ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
Corporate Friday Symposium 2001
Friday, December 7, 2001
Orlando, Florida
Continuing Medical Education Information
Sponsored by the Strategic Institute for Continuing Health Care Education
Accreditation
The Strategic Institute for Continuing Health Care Education is accredited by the
Accreditation Council for Continuing Medical Education to provide
continuing medical education for physicians.
The Strategic Institute for Continuing Health Care Education designates this
continuing medical education activity for a maximum of 2 hours in category 1
credit toward the AMA Physician's Recognition Award. Each physician should
claim only those hours of credit that he/she actually spent in the educational
activity.
www.myeloma.org
www.multiplemyeloma.org
Support for this program is provided by an unrestricted educational grant from the
International Myeloma Foundation and the Multiple Myeloma Research Foundation.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
Overview
Survival and proliferation of multiple myeloma cells are largely dependent on a supportiv e
microenvironment. Targeting factors in the microenvironment and inhibiting angiogenesis
offers promising prognostic and therapeutic implications. An understanding of the impli-
cations and the pathogenic role of biological factors in the bone marrow microenviron-
ment provide a framework for emerging therapeutic management of multiple myeloma.
This symposium reviews advances in treat ment options such as the role of newly emerging
bisphosphonates and the direct antimultiple myeloma activity on multiple myeloma cells. Anti-
angiogenic and immunostimulating effects of immunomodulatory drugs (ImiDs) will be dis-
cussed, with an emphasis on the possible changes in the overal management of patients with
multiple myeloma.
Learning Objectives
Upon completion of this activity, participants will be able to:
· Evaluate advances in the treatment of multiple myeloma, including treatment options for
the newly diagnosed patient, relapse, and maintenance
· Understand disease pathogenesis as related to the development of novel therapies
and define the role of newly identified factors in the marrow microenvironment, such
as angiogenesis
· Reference pivotal data from the latest clinical trials with newly emerging bisphospho -
nates and novel immunomodulatory drugs
· Discuss drug resistance and drug development in multiple myeloma
Target Audience
This continuing medical education activity is intended for hematologists and oncologists with
an interest in treatment advances for multiple myeloma.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
Symposium Agenda
6:00 PM - 6:10 PM
Welcome and Introduction
Robert A. Kyle, MD, Program Chairman
6:10 PM - 6:25 PM
The Newly Diagnosed Patient: A Focus on
Treatment and Management Strategies
S. Vincent Rajkumar, MD
6:25 PM - 6:40 PM
Advances in Biology and Treatment of
Myeloma Bone Disease
James R. Berenson, MD
6:40 PM - 6:55 PM
Moving Disease Biology from the Lab to the Clinic
Kenneth C. Anderson, MD
6:55 PM - 7:10 PM
Drug Resistance and Drug Development in Multiple Myeloma
William S. Dalton, PhD, MD
7:10 PM - 7:25 PM
High-dose Therapy and Immunomodulatory Drugs in Multiple
Myeloma
Bart Barlogie, PhD, MD
7:25 PM - 7:40 PM
Low-dose Agents for Relapse and Maintenance
Brian G.M. Durie, MD
7:40 PM - 8:00 PM
Ask the Experts
Faculty Panel Discussion

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
Faculty
P ro gram Chairman
Robert A. Kyle, MD
Professor of Medicine and Laboratory Medicine
Mayo Clinic
Rochester, Minnesota
P re s e n te rs
Kenneth C. Anderson, MD
Director, Jerome Lipper Multiple Myeloma Center
Dana-Farber Cancer Institute
Professor of Medicine
Harvard Medical School
Boston, Massachusetts
Bart Barlogie, PhD, MD
Director, Arkansas Cancer Research Center
University of Arkansas for Medical Sciences
Little Rock, Arkansas
James R. Berenson, MD
Director, Multiple Myeloma and Bone Metastasis Programs
Cedars-Sinai Medical Center
Professor of Medicine
UCLA School of Medicine
Los Angeles, California
William S. Dalton, PhD, MD
Deputy Director, H. Lee Moffitt Cancer Center and Resear ch Institute
Chair, Interdisciplinary Oncology Program
Professor of Oncology, Medicine, and Biochemistry
University of South Florida
Tampa, Florida
Brian G.M. Durie, MD
Chairman and Medical Director
International Myeloma Foundation
Los Angeles, California
S. Vincent Rajkumar, MD
Assistant Professor of Medicine
Mayo Medical School
Rochester, Minnesota

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
Faculty Disclosure Statement
In accordance with the ACCME Standards for Commercial Support, the audience is
advised that 1 or more presentations in this continuing medical education activity
may contain references to unlabeled or unapproved uses of drugs.
As a sponsor accredited by the Accreditation Council for Continuing Medical
Education (ACCME), the Strategic Institute for Continuing Health Care Education must
ensure balance, independence, objectivity, and scientific rigor in all of its individually
sponsored or jointly sponsored educational activities. All faculty participating in a
sponsored activity are expected to disclose to the activity audience any significant
financial interest or other relationship (1) with the manufacturer(s) of any commer-
cial product(s) and/or pr ovider(s) of commercial services discussed in an educational
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cial interest or other relationship can include such things as grants or resear ch sup-
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intent of this disclosure is not to prevent a speaker with a significant financial or
other relationship from making a presentation, but rather to provide listeners with
information on which they can make their own judgments. It remains for the audience
to determine whether the speaker's interests or relationships may influence the
presentation.
Disclosure Statements
Kenneth C. Anderson, MD
Grant/Research Support: Celgene Corporation; Novartis Pharmaceuticals;
Millennium
Speakers' Bureau: Novartis Pharmaceuticals
Bart Barlogie, PhD, MD
Grant/Research Support: Celgene Corporation
James R. Berenson, MD
Grant/Research Support: Amgen; Celgene Corporation; Chogal; Millennium; Novartis
Pharmaceuticals; Pharmacia
Speakers' Bureau: Celgene Corporation; Novartis Pharmaceuticals
Consultant: Amgen; Celgene Corporation; Chogal; Millennium; Novartis
Pharmaceuticals; Pharmacia
Honorarium: Celgene Corporation; Novartis Pharmaceuticals
William S. Dalton, PhD, MD
Grant/Research Support: Novartis Pharmaceuticals
Consultant: Celgene Corporation; Novartis Pharmaceuticals
Brian G.M. Durie, MD
Speakers' Bureau: Celgene Corporation
Honorarium: Celgene Corporation; Novartis Pharmaceuticals
Robert A. Kyle, MD
Consultant: Celgene Corporation
Honorarium: Celgene Corporation; Novartis Pharmaceuticals
S. Vincent Rajkumar, MD
Research Support for Mayo Clinic Clinical Trials: Celgene Corporation

ADV
D ANCES
V
IN MULTIPLE MYELOMA:
YELOMA
PA
P THOGENESIS
A
AND TREATMENT
Robert A. Kyle, MD
Robert A. Kyle, MD, is Professor of Medicine and Professor of Laboratory Medicine at
the Mayo Medical School in Rochester, Minnesota. In addition, he is a consultant in inter-
nal medicine for the Mayo Clinic, also in Roches ter.
Dr. Kyle earned his AA at the North Dakota School of Forestry in Bottineau, his BS at the
University of North Dakota in Grand Forks, his MD with distinction at Northwestern
University Medical School in Chicago, Illinois, and his MS at the University of Minnesota,
Minneapolis. After graduating from medical school, he completed his internship at
Evanston Hospital in Evanston, Illinois. His fello wship in internal medicine and his research
fellowship in hematology were conducted at the Mayo Graduate School and Tufts University
School of Medicine, respectively.
