A probable case of multiple myeloma from Bronze Age China

OBJECTIVE

Paleopathological evidence of cancer from past populations is rare, especially outside of Europe and North Africa. This study expands upon the current temporal and spatial distribution of cancer by presenting a probable case of multiple myeloma from Bronze Age China.

MATERIAL

The human skeletal remains of an adult male from the Qijia culture horizon (1750-1400 BCE) of the Bronze Age cemetery of Mogou (), located in Gansu Province, Northwest China.

METHODS

The human skeletal remains were assessed macroscopically and radiographically using plain x-rays.

RESULTS

Multiple ovoid-shaped osteolytic lesions with sharply demarcated margins were observed. The axial skeletal had the greatest involvement, specifically the vertebrae, ribs, and sternum. Radiographic imaging revealed more extensive destruction of cancellous than cortical bone, indicating that the marrow was the focal point of the disease.

CONCLUSION

Based on the nature, distribution, and radiographic appearance of the lesions, the most likely diagnosis is multiple myeloma.

SIGNIFICANCE

This is one of the only cases of cancer identified in archaeological human skeletal remains from East Asia and is the first published case of a hematopoietic malignancy from mainland China. The analysis and publication of examples of neoplasia from areas that expand upon the current known temporal and spatial distribution is necessary in order to better reconstruct the history and evolution of cancer.

LIMITATIONS

Poor skeletal preservation prevented the full extent of osteolytic lesions to be observed.

SUGGESTIONS FOR FUTURE RESEARCH

By placing case studies such as this into a temporal and spatial framework, it is possible for future research to begin to interrogate possible underlying causes of cancer in ancient populations within the context of changing environmental conditions and subsistence strategies.

Multiple myeloma in paleopathology: A critical review

This paper provides a critical literature review concerning paleopathological evidence of multiple myeloma discovered both in the Old and in the New World. A critical assessment of the bioarchaeological and paleopathological documentary sources permitted to identify a total of 25 ascertained cases of multiple myeloma from different geographical areas in the world ranging from Prehistoric times up to the Contemporary age. The distribution of multiple myeloma findings in past times shows that the majority of cases have been discovered in the Old World (n = 18) and extend back to the Middle Ages, while the evidences in the New World (n = 7) seems to date back to the pre-Columbian era. The demographic profile suggests a sex ratio of 1.3:1, while 91.7% of affected individuals (n = 24) are adults. This critical review also discusses the diagnostic criteria and methodological issues commonly attempted in paleo-oncological research, with particular regard to the differential diagnosis of multiple myeloma. As such, the main focus of this work is to present a comprehensive and exhaustive scrutiny of the skeletal manifestations identified as multiple myeloma in order to improve the accuracy of diagnoses within the field of paleopathology.

A probable case of multiple myeloma in a female individual from the Simon Identified Skeletal Collection (late 19th-early 20th century, Vaud, Switzerland)

We present the case of an individual from the Simon Identified Skeletal Collection (Vaud, Switzerland) who appears to have been affected by a form of neoplastic disease. A detailed description and differential diagnosis of the lesions was conducted and is presented here. Considering the biological profile of the individual, the distribution of the lesions, and their appearance, a case is made for multiple myeloma as the most likely diagnosis. This case study demonstrates the importance of adopting a detailed approach for recording the metric and non-metric traits of lesions, using multiple methods of analysis, and providing graphic and photographic documentation in order to provide valuable comparison material through publication. The good preservation of the remains and the background information available for the individual also make this case ideal for inclusion in future comparative studies.

Human tumor stem cells, the petri dish and the patient. A tribute to Sydney E. Salmon

During the last ten years, much work has been devoted to the concept of tumor stem cells, a concept first introduced by Virchow in 1855. Despite the importance and the quality of these works, they ignore the major step forward made by SE Salmon and his group from the University ofArizona atTucson, USA, during the seventies'. The purpose of this review is to (i) contribute to the original work of SE Salmon as a pioneer in the field of cancer stem cell research (ii) emphasize the importance of his contribution in this field of research and (iii) underline the other fields of his research, especially in the domain of mathematical oncology. Finally, we would like to show that SE Salmon made Multiple Myeloma a model in Oncology, many study groups being engaged into Myeloma research now in the world.

