoxicity in MM. Furthermore, it highlights current immunotherapies being used to restore adaptive T-cell immune responses in MM and describes strategies created to escape these multiple immune evasion mechanisms.
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Affiliation(s)
- Noémie Leblay
- Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, AB, Canada
| | - Ranjan Maity
- Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, AB, Canada
| | - Fajer Hasan
- Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, AB, Canada
| | - Paola Neri
- Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, AB, Canada
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Immunotherapeutics in Multiple Myeloma: How Can Translational Mouse Models Help? JOURNAL OF ONCOLOGY 2019; 2019:2186494. [PMID: 31093282 PMCID: PMC6481018 DOI: 10.1155/2019/2186494] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 03/04/2019] [Indexed: 12/30/2022]
Abstract
Multiple myeloma (MM) is usually diagnosed in older adults at the time of immunosenescence, a collection of age-related changes in the immune system that contribute to increased susceptibility to infection and cancer. The MM tumor microenvironment and cumulative chemotherapies also add to defects in immunity over the course of disease. In this review we discuss how mouse models have furthered our understanding of the immune defects caused by MM and enabled immunotherapeutics to progress to clinical trials, but also question the validity of using immunodeficient models for these purposes. Immunocompetent models, in particular the 5T series and Vk⁎MYC models, are increasingly being utilized in preclinical studies and are adding to our knowledge of not only the adaptive immune system but also how the innate system might be enhanced in anti-MM activity. Finally we discuss the concept of immune profiling to target patients who might benefit the most from immunotherapeutics, and the use of humanized mice and 3D culture systems for personalized medicine.
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29
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Lad D, Huang Q, Hoeppli R, Garcia R, Xu L, Levings M, Song K, Broady R. Evaluating the role of Tregs in the progression of multiple myeloma. Leuk Lymphoma 2019; 60:2134-2142. [PMID: 30773086 DOI: 10.1080/10428194.2019.1579324] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The role of regulatory T-cells (Treg) and Th17 cells in the progression of multiple myeloma has been unclear. There are conflicting reports of the Treg and Th17 frequency being increased, decreased, and unchanged as compared with controls. In this study, we sought to characterize the T-cell subsets including Treg function in both blood and marrow compartments of monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma (MM). The Treg/Th17 ratio is skewed toward the suppressive phenotype in MGUS and MM. There are more activated and memory Tregs in the myeloma marrow. Although the myeloma Tregs are functional, they are less suppressive than Tregs in chronic lymphocytic leukemia where they drive disease progression. None of the T-cell subsets were found to have a clinical correlation with time to progression in MGUS or progression-free survival in myeloma. Tregs are important but unlikely major players in the progression of MGUS to MM.
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Affiliation(s)
- Deepesh Lad
- Clinical Hematology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Qing Huang
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Romy Hoeppli
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Rosa Garcia
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Lixin Xu
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Megan Levings
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Kevin Song
- Leukemia/BMT Program of BC, British Columbia Cancer Agency, University of British Columbia, Vancouver, BC, Canada
| | - Raewyn Broady
- Leukemia/BMT Program of BC, British Columbia Cancer Agency, University of British Columbia, Vancouver, BC, Canada
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30
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Franssen LE, Mutis T, Lokhorst HM, van de Donk NWCJ. Immunotherapy in myeloma: how far have we come? Ther Adv Hematol 2019; 10:2040620718822660. [PMID: 30719268 PMCID: PMC6348514 DOI: 10.1177/2040620718822660] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 12/06/2018] [Indexed: 12/31/2022] Open
Abstract
The treatment of multiple myeloma (MM) has evolved substantially over the past decades, leading to a significantly improved outcome of MM patients. The introduction of high-dose therapy, especially, and autologous stem cell transplantation, as well as the development of new drugs, such as immunomodulatory drugs (IMiDs) and proteasome inhibitors have contributed to the improvement in survival. However, eventually most MM patients relapse, which indicates that there is a need for new agents and novel treatment strategies. Importantly, the long-term survival in a subset of MM patients after allogeneic stem cell transplantation illustrates the potential of immunotherapy in MM, but allogeneic stem cell transplantation is also associated with a high rate of treatment-related mortality. Recently, a better insight into several immune-evasion mechanisms, which contribute to tumor progression, has resulted in the development of active and well-tolerated novel forms of immunotherapy. These immunotherapeutic agents can be used as monotherapy, or, even more successfully, in combination with other established anti-MM agents to further improve depth and duration of response by preventing the outgrowth of resistant clones. This review will discuss the mechanisms used by MM cells to evade the immune system, and also provide an overview of currently approved immunotherapeutic drugs, such as IMiDs (e.g. lenalidomide and pomalidomide) and monoclonal antibodies that target cell surface antigens present on the MM cell (e.g. elotuzumab and daratumumab), as well as novel immunotherapies (e.g. chimeric antigen receptor T-cells, bispecific antibodies and checkpoint inhibitors) currently in clinical development in MM.