Dr. Kyle's research interests are primarily devoted to the study and treatment of multiple
myeloma. He serves on the editorial boards for Leukemia Research, Leukemia, and
International Journal for Experimental and Clinical Investigation. He is a member of
the American Medical Association, the American Society of Hematology, the International
Society of Hematology, the New York Academy of Sciences, the American Federation for
Clinical Research, the American Association for the Advancement of Science, the
American Society of Clinical Oncology, and the American Association for Cancer Research,
among others. Dr. Kyle is a recipient of more than 65 honors and awards, including the
Waldenström Award presented by the First International Workshop on Multiple Myeloma.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
DIAGNOSIS OF MULTIPLE MYELOMA
Robert A. Kyle, MD
LEARNING OBJECTIVES
Upon completion of this educational activity, participants should be able to:
· List the diagnostic criteria for multiple myeloma
· Discuss parameters used to diagnose multiple myeloma
· Discuss the diagnostic criteria of other diseases that should be
considered in the differential diagnosis of multiple myeloma
ABSTRACT
Multiple myeloma must be considered when a patient presents with bone pain and lytic
lesions. The presence of hypercalcemia, renal insufficiency, and anemia should also
alert the physician to the possibility of multiple myeloma. An increased total protein
and/or a monoclonal pr otein in the urine or serum strongly suggests the diagnosis.
Minimal criteria for the diagnosis of multiple myeloma include a bone marrow contain-
ing more than 10% plasma cells or a plasmacytoma, in addition to at least 1 of the fol-
lowing: 1) an M-protein in the serum (usually >3 g/dL), 2) an M-protein in the urine, or
3) lytic bone lesions. The usual clinical features of multiple myeloma must be present.
Metastatic carcinoma, lymphoma, leukemia, and connective tissue disorders may
resemble multiple myeloma and must be excluded in the differential diagnosis. Multiple
myeloma must also be distinguished from monoclonal gammopathy of undetermined
significance (MGUS)1 and smoldering multiple myeloma (SMM).2
The following laboratory tests should be obtained when multiple myeloma is suspected:
1) complete blood count with differential and a peripheral blood smear, 2) serum calci-
um and creatinine, 3) serum protein electrophoresis with immunofixation and quanti-
tation of immunoglobulins, 4) routine urinalysis and a 24-hour urine collection for elec-
trophoresis and immunofixation, 5) roentgenographic metastatic bone survey including
the humeri and femurs, and 6) bone marrow aspirate and biopsy with cytogenetics and
plasma cell labeling index if available.
Electrophoresis of the serum reveals an M-spike in 80% of patients. Ninety percent of
multiple myeloma patients have a monoclonal protein in the serum and approximately
70% have a monoclonal light chain in the urine. Ninety-eight percent of patients with
multiple myeloma will have a monoclonal pr otein in the serum or urine with immunofix-
ation at the time of diagnosis. For this reason, only 2% are nonsecretory.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
Differential Diagnosis
The differential diagnosis of multiple myeloma includes MGUS, SMM, primary amyloidosis
(AL), and metastatic carcinoma.
MGUS is characterized by the absence of symptoms, an M-component of 3 g/dL or less,
fewer than 10% plasma cells in the bone marrow, and no lytic lesions, anemia, hypercal-
cemia, or renal insuffiency. A higher concentration of an M-protein is associated with a
greater likelihood of malignancy. Although an M-protein concentration greater than 3 g/dL
usually indicates overt multiple myeloma, some patients remain stable for long periods of
follow-up.3,4 The presence of monoclonal light chains in the urine (Bence Jones proteinuria)
suggests a neoplastic process. However, we have seen many patients with MGUS who
excreted small amounts of monoclonal light chain in the urine and remained stable for
many years. Even some patients with large amounts of Bence Jones proteinuria may
remain stable and not require therapy.5 A reduction in the serum level of normal polyclon-
al or background immunoglobulins is typical of multiple myeloma, but more than one third
of patients with MGUS also have a reduction in 1 or more uninvolved immunoglobulins.1 The
presence of more than 10% plasma cells in the bone marrow is characteristic of myelo-
ma, but some patients with a greater degree of plasmacytosis may remain stable for long
periods of time.2 The morphologic appearance of plasma cells is of little help unless plas-
mablastic morphologic features are present. The presence of plasmablastic morphologic
features suggests a diagnosis of multiple myeloma.6 Elevation of the serum -microglobu-
2
lin concentration, C-reactive protein level, and chromosomal abnormalities with FISH analy-
sis are unreliable for differentiation of MGUS and multiple myeloma.
SMM is characterized by an M-protein greater than 3 g/dL or greater than 10% plasma
cells in the bone marrow. These patients have no lytic bone lesions, anemia, or hypercal-
cemia. The plasma-cell labeling index is helpful in the differential diagnosis of MGUS or
SMM from multiple myeloma.7,8 The monoclonal antibody (BU-1) reactive with 5-bromo 2-
deoxyuridine identifies cells that synthesize DNA. The BU-1 monoclonal antibody does not
require denaturation and, therefore, fluorescent-conjugated immunoglobulin antisera
(kappa and lambda) identifies monoclonal plasma cells when their morphologic appearance
is atypical. An elevated plasma-cell labeling index strongly suggests the patient has or will
soon have symptomatic disease.9 Patients with SMM or MGUS have a normal plasma-cell
labeling index. However, a normal labeling index is observed in 40% of patients with symp-
tomatic multiple myeloma requiring therapy. Monoclonal plasma cells can be detected in
the peripheral blood of 80% of patients with active multiple myeloma and in more than
90% of those with relapsed or refractory myeloma. In comparison, patients with MGUS or
SMM have few or no circulating plasma cells.10
Primary amyloidosis must be considered in the differential diagnosis of multiple myeloma.
Patients with amyloidosis have tissue deposits of amyloid fibrils, which may produce
nephrotic syndrome, congestive heart failure, hepatomegaly, or peripheral neuropathy. The
bone marrow usually contains fewer than 20% plasma cells. No lytic lesions are present
and the amount of monoclonal light chain in the urine is modest. The diagnosis of amyloi-

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
dosis is established by demonstrating amyloid fibrils in a biopsy of affected tissue. The
abdominal fat and/or bone marrow are positive in 90% of patients. If the suspicion of amy-
loidosis exists after a negative fat aspirate and bone marrow biopsy, a rectal biopsy or biop-
sy of an involved organ such as the kidney, heart, sural nerve, or liver should be performed.
Metastatic carcinoma is characterized by the presence of lytic lesions; in addition,
plasmacytosis and an unrelated monoclonal gammopathy may also be present. The pres-
ence of constitutional symptoms and a small M-protein should raise the suspicion of
metastatic carcinoma.
No single technique reliably differentiates a patient with MGUS from a patient in whom
multiple myeloma or other related disorders will subsequently develop. The serum and
urine M-protein should be measured periodically and clinical and other laboratory features
should be examined to determine whether myeloma, amyloidosis, macroglobulinemia, or
lymphoproliferative disorders have developed.
Not all patients who fulfill the minimal criteria for the diagnosis of multiple myeloma should
be treated. If there are doubts about whether to begin chemotherapy immediatel y, treat-
ment should be withheld. The patient should be re-evaluated in 2 or 3 months because
some patients remain stable for long periods of time.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
REFERENCES
1. Kyle RA. "Benign" monoclonal gammopathy--after 20 to 35 years of follow-up. Mayo
Clin Proc. 1993;68:26-36.
2. Kyle RA, Greipp PR. Smoldering multiple myeloma. N Engl J Med. 1980;302:
1347-1349.
3. Bladé J, Lopéz-Guillermo A, Rozman C, et al. Malignant transformation and life
expectancy in monoclonal gammopathy of undetermined significance. Br J Haematol.
1992;82:391-394.
4. Carter A, Tatarsky I. The physiopathological significance of benign monoclonal
gammopathy: a study of 64 cases. Br J Haematol. 1980;46:565-574.
5. Kyle RA, Greipp PR. "Idiopathic" Bence Jones proteinuria: long-term follow-up in seven
patients. N Engl J Med. 1982;306:564-567.
6. Milla F, Oriol A, Aguilar J, et al. Usefulness and reproducibility of cytomorphologic
evaluations to differentiate myeloma from monoclonal gammopathies of unknown
significance. Am J Clin Pathol. 2001;115:127-135.