Battling the hematological malignancies: the 200 years' war

The delineation of the hematological malignancies began near the end of the first third of the 19th century with the recognition of the similarity among cases with lymph node tumors and an enlarged spleen (Hodgkin's disease). Descriptions of chronic and acute leukemia and myeloma followed thereafter. In the first years of the 20th century the discovery of x-radiation permitted palliative orthovoltage radiation therapy of Hodgkin's disease. Following World War II, legitimate drug therapy for the hematological malignancies was introduced: nitrogen mustard, adrenocorticotropic hormone and cortisone acetate, and anti-folic acid derivatives, initially aminopterin. Today, about 14 classes of drugs (different mechanisms of action) and >50 individual agents are being used, with others under study. Several examples of agents targeting specific transcription factors or oncoproteins have been introduced. Despite remarkable progress, including the ability to cure acute leukemia in about 70% of children, cure several genetic variants of acute myelogenous leukemia in younger adults, cure some cases of lymphoma in children and younger adults, and induce prolonged remission in many affected persons, the majority of patients face an uncertain outcome and shortened life. Thus, we have much to do in the next several decades. The significant hurdles we must overcome include: the apparent infrequency of an exogenous cause that can be avoided, the exponential increase in incidence rates with age and the dramatic negative effect of aging on the results of treatment, the challenge of one trillion or more disseminated cancer cells among which are a smaller population of cancer stem cells, the profound genetic diversity of the hematological malignancies (apparently hundreds of unique genetic primary lesions), the redundant growth and survival pathways defining the cancer phenotype, the decreasing market for pharmaceutical companies as therapy becomes more specific (fewer target patients) and drug development costs become more expensive, and the significant negative long-term effects of current therapy on both children and adults. These challenges will be gradually overcome, if we (a) develop new models of cooperation among academia, industry, and government, (b) continue the growth of international participation in cancer research (more keen minds to the task), and (c) convince the governments of the world, including that of the U.S., that an investment in minimizing the effects of cancer is as important as defending against other threats to the welfare and longevity of their citizens.

Multiple myeloma

Multiple myeloma is a clonal plasma cell malignancy that accounts for slightly more than 10% of all hematologic cancers. In this paper, we present a historically focused review of the disease, from the description of the first case in 1844 to the present. The evolution of drug therapy and stem-cell transplantation for the treatment of myeloma, as well as the development of new agents, is discussed. We also provide an update on current concepts of diagnosis and therapy, with an emphasis on how treatments have emerged from a historical perspective after certain important discoveries and the results of experimental studies.

The emerging role of arsenic trioxide as an immunomodulatory agent in the management of multiple myeloma

Multiple myeloma is a clonal disorder of plasma cells which is considered incurable with currently available therapies. Substantial advances have been achieved in the past decade with the identification of cellular mechanisms that confer drug resistance. This has resulted in newer agents such as arsenic trioxide (Trisenoxt), lenalidomide (Revlimid) and bortezomib (Velcade) with promising activity in this disease. In this review article we will outline the history, mechanisms of action, pharmacology, and clinical trials of arsenic trioxide in multiple myeloma.

[Myeloma in an archaeological skeleton from Hofstadir in Mývatnssveit]

Archaeological investigations have been ongoing in the cemetery at Hofstadir in Mývatnssveit since the summer of 1999. To date, the remains of two chapels as well as 78 skeletons have been excavated, dated to between the 11th and 15th century. A skeleton was excavated in the summer of 2003 which showed pathological changes indicative of a malignant disease. Palaeopathological cases of malignancies are very rare, and it is therefore important to report on each case. Skeleton HST-027 was a female, aged 45-50 years at the time of death. Standard osteological methods were used to determine the sex, age and stature. Macroscopic analysis was carried out on the skeleton and all pathological changes on each bone described. The cranium, ribs, left os coxa and all left long bones were then radiographed to aid in the diagnosis. The analysis showed lytic lesions in all the flat bones, as well as the vertebrae, ribs and the proximal end of the left femur, all changes indicative of multiple myeloma. Palaeopathologically myeloma and metastatic cancer (then usually due to breast cancer in the case of women) are often difficult to distinguish. However there is no new bone formation surrounding the lesions, which means that metastatic cancer is unlikely to be the cause. Skeleton HST-027 from Hofstadir is the first published case of malignant disease in Iceland, and one of the clearer cases of myeloma in an archaeological specimen, but to date, approximately twenty cases have been reported world-wide.

Treatment of multiple myeloma

Autologous peripheral blood stem cell (PBSC)-supported high-dose melphalan is now considered standard therapy for myeloma, at least for younger patients. The markedly reduced toxicity of allotransplants using nonmyeloablative regimens (mini-allotransplantations) may hold promise for more widely exploiting the well-documented graft-versus-myeloma (GVM) effect. New active drugs include immunomodulatory agents, such as thalidomide and CC-5013 (Revimid; Celgene, Warren, NJ), and the proteasome inhibitor, PS 341 (Velcade; Millenium, Cambridge, MA), all of which not only target myeloma cells directly but also exert an indirect effect by suppressing growth and survival signals elaborated by the bone marrow microenvironment's interaction with myeloma cells. Among the prognostic factors evaluated, cytogenetic abnormalities (CAs), which are present in one third of patients with newly diagnosed disease, identify a particularly poor prognosis subgroup with a median survival not exceeding 2 to 3 years. By contrast, in the absence of CAs, 4-year survival rates of 80% to 90% can be obtained with tandem autotransplantations. Fundamental and clinical research should, therefore, focus on the molecular and biologic mechanisms of treatment failure in the high-risk subgroup.