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Affiliation(s)
- Laurens E Franssen
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Tuna Mutis
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Henk M Lokhorst
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Niels W C J van de Donk
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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31
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The contribution of immune activation and accelerated aging in multiple myeloma occurring in HIV-infected population. AIDS 2018; 32:2841-2846. [PMID: 30234600 DOI: 10.1097/qad.0000000000002015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: The widespread use of antiretroviral treatment results in a significant improvement in immunological condition of people living with HIV (PLWH) who nevertheless experience a significantly increased risk to develop non-Hodgkin lymphoma compared with the general population. Despite many literature observations regarding multiple myeloma in PLWH, a consensus on its relevance in HIV infection does not exist. A number of large population studies on multiple myeloma in PLWH gave contrasting results, fluctuating from increased standardized incidence ratios to the lack of observed cases of multiple myeloma. Use of antiretroviral treatment, in this context, seems to induce a slight reduction of standardized incidence ratio, although with a partial effect, especially in young patients. However, a high variability in clinical onset has been described in different reports: the only common feature of multiple myeloma in PLWH is an atypical presentation as compared with general population, with a worse prognosis in case of uncontrolled HIV infection. We identified three pathogenetic steps in the complex scenario of multiple myeloma in PLWH: first, antigenic trigger; second, persistent T cell deficiency/dysfunction; third, altered regulation of B cells. All these pathogenetic steps play a role in immunological dysregulation, leading to B cell abnormalities and hyperactivation and, finally, resulting in the development of lymphoid malignancies. HIV has a role in each one of these three steps, due to its ability to trigger and dysregulate immune system. We hypothesize that HIV could be closely implicated in the multiple myeloma development in PLWH by accelerating the carcinogenesis events in a complex and only partially understood early aging process.
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32
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Franssen LE, Nijhof IS, Bjorklund CC, Chiu H, Doorn R, van Velzen J, Emmelot M, van Kessel B, Levin MD, Bos GMJ, Broijl A, Klein SK, Koene HR, Bloem AC, Beeker A, Faber LM, van der Spek E, Raymakers R, Sonneveld P, Zweegman S, Lokhorst HM, Thakurta A, Qian X, Mutis T, van de Donk NWCJ. Lenalidomide combined with low-dose cyclophosphamide and prednisone modulates Ikaros and Aiolos in lymphocytes, resulting in immunostimulatory effects in lenalidomide-refractory multiple myeloma patients. Oncotarget 2018; 9:34009-34021. [PMID: 30338042 PMCID: PMC6188055 DOI: 10.18632/oncotarget.26131] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 09/10/2018] [Indexed: 11/25/2022] Open
Abstract
We recently showed that the outcome of multiple myeloma (MM) patients treated in the REPEAT study (evaluation of lenalidomide combined with low-dose cyclophosphamide and prednisone (REP) in lenalidomide-refractory MM) was markedly better than what has been described with cyclophosphamide-prednisone alone. The outcome with REP was not associated with plasma cell Cereblon expression levels, suggesting that the effect of REP treatment may involve mechanisms independent of plasma cell Cereblon-mediated direct anti-tumor activity. We therefore hypothesized that immunomodulatory effects contribute to the anti-MM activity of REP treatment, rather than plasma cell Cereblon-mediated effects. Consequently, we now characterized the effect of REP treatment on immune cell subsets in peripheral blood samples collected on day 1 and 14 of cycle 1, as well as on day 1 of cycle 2. We observed a significant mid-cycle decrease in the Cereblon substrate proteins Ikaros and Aiolos in diverse lymphocyte subsets, which was paralleled by an increase in T-cell activation. These effects were restored to baseline at day one of the second cycle, one week after lenalidomide interruption. In vitro, lenalidomide enhanced peripheral blood mononuclear cell-mediated killing of both lenalidomide-sensitive and lenalidomide-resistant MM cells in a co-culture system. These results indicate that the Cereblon-mediated immunomodulatory properties of lenalidomide are maintained in lenalidomide-refractory MM patients and may contribute to immune-mediated killing of MM cells. Therefore, combining lenalidomide with other drugs can have potent effects through immunomodulation, even in patients considered to be lenalidomide-refractory.
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Affiliation(s)
- Laurens E Franssen
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Inger S Nijhof
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Chad C Bjorklund
- Department of Translational Development, Celgene Corporation, Summit, NJ, USA
| | - Hsiling Chiu
- Department of Translational Development, Celgene Corporation, Summit, NJ, USA
| | - Ruud Doorn
- Laboratory for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen van Velzen
- Laboratory for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten Emmelot
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Berris van Kessel
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Mark-David Levin
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Gerard M J Bos
- Department of Hematology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Annemiek Broijl
- Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Saskia K Klein
- Department of Internal Medicine, Meander Medical Center, Amersfoort, The Netherlands
| | - Harry R Koene
- Department of Hematology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Andries C Bloem
- Laboratory for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Aart Beeker
- Department of Internal Medicine, Spaarne Hospital, Hoofddorp, The Netherlands
| | - Laura M Faber
- Department of Internal Medicine, Rode Kruis Hospital, Beverwijk, The Netherlands
| | - Ellen van der Spek
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Reinier Raymakers
- Department of Hematology, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - Pieter Sonneveld
- Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Sonja Zweegman
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Henk M Lokhorst
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Anjan Thakurta
- Department of Translational Development, Celgene Corporation, Summit, NJ, USA
| | - Xiaozhong Qian
- Department of Translational Development, Celgene Corporation, Summit, NJ, USA
| | - Tuna Mutis
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
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33
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Gallaher J, Larripa K, Renardy M, Shtylla B, Tania N, White D, Wood K, Zhu L, Passey C, Robbins M, Bezman N, Shelat S, Jay Cho H, Moore H. Methods for determining key components in a mathematical model for tumor-immune dynamics in multiple myeloma. J Theor Biol 2018; 458:31-46. [PMID: 30172689 DOI: 10.1016/j.jtbi.2018.08.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/25/2018] [Accepted: 08/29/2018] [Indexed: 12/29/2022]
Abstract
In this work, we analyze a mathematical model we introduced previously for the dynamics of multiple myeloma and the immune system. We focus on four main aspects: (1) obtaining and justifying ranges and values for all parameters in the model; (2) determining a subset of parameters to which the model is most sensitive; (3) determining which parameters in this subset can be uniquely estimated given certain types of data; and (4) exploring the model numerically. Using global sensitivity analysis techniques, we found that the model is most sensitive to certain growth, loss, and efficacy parameters. This analysis provides the foundation for a future application of the model: prediction of optimal combination regimens in patients with multiple myeloma.