7. Greipp PR, Witzig TE, Gonchoroff NJ, et al. Immunofluorescence labeling indices in
myeloma and related monoclonal gammopathies. Mayo Clin Proc. 1987;62:969-977.
8. Gonchoroff NJ, Greipp PR, Kyle RA, et al. A monoclonal antibody reactive with 5-bromo-
2-deoxyuridine that does not require DNA denaturation. Cytometry. 1985;6;506-512.
9. Steensma DP, Gertz MA, Greipp PR, et al. A high bone marrow plasma cell labeling
index in stable plateau-phase multiple myeloma is a marker for early disease progres-
sion and death. Blood. 2001;97:2522-2523.
10. Witzig TE, Gertz MA, Lust JA, et al. Peripheral blood monoclonal plasma cells as a pre-
dictor of survival in patients with multiple myeloma. Blood.1996;88:1780-1787.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
SELF-ASSESSMENT QUESTIONS
1. Which of the following should alert a physician of the possible diagnosis of
multiple myeloma:
a. Bone pain and lytic lesions
b. Hypercalcemia
c. Renal insufficiency
d. Anemia
e. All of the above
2. Diagnostic criteria for multiple myeloma include:
a. Bone marrow containing more than 10% plasma cells or a plasmacytoma
b. M-protein in serum
c. M-protein in urine
d. All of the above
3. Multiple myeloma must be distinguished from:
a. Pregnancy
b. Monoclonal gammopathy of undetermined significance (MGUS)
c. Smoldering multiple myeloma (SMM)
d. Metastatic carcinoma, lymphoma, leukemia, and connective tissue disorders
e. b, c, and d only
4. The following laboratory tests should be obtained for the diagnosis of multiple
myeloma:
a. CBC with a differential count and peripheral blood smear plus serum calcium
and creatinine
b. Serum protein electrophoresis with immunofixation and quantitation
of immunoglobulins
c. Routine urinalysis and a 24-hour urine collection for electrophoresis
and immunofixation
d. Roentgenographic metastatic bone survey, including the humeri and
femurs plus bone marrow aspirate and biopsy with cytogenetics and
plasma cell labeling index if available
e. All of the above

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
S. Vincent Rajkumar, MD
S. Vincent Rajkumar, MD, is Assistant Professor of Medicine at the Mayo Medical School
in Rochester, Minnesota. In addition, he is Senior Associate Consultant for the Division of
Hematology at the Mayo Clinic, also in Roches ter.
Dr. Rajkumar earned his MBBS/MD at the University of Madras in India. After graduating,
he completed his rotary internship at the Christian Medical College Hospital in Vellore,
India, and his residency in internal medicine at the University of North Dakota School of
Medicine in Fargo. His fellowship in hematology and oncology was conducted at the Mayo
Graduate School of Medicine.
Dr. Rajkumar's research interests include angiogenesis in myeloma and other cell neo-
plasms, the evaluation of expression and the role of VEGF, bFGF, and other cytokines in
myeloma angiogenesis, thalidomide therapy for plasma cell disorders, the study of 2-
methoxyestradiol, and epidemiology of monoclonal gammopathies. He is currently Principal
Investigator and Co-investigator for 8 clinical trials. He has authored and co-authored more
than 45 articles, 8 book chapters, and 65 abstracts. Dr. Rajkumar is a member of the
American Society of Hematology, Alpha Omega Alpha, the American Medical Association,
the American Society of Clinical Oncology, the American College of Physicians, and the
American Association for Cancer Research, among others.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
MYELOMA AND THE NEWLY DIAGNOSED PATIENT:
A FOCUS ON TREATMENT AND MANAGEMENT
S. Vincent Rajkumar, MD
LEARNING OBJECTIVES
Upon completion of this educational activity, participants should be able to:
· Discuss an evidence-based approach to the management of newly diagnosed myelo-
ma and diagnostically dif ferentiate smoldering multiple myeloma (SMM), monoclonal
gammopathy of undetermined significance, and solitary plasmacytoma from multiple
myeloma (MM)
· Describe the optimum pretransplant induction regimen for MM
· Discuss outcomes for early vs delayed transplantation and 1 vs 2 transplants
· Discuss the role of maintenance therapy in MM and supportive care strategies for
patients with MM bone disease, such as the use of bisphosphonates
· Describe the role of thalidomide in SMM
ABSTRACT
Introduction
Multiple myeloma accounts for 1% of all malignancies and 10% of malignant hematologic
neoplasms.1,2 In 2001, appr oximately 14,400 new cases of myeloma will be diagnosed in
the United States and more than 11,200 patients will die of the disease.2 At present, there
is no treatment to the cure of myeloma, and median survival with standard therapy is
approximately 4 years. An evidence-based approach to the management of newly diag-
nosed myeloma, which was developed at the Ma yo Clinic, is summarized below.
MGUS
Patients with a serum M-protein less than 3g/dL, bone marrow plasma cells less than
10%, and no evidence of anemia, hypercalcemia, renal failure, or bone lesions are consid-
ered to have monoclonal gammopathy of undetermined significance (MGUS). These
patients need indefinite follow-up, as 20% to 25% will eventually progress to overt myelo-
ma, amyloidosis, or a non-Hodgkin lymphoma at a rate of 1% per year.3,4 The serum M-pro-
tein in MGUS is rechecked at 6 months. If it remains stable, it is checked yearly thereafter.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
SMM
Patients who have a serum M-protein of 3g/dL or higher and/or 10% or more of
plasma cells in the bone marrow without anemia, bone lesions, hypercalcemia, or renal
insufficiency are considered to have smoldering multiple myeloma (SMM).4,5 These patients
have a higher risk of transformation to myeloma than do those with MGUS. Many patients
meet criteria for Durie-Salmon Stage 1 myeloma. SMM patients can be observed without
therapy for months to years, and close follow-up is recommended.
Solitary Plasmacytoma
Patients with a single plasmacytoma, with no evidence of other bone or extramedullary
lesions, are considered to have a solitary plasmacytoma. The usual treatment consists of
radiation therapy in the affected area, followed by close observation. These patients also
are at risk for overt multiple myeloma, particularly if they have a residual MGUS af ter radi-
ation therapy.
Figure 1 provides a schematic approach to the management of patients with newly diag-
nosed myeloma. The first step in managing myeloma is to determine if the patient needs
therapeutic inter vention. Patients with SMM are usually closely observed without therapy.
These patients also are candidates for clinical trials that use novel agents to delay pro-
gression to active myeloma. Once therapy is indicated, the physician must determine if the
patient is a candidate for autologous stem cell transplantation.
Patients who are not candidates for autologous stem cell transplantation should receive
standard dose therapy with melphalan and prednisone. The overall response rate with this
regimen is about is 50%.6 The complete response rate is less than 10%, and the median
survival is about 3 years.7 The 5-year survival rate in patients treated with this therapy is
24%.6 More aggressive combination chemotherapy regimens such as vincristine, carmus-
tine (BCNU), melphalan, cyclophosphamide, and prednisone (VBMCP) result in superior
response rates (60% to 70%), but offer no substantial survival benefit.6,8,9
High-dose therapy followed by autologous stem cell transplantation improves response
rate and survival in myeloma, but it is not a cure.10-12 Response rates exceed 75% to 90%,7,8
and complete response rates range from 20% to 40%.11,13 A French randomized trial in
previously untreated myeloma patients showed improved survival with autologous marrow
transplantation compared with conventional chemotherapy with 5-year survival rates of
52% and 12%, respectively.13 Based on these results, stem cell transplantation is now
standard therapy for patients younger than 65 years with good performance status.