[Multiple pathology in a Merowingian individual of a graveyard near Insheim (Rhineland-Pfalz)]

The following case report describes in detail a 57 years old (+/- 5 years) male individual from a Franconian graveyard in Insheim, Province of Rhineland-Palatinate, dating to between the 6th and 7th century A.D. The individual displays a number of unusual pathologies. The atlas shows a complete aplasia of the posterior arch, probably resulting in a torticollis. The changed static induced a massive spondylar-arthrotic degeneration of the cervical spine on the right-lateral portion. On the fronto-parietal section two fractures are visible which were caused by a sharp and violent force. The area in question measures 7 by 10 cm. It has healed in a dislocated position. The second location displays marks of a 6 cm long sword-cut which did strike the skull obtusely on the left parietal. In addition to the above the skull displays on its right side a great number of small circular hole defects which also appear on ribs, vertebrae, clavicula and the mandible. They present the typical picture of a plasmocytoma. As an expression of a secondary hyperparathyreoidism one can recognize ossifications of soft tissue on the calcaneus, tibia, fibula and patella as well as intravital loss of mandibular dentition. It is quite remarkable that the individual reached a relative old age despite of his numerous and serious physical encroachments due to the apparent and obvious intentions of his aggressive contemporaries to kill him.

[Who was Mr. McBean and what resulted from his death?]

Authors present a historical overview of multiple myeloma. The first well-known case of multiple myeloma was that of Mr. McBean described in 1846, 1847, and 1850 by John Darlympe, Henry Bence Jones, and William MacIntyre. The term multiple myeloma dates from 1873, and was introduced by von Rusitzky. In 1889, Otto Kahler published the case report about Dr. Loos, his patient with multiple myeloma. In 1895, Marschalkó described the essential characteristics of plasma cells. Authors present other interesting early cases of multiple myeloma and diagnostic advances in this disease.

Malignant tumors in an ancient Egyptian population

Since it is still an open debate whether malignant tumors are mainly influenced by environmental factors, the frequency of such malignant tumors in historic populations with different living conditions is of particular interest. In the present study, we investigated the occurrence of malignant tumors affecting bone tissue in a population of mumrnies and skeletons, which had been excavated from the large necropolis of Thebes-West, Upper Egypt. Our study material comprised a series of at least 415 individuals (thereof 325 adults) dating from approx. 1500-500 B.C. All individuals had been mummified, but were severely damaged and partially broken by grave robbers, so that often only parts of the mummies/skeletons were available for investigation. The available specimens were subjected to careful macroscopic examination, while isolated findings were radiologically analyzed. Using this approach, we identified at least 4 cases showing malignant tumors affecting the skeleton. In two cases, multiple mixed osteolytic-osteoblastic lesions suggested multiple metastases from carcinomas. Two further individuals presented with multiple osteolyses (vertebra, pelvis, skull) most suggestive of multiple myeloma. The observation of at least 4 cases of malignant tumors with osseous manifestation in a series of 325 adult individuals provides clear evidence that malignant tumors were not a rare event in the ancient Egyptian study population, particularly when the limitations of a study of tumors manifested only in osseous remnants are taken into consideration. A calculation of the age- and sex-adjusted tumor frequency in our material in comparison with a recent model for such a material by Waldron (1996) indicates that the rate of malignant tumors with bone affection in our series is higher than in an English population from 1901-1905, although lower than in a comparable present day population. This clearly indicates that important factors affecting malignant tumors were effective even in historic populations.

Multiple myeloma: how did it begin?

OBJECTIVE

To present a historical overview of multiple myeloma.

DESIGN

The pertinent literature, from the early cases of this disorder to subsequent diagnostic advances, was reviewed.

RESULTS

The first well-known case of multiple myeloma (described in the 1840s) was that of Mr. McBean, a highly respectable tradesman from London. Although the features of Bence Jones proteinuria were recognized by his physician, Dr. William Macintyre, urine specimens from Mr. McBean were studied in detail by Henry Bence Jones, a well-known chemical pathologist, who confirmed the findings of Macintyre. The disease was rarely recognized until 1889, when the famous case report by Kahler was published. Interestingly, the subject of this case report (Dr. Loos) survived for 8 years despite inadequate chemotherapy. The role of plasma cells was recognized at the turn of the century. In 1922, Bayne-Jones and Wilson identified two distinct groups of Bence Jones protein, but a relationship between Bence Jones protein and the serum proteins of multiple myeloma was not demonstrated until 1956, in a study performed by Korngold and Lipari. (The designation of the two main classes of Bence Jones protein as kappa and lambda is a tribute to these two investigators.) The major breakthrough was the discovery that light chains from a serum IgG myeloma protein and the Bence Jones protein from the same patient's urine were identical.

CONCLUSION

Multiple myeloma is a devastating disorder of plasma cell proliferation in the bone marrow that can result in skeletal destruction. Immunoelectrophoresis is useful as the initial diagnostic procedure.

Prehistoric multiple myeloma

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