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Affiliation(s)
| | - Kamila Larripa
- Department of Mathematics, Humboldt State University, Arcata, CA 95521, USA.
| | - Marissa Renardy
- Department of Mathematics, The Ohio State University, Columbus, OH 43210, USA; Current affiliation: Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI 48109, USA.
| | - Blerta Shtylla
- Mathematics Department, Pomona College, Claremont, CA 91711, USA.
| | - Nessy Tania
- Department of Mathematics and Statistics, Smith College, Northampton, MA 01063,USA.
| | - Diana White
- Department of Mathematics, Clarkson University, Potsdam, NY 13699, USA.
| | - Karen Wood
- Department of Mathematics, University of California at Irvine, Irvine, CA 92697, USA; Current affiliation: The Aerospace Corporation, El Segundo, CA 90245, USA.
| | - Li Zhu
- Clinical Pharmacology and Pharmacometrics, Bristol-Myers Squibb, Princeton, NJ 08543, USA.
| | - Chaitali Passey
- Clinical Pharmacology and Pharmacometrics, Bristol-Myers Squibb, Princeton, NJ 08543, USA; Current affiliation: Genmab, Monmouth Junction, NJ 08852, USA
| | - Michael Robbins
- Hematology Medical Strategy, Bristol-Myers Squibb, Lawrence Township, NJ 08648, USA.
| | - Natalie Bezman
- Immuno-Oncology Discovery, Bristol-Myers Squibb, Redwood City, CA 94063, USA.
| | - Suresh Shelat
- Oncology Clinical Development, Bristol-Myers Squibb, Lawrence Township, NJ 08648, USA.
| | - Hearn Jay Cho
- Tisch Cancer Institute, Mt. Sinai School of Medicine, New York, NY 10029, USA.
| | - Helen Moore
- Bristol-Myers Squibb, Princeton, NJ 08543, USA; Current affiliation: AstraZeneca, Waltham, MA 02451, USA.
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34
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Tai YT, Cho SF, Anderson KC. Osteoclast Immunosuppressive Effects in Multiple Myeloma: Role of Programmed Cell Death Ligand 1. Front Immunol 2018; 9:1822. [PMID: 30147691 PMCID: PMC6095980 DOI: 10.3389/fimmu.2018.01822] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 07/24/2018] [Indexed: 12/21/2022] Open
Abstract
Immunomodulatory drugs and monoclonal antibody-based immunotherapies have significantly improved the prognosis of the patients with multiple myeloma (MM) in the recent years. These new classes of reagents target malignant plasma cells (PCs) and further modulate the immune microenvironment, which prolongs anti-MM responses and may prevent tumor occurrence. Since MM remains an incurable cancer for most patients, there continues to be a need to identify new tumor target molecules and investigate alternative cellular approaches using gene therapeutic strategies and novel treatment mechanisms. Osteoclasts (OCs), as critical multi-nucleated large cells responsible for bone destruction in >80% MM patients, have become an attractive cellular target for the development of novel MM immunotherapies. In MM, OCs are induced and activated by malignant PCs in a reciprocal manner, leading to osteolytic bone disease commonly associated with this malignancy. Significantly, bidirectional interactions between OCs and MM cells create a positive feedback loop to promote MM cell progression, increase angiogenesis, and inhibit immune surveillance via both cell-cell contact and abnormal production of multiple cytokines/chemokines. Most recently, hyper-activated OCs have been associated with activation of programmed cell death protein 1 (PD-1)/programmed cell death ligand 1 (PD-L1) pathway, which impairs T cell proliferation and cytotoxicity against MM cells. Importantly, therapeutic anti-CD38 monoclonal antibodies and checkpoint inhibitors can alleviate OC-induced immune suppression. Furthermore, a proliferation-inducing ligand, abundantly secreted by OCs and OC precursors, significantly upregulates PD-L1 expression on MM cells, in addition to directly promoting MM cell proliferation and survival. Coupled with increased PD-L1 expression in other immune-suppressive cells, i.e., myeloid-derived suppressor cells and tumor-associated macrophages, these results strongly suggest that OCs contribute to the immunosuppressive MM BM microenvironment. Based on these findings and ongoing osteoimmunology studies, therapeutic interventions targeting OC number and function are under development to diminish both MM bone disease and related immune suppression. In this review, we discuss the classical and novel roles of OCs in the patho-immunology of MM. We also describe novel therapeutic strategies simultaneously targeting OCs and MM interactions, including PD-1/PD-L1 axis, to overcome the immune-suppressive microenvironment and improve patient outcome.