Optimum Pretransplant Induction Regimen
Although the combination of vincristine, Adriamycin, and dexamethasone (VAD) is consid-
ered the s tandard pretransplant induction therapy, it is cumbersome to administer and is
associated with substantial toxicity. Lack of response to initial VAD (primary refractory dis-
ease) does not predict poor survival following transplantation, and patients are treated

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
with transplantation regardless of response status to VAD.14 Dexamethasone accounts
for a significant proportion of the activity of VAD; although the response rate may be
lower, there is no effect on overall survival.15 For this reason, dexamethasone is a good
substitute for VAD as pretransplant induction therapy. Recent interest has focused on
the combination of thalidomide and dexamethasone as induction therapy. In a Mayo
Clinic study of 50 patients with newly diagnosed myeloma, the combination of thalido-
mide and dexamethasone resulted in a 64% response rate.16 In this study, thalidomide
was given orally at a fixed dose of 200 mg/d. Dexamethasone was given orally at a
dose of 40 mg/d orally on days 1 to 4, 9 to 12, 17 to 20 (odd cycles), and 40 mg/d
on days 1 to 4 (even cycles), repeated monthly. Grade 3 or higher toxicity was observed
in 16 patients (32%); the most frequent were venous thrombosis (10%), constipation
(8%), rash (6%), and dyspnea (4%). An upcoming Eastern Cooperative Oncology Group
randomized trial will compare dexamethasone and thalidomide plus dexamethasone as
induction therapy for myeloma.
Early vs Delayed Transplantation
Stem cell transplantation for myeloma is often performed early in the course of the dis-
ease, fol owing 3 to 4 cycles of induction chemotherapy. However, it is possible to delay
transplantation until relapse without compromising survival, provided hematopoietic
stem cells are harvested and cryopreserved early in the disease course. Data from
randomized trials comparing early versus delayed transplantation indicate that there is
no significant difference in outcome between the 2 strategies.17,18 The choice between
the 2 options is based on patient preference and other clinical conditions.
One vs Two Transplants
Currently, the role of tandem transplantation is not fully understood. Preliminary data
from 4 randomized trials were presented at the recent International Myeloma
Workshop in Banff, Alberta, Canada (May 2001). The trials indicate some improve-
ment in response rates and possibly event-free survival with tandem transplantation.
However, none of the trials showed an improvement in o verall survival using an intent-
to-treat analysis. Final results of the trials will provide an answer to this important ques-
tion. Since the role of twin/tandem transplantation is not settled, it is wise to harvest
enough stem cells for 2 transplants. At the Mayo Clinic, a single transplant is complet-
ed and the second transplant is reserved for relapse.
Role of Allogenic Transplantation
Allogenic transplantation may lead to prolonged disease-free survival in a relatively
small percentage of patients.19,20 High treatment-related mortality and toxicity has lim-
ited the role of the procedure as initial treatment. There is recent interest in studying
non-myeloablative (mini) allogenic transplantation for selected patients with myeloma,
either immediately following autologous stem cell transplantation21 or at relapse.
Currently, the role of allogenic stem cell transplantation as initial therapy in myeloma
must be considered investigational.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
Maintenance Therapy
The role of maintenance therapy in myeloma remains investigational. Several studies show
that interferon-alpha as maintenance therapy prolongs plateau phase in myeloma.22-25
However, other studies fail to show such an effect, and overall survival was not prolonged
in any study.26-28 A meta-analysis studying the role of interferon-alpha is ongoing. A nation-
wide, large randomized trial in the United States that evaluated the role of interferon-alpha
as maintenance therapy in myeloma is awaiting analysis. At low doses, prednisone also has
been studied as maintenance therapy.29 Clinical trials are being designed to study the role
of thalidomide, dendritic cell vaccination, and other novel approaches as maintenance ther-
apy following stem cell transplantation or conventional chemotherapy.
Supportive Care Strategies
Bisphosphonates such as pamidronate are routinely used in myeloma for patients with
multiple lytic bone lesions. The goal of therapy is to prevent or delay progression of lytic
bone lesions.30 Pamidronate is shown to reduce skeletal complications and improve the
quality of life of patients with myeloma.31,32 Other supportive care strategies such as pain
control measures and erythropoietin therapy should be considered.
Role of Thalidomide in Smoldering Multiple Myeloma
Thalidomide is being studied as a single agent for patients with SMM. Initial reports show
a response rate of approximately 35%.33,34 Because the main goal of therapy in patients
with SMM is to delay the need for chemotherapy, more data on the durability of response
are needed before recommending this strategy for standard clinical practice.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
Future Directions
The primary goal in myeloma is cure. Future studies will help define the role of novel agents,
improve transplant conditioning regimens, and develop effective maintenance therapy.
Figure 1. Mayo Clinic approach to newly diagnosed multiple myeloma.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
REFERENCES
1. Bataille R, Harousseau JL. Multiple myeloma. N Engl J Med. 1997;336:1657-1664.
2. Greenlee RT, Hill-Harmon MB, Murray T, Thun M. Cancer statistics, 2001. CA Cancer
J Clin.2001;51:15-36.
3. Kyle RA. Benign monoclonal gammopathy after 20 to 35 years of follow-up. Mayo
Clin Proc. 1993;68:26-36.
4. Rajkumar SV, Dispenzieri A, Fonseca R, et al. Thalidomide for previously untreated
indolent or smoldering multiple myeloma. Leukemia. 2001:15:1274-1276.
5. Greipp PR, Kyle RA. Staging, kinetics, and prognosis of multiple myeloma. In: Wiernik
PH, Canellos GP, Dutcher JP, Kyle RA, eds. Neoplastic Diseases of the Blood. New
York, NY: Churchill Livingstone; 1996:537-559.
6. Myeloma Trialists Collaborative Group. Combination chemotherapy versus melpha-
lan plus prednisone as treatment for multiple myeloma: an overview of 6,633
patients from 27 randomized trials. J Clin Oncol. 1998;16:3832-3842.
7. Kovacsovics T, Delaly A. Intensive treatment strategies in myeloma. Semin Hematol.
1997;34:49-60.
8. Alexanian R, Dimopoulos M. The treatment of multiple myeloma. N Engl J Med
1994;330:484-489.
9. Oken MM, Harrington DP, Abramson N, Kyle RA, Knospe W, Glick JH. Comparison of
melphalan and prednisone with vincristine, carmustine, melphalan, cyclophos-
phamide, and prednisone in the treatment of multiple myeloma: results of Eastern
Cooperative Oncology Group Study E2479. Cancer.1997;79:1561-1567.
10. Harousseau JL, Attal M. The role of autologous hematopoietic stem cell transplan-
tation in multiple myeloma. Semin Hematol.1997;34:61-66.
11. Barlogie B, Jagannath S, Epstein J, et al. Biology and therapy of multiple myeloma in
1996. Semin Hematol. 1997;34:67-72.
12. Gertz MA, Pineda AA, Chen MG, et al. Refractory and relapsing multiple myeloma
treated by blood stem cell transplantation. Am J Med Sci.1995;309:152-161.
13. Attal M, Harousseau JL, Stoppa AM, et al. A prospective, randomized trial of autolo-
gous bone marrow transplantation and chemotherapy in multiple myeloma:
Intergroupe Francais du Myelome. N Engl J Med. 1996;335:91-97.
14. Rajkumar SV, Fonseca R, Lacy MQ, et al. Autologous stem cell transplantation for
relapsed and primary refractory myeloma. Bone Marrow Transplant. 1999;23:
1267-1272.
15. Alexanian R, Dimopoulos MA, Delasalle K, Barlogie B. Primary dexamethasone treat-
ment of multiple myeloma. Blood. 1992;80:887-890.
16. Rajkumar SV, Hayman S, Gertz MA, et al. Combination therapy with thalidomide plus
dexamethasone (thal/dex) for newly diagnosed myeloma
(MM). Blood.
2001;98:849a.
17. Fermand JP, Ravaud P, Chevret S, et al. Early versus late high dose therapy (HDT) and
autologous peripheral blood stem cell transplantation in multiple myeloma (MM):
results of a prospective randomized trial. Blood. 1996;88(suppl 1):685a.