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Affiliation(s)
- Yu-Tzu Tai
- LeBow Institute for Myeloma Therapeutics and Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - Shih-Feng Cho
- LeBow Institute for Myeloma Therapeutics and Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States.,Division of Hematology & Oncology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kenneth C Anderson
- LeBow Institute for Myeloma Therapeutics and Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
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35
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Zhu MX, Wan WL, Tian L, Hu K, Wang J, Wang YF, Gao JJ, Zhu XW, Jing HM, Ke XY. [Prognostic significance of Treg/Th17 cells imbalance in patients with diffuse large B cell lymphoma]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 39:507-510. [PMID: 30032570 PMCID: PMC7342911 DOI: 10.3760/cma.j.issn.0253-2727.2018.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Indexed: 01/25/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - X Y Ke
- Department of Hematology, Peking University Third Hospital, Beijing 100191, China
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36
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Jiménez JJ, Pais TM, Barbosa N, Campos ML, Díaz MAP, de Larramendi CH. Severe Isotype-Matched Immunosuppression (IMI) as a Potential Risk Factor for Progression of MGUS Patients. J Appl Lab Med 2018; 2:700-710. [DOI: 10.1373/jalm.2017.024307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 09/05/2017] [Indexed: 01/09/2023]
Abstract
Abstract
Background
Monoclonal gammopathy of undetermined significance (MGUS) precedes multiple myeloma in virtually every case. However, only a small percentage will progress and at very different rates. In addition, recent data have suggested that MGUS is associated with other comorbidities including infections, suggesting impaired immune function in some MGUS patients. Therefore, we aimed at assessing the value of isotype-matched immunosuppression (IMI; e.g., suppression of an IgAκ in an IgAλ patient), a type of immunosuppression more specific than classical immunoparesis (IP; e.g., IgG and/or IgM suppression in an IgA patient), as a prognostic marker for MGUS progression.
Methods
The Hevylite assay was used to assess IMI and immunoglobulin ratios in 307 serum samples from a cohort of 248 MGUS patients. Follow-up clinical records were available for 154 individuals.
Results
A greater incidence of IMI (51%) over classical IP (37%) was observed, although both show a progressive increase with higher risk groups. Survival analysis of 154 patients showed that severe IMI (>50% suppression) differentiates 2 groups with significantly different time to progression (P = 0.024) while severe IP does not (P = 0.48). Also, a combination of severe IMI and involved monoclonal immunoglobulin >1.5g/dL by Hevylite (both variables found to be independent prognostic markers in multivariate analysis) identified a group of patients with a median time to progression 6-fold shorter than the remaining group (P < 0.0001).
Conclusions
These findings indicate a possible role for IMI in the malignant transformation of MGUS patients and a potential utility as a new risk factor.
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Affiliation(s)
- Juana J Jiménez
- Department of Clinical Chemistry, University Hospital Severo Ochoa, Madrid, Spain
| | - Tiago M Pais
- Scientific Department, The Binding Site Iberia, Barcelona, Spain
| | - Nuno Barbosa
- Scientific Department, The Binding Site Iberia, Barcelona, Spain
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37
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Oncolytic virotherapy as an immunotherapeutic strategy for multiple myeloma. Blood Cancer J 2017; 7:640. [PMID: 29208938 PMCID: PMC5802552 DOI: 10.1038/s41408-017-0020-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/03/2017] [Accepted: 10/12/2017] [Indexed: 12/22/2022] Open
Abstract
Multiple Myeloma (MM), a clonal malignancy of antibody-producing plasma cells, is the second most common hematologic malignancy and results in significant patient morbidity and mortality. The high degree of immune dysregulation in MM, including T cell imbalances and up-regulation of immunosuppressive checkpoint proteins and myeloid derived suppressor cells, allows this malignancy to escape from host immune control. Despite advances in the therapeutic landscape of MM over the last decade, including the introduction of immunomodulatory drugs, the prognosis for this disease is poor, with less than 50% of patients surviving 5 years. Thus, novel treatment strategies are required. Oncolytic viruses (OV) are a promising new class of therapeutics that rely on tumour specific oncolysis and the generation of a potent adaptive anti-tumour immune response for efficacy. To date, a number of OV have shown efficacy in pre-clinical studies of MM with three reaching early phase clinical trials. OVs represent a rational therapeutic strategy for MM based on (1) their tumour tropism, (2) their ability to potentiate anti-tumour immunity and (3) their ability to be rationally combined with other immunotherapeutic agents to achieve a more robust clinical response.
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38
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Mansour A, Wakkach A, Blin-Wakkach C. Emerging Roles of Osteoclasts in the Modulation of Bone Microenvironment and Immune Suppression in Multiple Myeloma. Front Immunol 2017; 8:954. [PMID: 28848556 PMCID: PMC5554508 DOI: 10.3389/fimmu.2017.00954] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 07/26/2017] [Indexed: 12/26/2022] Open
Abstract
Multiple myeloma (MM) is one of the most common forms of hematologic malignancy resulting from cancerous proliferation of mature malignant plasma cells (MPCs). But despite the real improvement in therapeutics in the past years, it remains largely incurable. MM is the most frequent cancer to involve bone due to the stimulation of osteoclast (OCL) differentiation and activity. OCLs have a unique capacity to resorb bone. However, recent studies reveal that they are not restrained to this sole function. They participate in the control of angiogenesis, medullary niches, and immune responses, including in MM. Therefore, therapeutic approaches targeting OCLs probably affect not only bone resorption but also many other functions, and OCLs should not be considered anymore only as targets to improve the bone phenotype but also to modulate bone microenvironment. In this review, we explore these novel contributions of OCLs to MM which reveal their strong implication in the MM physiopathology. We also underline the therapeutic interest of targeting OCLs not only to overcome bone lesions, but also to improve bone microenvironment and anti-tumoral immune responses.
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Affiliation(s)
- Anna Mansour
- CNRS, UMR7370, LP2M, Faculté de Médecine, Nice, France.,Université Nice Sophia Antipolis, Nice, France.,Faculté de Médecine, Université Aix-Marseille, Marseille, France
| | - Abdelilah Wakkach
- CNRS, UMR7370, LP2M, Faculté de Médecine, Nice, France.,Université Nice Sophia Antipolis, Nice, France
| | - Claudine Blin-Wakkach
- CNRS, UMR7370, LP2M, Faculté de Médecine, Nice, France.,Université Nice Sophia Antipolis, Nice, France
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39
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Hansmann L, Han A, Penter L, Liedtke M, Davis MM. Clonal Expansion and Interrelatedness of Distinct B-Lineage Compartments in Multiple Myeloma Bone Marrow. Cancer Immunol Res 2017; 5:744-754. [PMID: 28768640 PMCID: PMC5590392 DOI: 10.1158/2326-6066.cir-17-0012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 04/05/2017] [Accepted: 07/25/2017] [Indexed: 11/16/2022]
Abstract
Multiple myeloma is characterized by the clonal expansion of malignant plasma cells in the bone marrow. But the phenotypic diversity and the contribution of less predominant B-lineage clones to the biology of this disease have been controversial. Here, we asked whether cells bearing the dominant multiple myeloma immunoglobulin rearrangement occupy phenotypic compartments other than that of plasma cells. To accomplish this, we combined 13-parameter FACS index sorting and t-Stochastic Neighbor Embedding (t-SNE) visualization with high-throughput single-cell immunoglobulin sequencing to track selected B-lineage clones across different stages of human B-cell development. As expected, the predominant clones preferentially mapped to aberrant plasma cell compartments, albeit phenotypically altered from wild type. Interestingly, up to 1.2% of cells of the predominant clones colocalized with B-lineage cells of a normal phenotype. In addition, minor clones with distinct immunoglobulin sequences were detected in up to 9% of sequenced cells, but only 2 out of 12 of these clones showed aberrant immune phenotypes. The majority of these minor clones showed intraclonal silent nucleotide differences within the CDR3s and varying frequencies of somatic mutations in the immunoglobulin genes. Therefore, the phenotypic range of multiple myeloma cells in the bone marrow is not confined to aberrant-phenotype plasma cells but extends to low frequencies of normal-phenotype B cells, in line with the recently reported success of B cell-targeting cellular therapies in some patients. The majority of minor clones result from parallel nonmalignant expansion. Cancer Immunol Res; 5(9); 744-54. ©2017 AACR.
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Affiliation(s)
- Leo Hansmann
- Department of Microbiology and Immunology, Stanford University, Stanford, California. .,Department of Hematology, Oncology, and Tumor Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Arnold Han
- Department of Microbiology and Immunology, Stanford University, Stanford, California
| | - Livius Penter
- Department of Hematology, Oncology, and Tumor Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Michaela Liedtke
- Division of Hematology, Department of Medicine, Stanford University, Stanford, California
| | - Mark M Davis
- Department of Microbiology and Immunology, Stanford University, Stanford, California. .,Institute for Immunity, Transplantation, and Infection, Stanford University, Stanford, California.,The Howard Hughes Medical Institute, Stanford University, Stanford, California
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40
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Immune signatures associated with improved progression-free and overall survival for myeloma patients treated with AHSCT. Blood Adv 2017; 1:1056-1066. [PMID: 29296748 DOI: 10.1182/bloodadvances.2017005447] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 05/12/2017] [Indexed: 11/20/2022] Open
Abstract
Multiple therapeutic options exist for multiple myeloma (MM), including autologous hematopoietic stem cell transplantation (AHSCT). Measurement of minimal residual disease (MRD) and immune reconstitution is rapidly becoming an integral part of the care of MM patients. We investigated comprehensive immune profiling (IP) associated with progression-free survival (PFS) and overall survival (OS). From August 2007 to January 2014, 101 consecutive MM patients underwent peripheral blood IP and marrow MRD testing before and approximately 100 days after AHSCT. Higher pre-AHSCT CD19+ B-cell counts correlated with improved 2-year PFS (83% [highest quartile] vs 53% [lowest quartile]; P = .01) and OS (93% [highest quartile] vs 63% [lowest quartile]; P = .0003). This effect was seen primarily in patients with MRD-positive marrow tests. Higher γδ T-cell counts post-AHSCT correlated with improved 2-year PFS (65% [highest quartile] vs 45% [lowest quartile]; P = .02) and OS (89% [highest quartile] vs 65% [lowest quartile]; P = .01). Higher CD4+ central memory (CM) cell counts post-AHSCT were associated with improved 2-year OS (95% [upper quartile] vs 47% [lowest quartile]; P = .0003) but not PFS. The higher γδ T-cell and CD4+ CM-cell count associations were primarily observed in MRD-negative patients post-AHSCT and in patients not receiving maintenance therapy. This proof-of-concept study demonstrates that IP before and after AHSCT can be of complementary prognostic value for depth of response. Maintenance therapy seems to overcome negative IP. IP and MRD should be measured in clinical trials of maintenance therapy with novel agents post-AHSCT for MM to confirm their utility for prognosis and management.