18. Facon T, Mary JY, Harousseau JL, et al. Front-line or rescue autologous bone mar-
row transplantation (ABMT) following a first course of high dose melphalan (HDM) in
multiple myeloma (MM): preliminary results of a prospective randomized trial (CIAM)
protocol. Blood. 1996;88(suppl):685a.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
19. Bensinger WI, Buckner CD, Anasetti C, et al. Allogeneic marrow transplantation for
multiple myeloma: an analysis of risk factors on outcome. Blood. 1996;88:2787-
2793.
20. Cavo M, Bandini G, Benni M, et al. High-dose busulfan and cyclophosphamide are
an effective conditioning regimen for allogeneic bone marrow transplantation in
chemosensitive multiple myeloma. Bone Marrow Transplant. 1998;22:27-32.
21. Molina A, Sahebi F, Maloney DG, et al. Non-myeloablative peripheral blood stem cell
(PBSC) allografts following cytoreductive autotransplants for treatment of multiple
myeloma (MM). Blood. 2000;96:168a. A2063.
22. Shustik C. Interferon in the treatment of multiple myeloma. Cancer Control. 1998;5:
226-234.
23. Mandelli F, Avvisati G, Amadori S, et al. Maintenance treatment with recombinant
interferon alfa-2b in patients with multiple myeloma responding to conventional
induction chemotherapy. N Engl J Med.1990;322:1430-1434.
24. Browman GP, Bergsagel D, Sicheri D, et al. Randomized trial of interferon mainte-
nance in multiple myeloma: a study of the National Cancer Institute of Canada Clinical
Trials Group. J Clin Oncol.1995;13:2354-2360.
25. Westin J, Rodjer S, Turesson I, Cortelezzi A, Hjorth M, Zador G. Interferon alfa-2b
versus no maintenance therapy during the plateau phase in multiple myeloma: a
randomized study: Cooperative Study Group. Br J Haematol 1995;89:561-568.
26. Salmon SE, Crowley JJ, Grogan TM, Finley P, Pugh RP, Barlogie B. Combination
chemotherapy, glucocorticoids, and interferon alfa in the treatment of multiple
myeloma: a Southwest Oncology Group study. J Clin Oncol.1994;12:2405-2414.
27. Peest D, Deicher H, Coldewey R, et al. A comparison of polychemotherapy and
melphalan/prednisone for primary remission induction, and interferon-alpha for
maintenance treatment, in multiple myeloma: a prospective trial of the German
Myeloma Treatment Group. Eur J Cancer.1995;2:146-151.
28. Ludwig H, Cohen AM, Polliack A, et al. Interferon-alpha for induction and maintenance
in multiple myeloma: results of two multicenter randomized trials and summary of
other studies. Ann Oncol. 1995;6:467-476.
29. Salmon SE, Crowley JJ, Balcerzak SP, et al. Interferon versus interferon plus pred-
nisone remission maintenance therapy for multiple myeloma: a Southwest Oncology
Group Study. J Clin Oncol.1998;16:890-896.
30. Kyle RA. The role of bisphosphonates in multiple myeloma. Ann Intern Med. 2000;132:
734-736.
31. Berenson JR, Lichtenstein A, Porter L, et al. Efficacy of pamidronate in reducing
skeletal events in patients with advanced multiple myeloma: Myeloma Aredia Study
Group. N Engl J Med. 1996;334:488-493.
32. Berenson JR, Lichtenstein A, Porter L, et al. Long-term pamidronate treatment of
advanced multiple myeloma patients reduces skeletal events: Myeloma Aredia Study
Group. J Clin Oncol.1998;16:593-602.
33. Rajkumar SV, Hayman S, Fonseca R, et al. Thalidomide plus dexamethasone
(Thal/Dex) and thalidomide alone (Thal) as first line therapy for newly diagnosed
myeloma (MM). Blood. 2000;96:168a. A722.
34. Weber DM, Rankin K, Gavino M, et al. Angiogenesis factors and sensitivity to thalido-
mide in previously untreated multiple myeloma (MM). Blood. 2000;96:168a. A724.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
SELF-ASSESSMENT QUESTIONS
1. Multiple myeloma (MM) dif fers from smoldering multiple myeloma (SMM) and mono-
clonal gammopathy of undetermined significance (MGUS) because:
a. In SMM and MGUS there is no evidence of hypercalcemia, renal insufficiency, or
anemia
b. In SMM and MGUS there is no evidence of bone lesions
c. With immediate chemo therapy SMM can be cured
d. All of the above
e. Only a and b
2. Standard dose therapy with melphalan and prednisone:
a. Is for patients who are not candidates for autologous stem cell transplantation
b. Has an overall response rate of 50%, a complete response rate of less than 10%,
and median survival of about 3 years
c. Has inferior survival compared with more aggressive combination chemotherapy
regimens
d. All of the above
e. Only a and b
3. High-dose chemotherapy followed by autologous stem cell transplantation:
a. Improves response rate and survival in myeloma
b. Is considered a cure for MM
c. Has response rates that are less than 50% and complete response rates that
range from 5% to 10%
d. Only a and c
e. All of the above
4. There is no significant difference in outcome between early vs delayed transplantation,
and the choice is based on patient preference and other clinical conditions.
a. True
b. False
5. The goal of adjuvant bisphosphonate therapy is to prevent or delay progression of lytic
bone lesions.
a. True
b. False
6. Thalidomide is being studied:
a. As a single agent for patients with SMM
b. In combination with dexamethasone for induction therapy for MM
c. As therapy for refractory myeloma
d. Only b and c
e. All of the above

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
James R. Berenson, MD
James R. Berenson, MD, is Professor of Medicine for the Hematology-Oncology Division at
the University of California, Los Angeles (UCLA) School of Medicine. In addition, he is
Director of the Multiple Myeloma and Bone Me tastasis Programs at Cedars-Sinai Medical
Center, also in Los Angeles.
Dr. Berenson earned his BS in biology with distinction at Stanford University in Stanford,
California, and his MD at the University of California, San Diego. After graduating, he
completed his internship and residency in internal medicine at the University of Utah
Medical Center in Salt Lake City. His fellowship in hematology and oncology was conducted
at the UCLA School of Medicine.
Dr. Berenson's research interests include the study of antibodies, T-cell receptors,
cytokines, oncogenes, viruses, bone disease, stem cell transplants in human lymphoid
malignancies, and the treatment of metastatic bone disease and lymphoid malignancies.
He has authored and co-authored more than 460 articles, book chapters, papers, reviews,
and abstracts concerning these and related topics. His articles are published in presti-
gious journals such as Blood, Science, the New England Journal of Medicine, and
Journal of Clinical Investigation. He is a member of the American College of Physicians,
the American Federation for Clinical Research, the American Society of Clinical Oncology,
the American Association for Cancer Research, and the American Society of Hematology.
He is on the Scientific Boards of the Multiple Myeloma Research Foundation, Lymphoma
and Leukemia Society, the Lymphoma Research Foundation, and the International Myeloma
Foundation, among others. Dr. Berenson is named among the 2000 Outstanding
Scientists of the 20th Century.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
ADVANCES IN BIOLOGY AND TREATMENT OF MYELOMA BONE DISEASE
James R. Berenson, MD
LEARNING OBJECTIVES
Upon completion of this educational activity, participants should be able to:
·Describe the cytokine network involved in myeloma bone disease
·Describe the signaling cascade involved in os teoclastogenesis
·Describe mechanisms of action of novel therapeutic options for myeloma bone dis-
ease, such as osteoprotegerin (OPG), RANK-human immunoglobulin fusion pr otein
(RANK-Fc), proteasome inhibitor PS-341, and bisphosphonates
·Summarize the latest clinical trial results using oral and intravenous bisphospho-
nates for bone disease in multiple myeloma
ABSTRACT
The major clinical manifestations of multiple myeloma (MM) are related to bone loss. Bone
loss often leads to pathologic fractures, spinal cord compression, hypercalcemia, and bone
pain. Enhanced bone loss occurs because of the stimulation of the cells responsible for
bone resorption (the osteoclasts) and results from the interplay between tumor cells,
other nonmalignant cells in the bone marrow microenvironment, and bone-resorbing
osteoclasts.