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41
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Burwick N. Vitamin D and plasma cell dyscrasias: reviewing the significance. Ann Hematol 2017; 96:1271-1277. [PMID: 28502031 DOI: 10.1007/s00277-017-3016-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 05/05/2017] [Indexed: 12/31/2022]
Abstract
Monoclonal gammopathy of undetermined significance (MGUS) is a clonal plasma cell disorder and precursor disease to multiple myeloma and other related cancers. While MGUS is considered a benign disorder, with a low risk of disease progression, patients have altered bone microarchitecture and an increased risk of bone fracture. In addition, alterations in immune function are regularly found to correlate with disease activity. Vitamin D, an important hormone for bone and immune health, is commonly deficient in multiple myeloma patients. However, vitamin D deficiency is also prevalent in the general population. The purpose of this review is to highlight the current understanding of vitamin D in health and disease and to parallel this with a review of the abnormalities found in plasma cell dyscrasias. While some consensus statements have advocated for vitamin D testing and routine supplementation in MGUS, there is no clear standard of care approach and clinical practice patterns vary. Further research is needed to better understand how vitamin D influences outcomes in MGUS patients.
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Affiliation(s)
- Nicholas Burwick
- VA Puget Sound Health Care System, Seattle, WA, USA.
- Division of Hematology, University of Washington School of Medicine, Seattle, WA, USA.
- Department of Medicine, University of Washington Medical Center, 1705 NE Pacific St, M/S 358280, Seattle, WA, 98195, USA.
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42
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Chung C. Role of Immunotherapy in Targeting the Bone Marrow Microenvironment in Multiple Myeloma: An Evolving Therapeutic Strategy. Pharmacotherapy 2017; 37:129-143. [PMID: 27870103 DOI: 10.1002/phar.1871] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Multiple myeloma (referred to henceforth as myeloma) is a B-cell malignancy characterized by unregulated growth of plasma cells in the bone marrow. The treatment paradigm for myeloma underwent significant evolution in the last decade, with an improved understanding of the pathogenesis of the disease as well as the development of therapeutic agents that target not only the tumor cells but also their microenvironment. Despite these therapeutic advances, the prognosis of patients with relapsed or refractory myeloma remains poor. Accordingly, a need exists for new therapeutic avenues that can overcome resistance to current therapies and improve survival outcomes. In addition, myeloma is associated with progressive immune dysregulation, with defects in T-cell immunity, natural killer cell function, and the antigen-presenting capacity of dendritic cells, resulting in a tumor microenvironment that promotes disease tolerance and progression. Together, the immunosuppressive microenvironment and oncogenic mutations activate signaling networks that promote myeloma cell survival. Immunotherapy incorporates novel treatment options (e.g., monoclonal antibodies, antibody-drug conjugates, chimeric antigen receptor T-cell therapy, immune checkpoint inhibitors, bispecific antibodies, and tumor vaccines) either alone or in combination with existing lines of therapies (e.g., immunomodulatory agents, proteasome inhibitors, and histone deacetylase inhibitors) to enhance the host anti myeloma immunity within the bone marrow microenvironment and improve clinical response. Following the U.S. Food and Drug Administration approval of daratumumab and elotuzumab in 2015, more immunotherapeutic agents are expected to be become available as valuable treatment options in the near future. This review provides a basic understanding of the role of immunotherapy in modulating the bone marrow tumor microenvironment and its role in the treatment of myeloma. Clinical efficacy and safety of recently approved therapeutic monoclonal antibodies (daratumumab, elotuzumab) are discussed, along with the therapeutic potential of emerging immunotherapies (antibody-drug conjugates, chimeric antigen receptor T-cell therapy, tumor vaccines, and immune checkpoint inhibitors).
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43
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Neri P, Bahlis NJ, Lonial S. New Strategies in Multiple Myeloma: Immunotherapy as a Novel Approach to Treat Patients with Multiple Myeloma. Clin Cancer Res 2016; 22:5959-5965. [PMID: 27797968 DOI: 10.1158/1078-0432.ccr-16-0184] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/16/2016] [Accepted: 09/22/2016] [Indexed: 11/16/2022]
Abstract
Multiple myeloma is a B-cell malignancy characterized by proliferation of monoclonal plasma cells in the bone marrow. Although new therapeutic options introduced in recent years have resulted in improved survival outcomes, multiple myeloma remains incurable for a large number of patients, and new treatment options are urgently needed. Over the last 5 years, there has been a renewed interest in the clinical potential of immunotherapy for the treatment of multiple myeloma. Clinical progression of myeloma is known to be associated with progressive immune dysregulation and loss of immune surveillance that contribute to disease progression in association with progressive genetic complexity, rendering signaling-based treatments less effective. A variety of strategies to reverse the multiple myeloma-induced immunosuppression has been developed either in the form of immunomodulatory drugs, checkpoint inhibitors, mAbs, engineered T cells, and vaccines. They have shown encouraging results in patients with relapsed refractory multiple myeloma and hold great promise in further improving patient outcomes in multiple myeloma. This review will summarize the major approaches in multiple myeloma immunotherapies and discuss the mechanisms of action and clinical activity of these strategies. Clin Cancer Res; 22(24); 5959-65. ©2016 AACR.
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Affiliation(s)
- Paola Neri
- Division of Hematology and Bone Marrow Transplant, University of Calgary, Alberta, Canada.,Southern Alberta, Cancer Research Institute (SACRI), Calgary, Alberta, Canada
| | - Nizar J Bahlis
- Division of Hematology and Bone Marrow Transplant, University of Calgary, Alberta, Canada.,Southern Alberta, Cancer Research Institute (SACRI), Calgary, Alberta, Canada
| | - Sagar Lonial
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia.
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44
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Wu XF, Wang YD, Hu Y. [Advances in CAR- T therapy for patients with multiple myeloma]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:921-925. [PMID: 27801331 PMCID: PMC7364869 DOI: 10.3760/cma.j.issn.0253-2727.2016.10.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- X F Wu
- Department of Hematology, Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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45
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Joshua D, Suen H, Brown R, Bryant C, Ho PJ, Hart D, Gibson J. The T Cell in Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16:537-542. [PMID: 27601001 DOI: 10.1016/j.clml.2016.08.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 07/15/2016] [Accepted: 08/02/2016] [Indexed: 11/16/2022]
Abstract
An active role for the immune system in controlling the malignant plasma cell clone in myeloma has been postulated for many years. The clinical states of monoclonal gammopathy of undetermined significance, plateau phase disease, and smoldering myeloma all suggest that a significant host-tumor interaction is taking place. The fundamental role of the cytotoxic T cell in tumor elimination and control has been exemplified by the dramatic efficacy of adoptive T-cell therapies in many hemopoietic malignancies. However, tumor-host cross-talk results in suppression of the endogenous cytotoxic T-cell response against the malignant plasma cell. Whereas patients with myeloma do not clinically exhibit a T-cell immunodeficiency state, with, for example, increased mycobacterial infections, a number of abnormalities of T-cell function are evident. The major abnormalities of T cells include clonal expansions and associated immunosenescence, alterations of regulatory T cells/T helper 17 cells (Treg/Th17 ratio) and acquired membrane abnormalities, due to trogocytosis, which result in acquired Treg cells. Dendritic cell dysfunction associated with impaired antigen processing and presentation caused by abnormalities of the bone marrow microenvironment plays an additional role. In this perspective, we examine the T-cell abnormalities in myeloma and postulate that, whereas cytotoxic T cells interacting with the tumor are dysfunctional, residual T cells still function adequately against external pathogens and thus protect patients from the infections normally associated with a generalized T-cell immunodeficiency state. The so-called 3 E's of host-tumor interaction (elimination, equilibrium, and escape) are clearly reflected in the immune landscape and clinical behavior of myeloma.
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Affiliation(s)
- Douglas Joshua
- Institute of Haematology, NSW Pathology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia.
| | - Hayley Suen
- Institute of Haematology, NSW Pathology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
| | - Ross Brown
- Institute of Haematology, NSW Pathology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
| | - Christian Bryant
- Institute of Haematology, NSW Pathology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia; Dendritic Cell Research, ANZAC Research Institute, University of Sydney, Concord, NSW, Australia
| | - P Joy Ho
- Institute of Haematology, NSW Pathology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
| | - Derek Hart
- Dendritic Cell Research, ANZAC Research Institute, University of Sydney, Concord, NSW, Australia
| | - John Gibson
- Institute of Haematology, NSW Pathology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
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46
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Suen H, Brown R, Yang S, Weatherburn C, Ho PJ, Woodland N, Nassif N, Barbaro P, Bryant C, Hart D, Gibson J, Joshua D. Multiple myeloma causes clonal T-cell immunosenescence: identification of potential novel targets for promoting tumour immunity and implications for checkpoint blockade. Leukemia 2016; 30:1716-24. [PMID: 27102208 DOI: 10.1038/leu.2016.84] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 03/09/2016] [Accepted: 03/30/2016] [Indexed: 02/07/2023]
Abstract
Tumour-induced dysfunction of cytotoxic T cells in patients with multiple myeloma (MM) may contribute to immune escape and be responsible for the lack of therapeutic efficacy of immune checkpoint blockade. We therefore investigated dysfunctional clonal T cells in MM and demonstrated immunosenescence but not exhaustion as a predominant feature. T-cell clones were detected in 75% of MM patients and their prognostic significance was revalidated in a new post-immunomodulatory drug cohort. The cells exhibited a senescent secretory effector phenotype: KLRG-1+/CD57+/CD160+/CD28-. Normal-for-age telomere lengths indicate that senescence is telomere independent and potentially reversible. p38-mitogen-activated protein kinase, p16 and p21 signalling pathways known to induce senescence were not elevated. Telomerase activity was found to be elevated and this may explain how normal telomere lengths are maintained in senescent cells. T-cell receptor signalling checkpoints were normal but elevated SMAD levels associated with T-cell inactivation were detected and may provide a potential target for the reversal of clonal T-cell dysfunction in MM. Low programmed death 1 and cytotoxic T-lymphocyte-associated antigen 4 expression detected on T-cell clones infers that these cells are not exhausted but suggests that there would be a suboptimal response to immune checkpoint blockade in MM. Our data suggest that other immunostimulatory strategies are required in MM.