Osteoblasts (the bone-forming cells) and the stromal cells have been shown to bind direct-
ly to osteoclasts and their precursors. This binding stimulates enhanced osteoclast activi-
ty and results in increased bone resorption. A number of cytokines have been implicated
in myeloma bone disease. Most of their activity results from indirect effects on other cells
in the bone microenvironment. The interaction of stromal cells and osteoblasts with osteo-
clasts that result in osteoclast activation is mediated by receptor activator of nuclear fac-
tor-B (RANK) expressed on the surface of osteoclasts and its ligand, RANKL, on
osteoblasts and stromal cells. Many of the cytokines implicated in myeloma bone disease
stimulate RANKL expression, ultimately enhancing RANK--RANKL signaling. Recent stud-
ies show that the malignant plasma cells from myeloma patients express RANKL and can
directly stimulate osteoclast development.
Importantly, a soluble decoy receptor called osteoprotegerin (OPG) binds RANKL and pre-
vents binding of the ligand to RANK. It is the delicate balance between soluble OPG and
RANKL that determines the amount of bone loss. In studies with murine models, OPG pre-
vented and reversed hypercalcemia of malignancy and blocked cancer-induced bone

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
destruction. OPG is now being evaluated in early clinical trials in myeloma and breast can-
cer patients with bone metastases. In vitro studies show that inhibitors of RANK--RANKL
signaling, including OPG and RANK-human immunoglobulin fusion protein (RANK-Fc), also
prevent myeloma cell-induced osteoclast development. Several studies show that inhibition
of the RANK--RANKL interaction by other inhibitors, such as RANK-Fc or TR-Fc, reduces
bone loss and tumor burden in murine models of myeloma. The new proteasome inhibitor,
PS-341, which inhibits NF-B activity, may also inhibit RANK signaling and be an effective
inhibitor of bone resorption.
The demonstration that bisphosphonates reduce skeletal complications and effectively
palliate symptoms related to bone disease in myeloma patients has resulted in a positive
and dramatic change. Because these agents lack significant bone marrow suppressive
effects, they can be administered as an adjunct to other cyt otoxic therapy. Newer, more
potent nitrogen-containing bisphosphonates are in active development and offer the poten-
tial to further reduce bone-related problems while improving the overall outcome of myelo-
ma patients.
Bisphosphonates are analogues of endogenous pyrophosphate (PP) in which a carbon
atom replaces the central atom of oxygen. The carbon substitution allows 2 additional
chains of variable structure so that different compounds with marked dif ferences in anti-
bone resorptive potency may be produced. These drugs have limited bioavailability (usually
<1%) and are also poorly tolerated orally, with significant gastrointestinal toxicity. The bis-
phosphonates are almost exclusively eliminated through renal excretion. Although signifi-
cant nephrotoxicity can occur, this is clearly related to the drug dose and rate of intra-
venous infusion. Impor tantly, this renal dysfunction results from the bisphosphonate back-
bone so that the newer, more potent bisphosphonates can be more rapidly administered
at therapeutic doses without significant risk of nephrotoxicity.
The inhibition of bone resorption occurs as a result of the direct and indirect effect of these
drugs on osteoclasts. Bisphosphonates were first shown to reduce osteoclast develop-
ment from their precursors as well as inhibit movement of osteoclasts to the bone surface
where they would normally reabsorb bone. These drugs are also capable of inducing apop-
tosis of osteoclasts, as well as tumor cells from myeloma patients. This has been shown to
occur as a result of inhibition of the mevalonic acid pathway, particularly in nitrogen-con-
taining bisphosphonates. Statin drugs that lower cholesterol also block enzymes in this
same pathway. Both types of drugs work to induce apoptosis by preventing the placement
of geranylgeranylated derivatives on specific intracellular proteins. Cholesterol-lowering
statin drugs have recently been shown to increase bone formation in rodent models, pos-
sibly by their induction of bone morphogenetic protein-2 (BMP-2), as well as their ability to
induce apoptosis of osteoclasts. In addition, this protein has been recently shown to induce
apoptosis of myeloma cells, providing additional rationale for using these drugs to treat
myeloma patients.
Bisphosphonates have many potential antimyeloma mechanisms of action, including reduc-
ing interleukin-6 (IL-6) levels, inducing apoptosis of malignant plasma cells, inhibiting angio-

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
genesis, and stimulating T-cell subsets that show antiplasma cell activity. In addition,
several animal models of human myeloma show antimyeloma ef fects of the nitrogen-con-
taining agents.
Small, open-label trials involving bisphosphonates suggest their potential role in myeloma
patients. The first 2 published, randomized, double-blind, placebo-controlled trials using
daily oral etidronate (5 mg/kg/d) or clodronate (2400 mg/d) in newly diagnosed patients
who also received oral melphalan and prednisone showed no clinical benefit, although
fewer patients developed new lytic lesions in the clodronate-treated group. In another ran-
domized trial involving oral clodronate, 536 newly diagnosed multiple myeloma patients
received either 1600 mg of drug or placebo daily in addition to chemotherapy. Although
fewer patients treated with clodronate experienced severe hypercalcemia and vertebral or
nonvertebral fractures, there were no differences in the time to first skeletal event or
requirement for radiotherapy. The drug had no significant effect on pain (except back pain)
at a single time point (24 months), and performance status was also unaffected except at
this same time point. Oral pamidronate (300 mg/d) was compared with placebo in 300
newly diagnosed myeloma patients also receiving intermittent oral melphalan and pred-
nisone. Pamidronate had no effect on skeletal-related morbidity or survival.
Several small, open-label studies suggest the possible benefit of infusional pamidronate in
myeloma patients. As a result, a large, placebo-controlled trial was conducted with 392
myeloma patients with Durie-Salmon stage III multiple myeloma and at least 1 lytic
lesion who were randomized to receive monthly 4-hour infusions of either placebo or
pamidronate (90 mg) for 21 cycles. Patients receiving pamidronate showed a reduction in
the likelihood of having a skeletal complication, less bone pain, and no increase in analgesic
use or deterioration in performance status or quality of life, in contrast to placebo patients.
Although there was no dif ference in overall survival between the pamidronate and placebo
groups (392 patients), patients receiving pamidronate who were on salvage antimyeloma
therapy showed a median survival of 21 months compared with 14 months for placebo
patients.
More potent bisphosphonates (zoledronic acid and ibandronate) are being evaluated clini-
cally. Very small doses of these agents effectively restore normocalcemia in patients with
tumor-induced hypercalcemia. Recent results show the superiority of zoledronic acid (4 mg
or 8 mg) compared with pamidronate (90 mg) in reversing hypercalcemia of malignancy,
and has led to the recent Food and Drug Administration approval of the newer bisphos-
phonate, zoledronic acid, for patients with this metabolic disorder. Both zoledronic acid
and ibandronate are also being evaluated for the treatment of patients with bone metas-
tases. Ibandronate has been evaluated in a phase III, placebo-controlled trial of 214 myelo-
ma patients, where it proved ineffective at a dose of 2 mg monthly. Zoledronic acid can be
given safely over 15 minutes and can produce similar antiresorptive ef fects, as assessed
by bone resorption marker as 90 mg of pamidronate. A randomized, phase II study com-
paring monthly infusions of zoledronic acid (0.4 mg, 2.0 mg, or 4.0 mg as a 5-minute infu-
sion) to pamidronate (90 mg as a 2-hour infusion) in 280 patients with lytic bone metas-
tases (109 myeloma) shows that the 0.4-mg dose is ineffective. A recently completed

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
phase III trial involving 1648 patients with myeloma or breast cancer metastatic to bone
shows that monthly administration of zoledronic acid (4 mg) infused over 15 minutes is
safe and equally effective as pamidronate (90 mg) infused over 2 hours in reducing skele-
tal complications among these patients.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
SELECTED READINGS
Altamirano CV, et al. Program and Abstracts of the 43rd Annual Meeting of the American
Society of Hematology; December 7-11, 2001; Orlando, Fla.
Berenson JR, Lipton A. Pharmacology and clinical efficacy of bisphosphonates. Curr Opin
Oncol.1998;10:566-571.
Berenson JR, Rosen LS, Howell A, et al. Zoledronic acid reduces skeletal-related events in
patients with osteolytic metastases. Cancer. 2001;91:1191-1200.
Berenson J, Rosen L, Vescio R, et al. Pharmacokinetics of pamidronate disodium in
patients with cancer with normal or impaired renal function. J Clin Pharmacol.
1997;37:285-290.
Body JJ, Lortholary A, Romieu G, et al. A dose-finding study of zoledronate in
hypercalcemic cancer patients. J Bone Miner Res.1999;14:1557-1561.
Green JR, Muller K, Jaeggi KA. Preclinical pharmacology of CGP 42'446, a new, potent, het-
erocyclic bisphosphonate compound. J Bone Miner Res. 1994;9:745-751.
Green JR, Seltenmeyer Y, Jaeggi KA, et al. Renal tolerability profile of novel, potent bisphos-
phonates in two short-term rat models. Pharmacol Toxicol. 1997;80:225-230.
Greipp P, et al. Program and Abstracts of the 43rd Annual Meeting of the American
Society of Hematology; December 7-11, 2001; Orlando, Fla.
Hofbauer LC, Heufelder AE. The role of osteoprotegerin and receptor activator of nuclear
factor Kappa B ligand in the pathogenesis and treatment of rheumatoid arthritis. Arthritis
& Rheum. 2001;44:253-259.
Kawamura C, Kizaki M, Yamato K, et al. Bone morphogenetic protein-2 induces
apoptosis in human myeloma cells with modulation of STAT3. Blood. 2000;96:
2005-2011.
Major P, Lortholary A, Hon J, et al. Zoledronic acid is superior to pamidronate in the treat-
ment of hypercalcemia of malignancy: a pooled analysis of two randomized, controlled clin-
ical trials. J Clin Oncol. 2001;19:558-567.
Mundy GR. Mechanisms of osteolytic bone destruction. Bone.1991;12:S1-S6.
Mundy G, Garrett R, Harris S, et al. Stimulation of bone formation in vitro and in rodents by
statins. Science. 1999;286:1946-1949.
Oyajobi BO, Anderson DM, Traianedes K, et al. Therapeutic efficacy of a soluble receptor
activator of nuclear factor kappaB-IgG Fc fusion protein in suppressing bone resorption
and hypercalcemia in a model of humoral hypercalcemia of malignancy. Cancer Res.
2001;61:2572-2578.
Rosen L, Gordon D, Antonio BS, et al. Zoledronic acid versus pamidronate in the treatment
of skeletal metastases in patients with breast cancer or osteolytic lesions of multiple
myeloma: a phase III, double-blind comparative trial. Cancer J. 2001;7:377-387.
Stashenko P, Dewhirst FE, Rooney ML, et al. Interleukin-1 beta is a potent inhibitor of bone
formation in vitro. J Bone Miner Res. 1987;2:559-565.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
SELF-ASSESSMENT QUESTIONS
1. Receptor activator of nuclear factor-B (RANK):
a. Mediates the interaction of stromal cells and osteoblasts with osteoclasts
b. Is expressed on the surface of osteoclasts
c. Is a receptor
d. Its ligand (RANKL) is expressed on osteoblasts and stromal cells
e. All of the above
2. Which of the following is correct:
a. Osteoprotegerin (OPG) promotes RANK-RANKL signaling
b. RANK-Fc promotes RANK-RANKL signaling
c. PS-341 promotes RANK-RANKL signaling
d. OPG, RANK-Fc, and PS-341 inhibit RANK-RANKL signaling
e. None of the above
3. Bisphosphonates:
a. Have limited oral bioavailability
b. Inhibit bone resorption
c. Act directly and indirectly on osteoclasts
d. Promote myeloma cell growth
e. a, b, and c only
4. Bisphosphonates:
a. Reduce interleukin-6 le vels
b. Induce myeloma cell apoptosis
c. Inhibit angiogenesis
d. Stimulate T-cell subsets that show antiplasma cell activity
e. All of the above
5. Clinical trials of oral bisphosphonates showed no clinical benefit on time to first skele-
tal-related events.
a. True
b. False
6. Clinical trials of intravenous bisphosphonates, zoledronic acid, and/or pamidronate
reduced skeletal complications in patients with myeloma, breast cancer, and pros-
tate cancer.
a. True
b. False

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
Kenneth C. Anderson, MD
Kenneth C. Anderson, MD, is Independent Investigator in the Hematologic Malignancies
Disease Center at the Dana-Farber Cancer Institute and Associate Professor of Medicine
at Harvard Medical School, bo th in Boston, Massachusetts.
Dr. Anderson graduated from Johns Hopkins Medical School in Baltimore, Maryland,
where he trained in internal medicine. He completed his training in hematology, medical
oncology, and tumor immunology at the Dana-Farber Cancer Institute.
Dr. Anderson's resear ch interests include cellular and molecular mechanisms regulating
myeloma cell growth and survival and novel immune-based therapies for myeloma. He host-
ed the 1997 VI International Workshop on Multiple Myeloma in Boston. He ser ves on the
Board of Directors and Board of Scientific Advisors of the International Myeloma
Foundation and is Chairman of the Board of Scientific Advisors of the Multiple Myeloma
Research Foundation. Dr. Anderson is the recipient of the Doris Duke Distinguished Clinical
Scientist Award in 1999.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
MOVING DISEASE BIOLOGY FROM THE LAB TO THE CLINIC
Kenneth C. Anderson, MD
LEARNING OBJECTIVES
Upon completion of this educational activity, participants should be able to:
· Describe the mechanisms by which multiple myeloma (MM) cells home to the bone
marrow and adhere to BM stromal cells (BMSCs) and extracellular matrix pro-
teins, as well as the functional sequelae of this binding
· Identify adhesion molecules mediating MM cell binding to BMSCs and discuss the-
growth and survival advantage conferred by this binding
· Discuss the biologic significance of cytokines in MM pathogenesis and describe the
signaling cascades mediating their effects
· Describe apoptotic and targeted therapeutic strategies to overcome drug resist-
ance based on interrupting growth or triggering apoptotic-signaling cascades
· Describe mechanisms of action of novel biologically based therapies, such as
thalidomide/immunomodulatory drugs (Thal/ImiDs), proteasome inhibitor PS-341,
arsenic trioxide (As O ), 2-methoxyestradiol, -lapachone, and AE-941 (Neovastat),
2
3
directed at targets in the MM cell and its microenvironment and their related clini-
cal trials
ABSTRACT
Kenneth C. Anderson, MD, and investigators at the Jerome Lipper Multiple Myeloma
Center, Dana-Farber Cancer Institute, in Boston, Massachusetts, addressed the need for
novel therapies for the treatment of multiple myeloma (MM) in their studies. Long-term
research has characterized the mechanisms of MM cells that integrate with the bone
marrow (BM) and adhere to BM stromal cells (BMSCs) and extracellular matrix proteins.