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Affiliation(s)
- H Suen
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,School of Life Sciences, University of Technology Sydney, Sydney, New South Wales, Australia
| | - R Brown
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - S Yang
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - C Weatherburn
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney University Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - P J Ho
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney University Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - N Woodland
- School of Life Sciences, University of Technology Sydney, Sydney, New South Wales, Australia
| | - N Nassif
- School of Life Sciences, University of Technology Sydney, Sydney, New South Wales, Australia
| | - P Barbaro
- Children's Medical Research Institute, Sydney, New South Wales, Australia
| | - C Bryant
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney University Medical School, University of Sydney, Sydney, New South Wales, Australia.,Dendritic Cell Research, ANZAC Research Institute, Sydney, New South Wales, Australia
| | - D Hart
- Sydney University Medical School, University of Sydney, Sydney, New South Wales, Australia.,Dendritic Cell Research, ANZAC Research Institute, Sydney, New South Wales, Australia
| | - J Gibson
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney University Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - D Joshua
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney University Medical School, University of Sydney, Sydney, New South Wales, Australia
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47
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Ex vivo evaluation of the effect of regulatory T cells on the anti-tumor activity of bortezomib in multiple myeloma. Exp Hematol 2016; 44:223-30. [DOI: 10.1016/j.exphem.2015.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 05/14/2015] [Accepted: 05/29/2015] [Indexed: 11/21/2022]
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48
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Muchtar E, Magen H, Itchaki G, Cohen A, Rosenfeld R, Shochat T, Kornowski R, Iakobishvili Z, Raanani P. Uninvolved immunoglobulins predicting hematological response in newly diagnosed AL amyloidosis. Leuk Res 2016; 41:56-61. [DOI: 10.1016/j.leukres.2015.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 10/30/2015] [Accepted: 11/19/2015] [Indexed: 12/11/2022]
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49
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Di Lullo G, Marcatti M, Protti MP. Non-redundant roles for Th17 and Th22 cells in multiple myeloma clinical correlates. Oncoimmunology 2015; 5:e1093278. [PMID: 27141378 DOI: 10.1080/2162402x.2015.1093278] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 08/30/2015] [Accepted: 09/07/2015] [Indexed: 02/09/2023] Open
Abstract
We recently reported that in multiple myeloma increased Th22 cell frequencies correlate with poor prognosis. Here we show that within the same patients' cohort Th17 cells associate with bone disease and not with prognosis. Thus, we propose that Th22 and Th17 cells play non-redundant roles in multiple myeloma and constitute independent therapeutic targets.
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Affiliation(s)
- Giulia Di Lullo
- Tumor Immunology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Magda Marcatti
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute , Milan, Italy
| | - Maria Pia Protti
- Tumor Immunology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
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50
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Vetro C, Romano A, Ancora F, Coppolino F, Brundo MV, Raccuia SA, Puglisi F, Tibullo D, La Cava P, Giallongo C, Parrinello NL. Clinical Impact of the Immunome in Lymphoid Malignancies: The Role of Myeloid-Derived Suppressor Cells. Front Oncol 2015; 5:104. [PMID: 26052505 PMCID: PMC4440379 DOI: 10.3389/fonc.2015.00104] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 04/19/2015] [Indexed: 11/13/2022] Open
Abstract
The better definition of the mutual sustainment between neoplastic cells and immune system has been translated from the bench to the bedside acquiring value as prognostic factor. Additionally, it represents a promising tool for improving therapeutic strategies. In this context, myeloid-derived suppressor cells (MDSCs) have gained a central role in tumor developing with consequent therapeutic implications. In this review, we will focus on the biological and clinical impact of the study of MDSCs in the settings of lymphoid malignancies.
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Affiliation(s)
- Calogero Vetro
- Division of Haematology, AOU "Policlinico - Vittorio Emanuele", University of Catania , Catania , Italy
| | - Alessandra Romano
- Division of Haematology, AOU "Policlinico - Vittorio Emanuele", University of Catania , Catania , Italy
| | - Flavia Ancora
- Division of Haematology, AOU "Policlinico - Vittorio Emanuele", University of Catania , Catania , Italy
| | | | - Maria V Brundo
- Department of Biological, Geological and Environmental Sciences, University of Catania , Catania , Italy
| | - Salvatore A Raccuia
- Department of Biological, Geological and Environmental Sciences, University of Catania , Catania , Italy ; National Research Council Institute for Agricultural and Forest Systems in the Mediterranean, National Research Council , Catania , Italy
| | - Fabrizio Puglisi
- Division of Haematology, AOU "Policlinico - Vittorio Emanuele", University of Catania , Catania , Italy
| | - Daniele Tibullo
- Division of Haematology, AOU "Policlinico - Vittorio Emanuele", University of Catania , Catania , Italy
| | - Piera La Cava
- Division of Haematology, AOU "Policlinico - Vittorio Emanuele", University of Catania , Catania , Italy
| | - Cesarina Giallongo
- Division of Haematology, AOU "Policlinico - Vittorio Emanuele", University of Catania , Catania , Italy
| | - Nunziatina L Parrinello
- Division of Haematology, AOU "Policlinico - Vittorio Emanuele", University of Catania , Catania , Italy
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