The functional sequelae of this binding has also been characterized to identify targets for
novel therapies. The studies have identified adhesion molecules that mediate MM cell bind-
ing to BMSCs, as well as the growth and survival advantage conferred by this binding.1
Adhesion of MM cells to BMSCs mediates resistance to drug-induced apoptosis and trig-
gers the paracrine nuclear factor (NF)-Bdependent transcription and secretion of inter-
leukin-6 (IL-6; the major MM growth and survival factor in BMSCs).2 In addition, MM cells
are shown to be localized in the BM milieu secrete cytokines (tumor necrosis factor-
[TNF-], tumor growth factor- [TGF-], and vascular endothelial growth factor [VEGF]),
which further upregulate IL-6 secretion in BMSCs.3-5 Within the BM microenvironment, the
study demonstrates that these cytokines mediate growth, survival, and migration of MM
cells and triggers angiogenesis.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
After establishing the biologic significance of cytokines in MM pathogenesis, the study
delineates signaling cascades that mediate the effects. For example, the study shows that
IL-6 and VEGF trigger proliferation of MM cells via mitogen-activated protein kinase (MAPK)
signaling,5,6 and that VEGF induces MM cell migration via a protein kinase C (PKC) depend-
ent pathway.5 Although TNF- does not directly alter MM cell growth and survival, the study
shows that it induces NF-Bdependent changes in cell surface expression of adhesion
molecules on MM cells and BMSCs, resulting in increased binding and related IL-6 tran-
scription and secretion in BMSCs.3 In studies of apoptosis, gamma irradiation (IR), Fas, and
dexamethasone (Dex) induced MM cell apoptosis are shown to be mediated by distinct sig-
naling cascades.7-9 For example, Dex- (but not IR or Fas) triggered apoptosis is mediated via
activation of related adhesion focal tyrosine kinase (RAFTK).10 Furthermore, Dex-mediated
MM apoptosis is not associated with mitochondrial cytochrome c release,9 but is mediat-
ed by second mitochondria activator caspase (Smac) release from mitochondria.11
Cytosolic Smac disrupts the X-linked inhibitor of apoptosis (XIAP)/caspase 9 complex,
thereby allowing activation of caspase 9, caspase 3 cleavage, and apoptosis. Conversely, IL-
6 inhibits apoptosis triggered by Dex (but not IR) via Akt signaling12 and specific activation
of Src-homology-2containing phosphatase (SHP2), thereby blocking activation of RAFTK.13
We have recently begun using gene microarray to further delineate these growth and anti-
apoptotic pathways and to derive targeted therapeutic strategies for overcoming drug
resistance based on interrupting growth or triggering apoptotic signaling cascades.14
We have also developed models for the evaluation of cellular and molecular events regu-
lating the growth, survival, and migration of human MM cells in vivo. Specifically, we pio-
neered the SCID-hu model of human MM in which human fetal bone grafts are implanted
bilaterally in the flanks of SCID mice.15 Human MM cells implanted in the grafts proliferate
and trigger IL-6 secretion in BMSCs, secrete MM idiotypic protein detectable in mouse
serum, and migrate to the contralateral human BM graft, but not to murine BM. The in
vivo model of human MM provides a means for identifying adhesion molecules that medi-
ate specific homing of human MM cells as opposed to murine, BM microenvironment, as
well as for studying the role of microenvironmental factors (cytokines, angiogenesis) in MM
pathogenesis. More recently, we have established a beige-nude-xid mouse model that
allows for simultaneous in vivo measurement of MM cell growth and angiogenesis.16
Importantly, both models that facilitate studies of MM pathogenesis also provide a ready
means for assessing the effects of novel agents on human MM cell growth, cytokine pro-
duction, angiogenesis in vivo, and for correlating in vivo vs in vitro mechanisms of anti-MM
activity.
To develop mechanisms of action for novel biologically based therapies, we have used these
systems in the past 3 years to define novel therapeutic agents directed at targets in the
MM cell and its microenvironment. The studies were translated from bench to bedside in
related clinical trials: Thalidomide/Immunomodulatory Drugs (Thal/IMiDs),5,16-20 PS-341,3,21
and Arsenic trioxide (As2O3).22 Specifically, increased angiogenesis in MM BM, coupled with
the known anti-angiogenesis activity of Thal, provided the rationale for its use to treat
refractory MM. Our research, in addition to other research, shows remarkable responses

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
in MM refractory to all other known therapies. To date, our studies demonstrate that Thal
and IMiDs act to inhibit angiogenesis directly and induce apoptosis or G1 growth arrest in
MM cells; are refractory to conventional therapy17,23; abrogate the adhesion of MM cells t o
BMSCs and related protection against apoptosis18; block the increased secretion of MM
growth, survival, and migratory factors (including IL-6 and VEGF) triggered by binding of
MM cells to BMSCs16,18; expand patients' NK cell numbers and functions against human
MM cells19; and downregulate protectin expression in MM cells,24 thereby enhancing their
susceptibility to antibody-dependent cellular cytotoxicity (ADCC). Using our SCID model, we
show that Thal/IMiDs mediate anti-MM activity and anti-angiogenesis in vivo.16 Molecular
targets of these therapies have been characterized and NF-B was identified in our pre-
liminary studies.17,20 We translated the preclinical studies into ongoing, derived, clinical
treatment protocols using Thal and a phase I trial of the IMiD CC 5013. Remarkably, 15 of
19 patients with MM refractory to high-dose therapy and Thal achieved either stable dis-
ease or responded to escalating doses (5 mg to 25 mg) of IMiD CC 5013. All patients
treated with 50 mg have stabilized or responded to IMiD CC 5013 with no side effects
other than leukopenia. Encouraging preliminary clinical data validate the potential of our
preclinical models for developing therapies that target the MM cell and its microenviron-
ment, which can overcome classical drug resistance and improve patient outcome. In
ongoing studies, we will characterize NF-B as an in vitro and in vivo target of these ther-
apies to pr ovide the frame work for more potent, less toxic, and specific therapies.
Proteasome inhibitor PS-341 represents a second class of therapeutics that targets the
MM cell and its microenvironment, which has recently been studied in our laboratory.
Based on prior studies, IL-6 is the major growth and survival factor for human MM cells.25
Because MM cell adhesion to BMSCs triggers the transcription and secretion of IL-6 in
BMSCs via an NF-Bdependent mechanism,2 we reasoned that blockade of NF-B using
the proteasome inhibitor PS-341 may mediate anti-MM activity by inhibiting paracrine IL-6
production in BMSCs. Our studies demonstrate that PS-341 acts directly on MM cells to
induce apoptosis of MM cells resistant to known conventional therapies. In addition, it over-
comes the protective effects of IL-6, adds to the anti-MM effects of Dex,21 and inhibits the
binding of MM cells to BMSCs (the NF-Bdependent transcription and secretion of IL-6
triggered by MM to BMSC adhesion, and BM angiogenesis). Together with phase I studies
of PS-341, the study demonstrates that 9 of 30 patients responded (including 2 of 2 MM
patients treated) with a favorable toxicity profile. Our studies provided a strong rationale
for an ongoing multicenter phase II trial of PS-341 in MM. To date, 75 patients with refrac-
tory relapsed MM have been treated nationwide. Of 6 patients with MM refractory to high-
dose therapy and Thal treated at our center, 2 achieved partial response and the other 4
achieved stable disease. This remarkable anti-MM activity not only provides a strong
rationale for including these agents in therapeutic armamentarium, but it also strongly
suggests NF-B as a potential therapeutic target in MM. Recent studies, however, using
the specific IB kinase inhibitor PS-1145 suggest that it alters adhesion and cytokine
secretion in BM without directly acting on the MM cell. This suggests that NF-B inhibition
cannot account for all the anti-MM activity of PS-341.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
Recent studies in our laboratory have also identified As O as a third agent targeting the
2
3
MM cell and its microenvironment. At clinically achievable levels, As2O3 induces apoptosis
of drug-resistant MM cell lines and patient cells via caspase 9 activation, adds to Dex, and
can overcome the anti-apoptotic effects of IL-6 in vitro.22 It also decreases MM cell binding
to BMSCs, inhibits IL-6 and VEGF secretion in BMSCs induced by MM cell adhesion, and
blocks proliferation of MM cells that adhere to BMSCs. Like Thal/IMiD and PS-341, As2O3
inhibits NF-B activation as one of its in vitro bioactivities. A derived clinical trial of As2O3 is
ongoing at our center. Other agents acting on the tumor cell and the BM microenviron-
ment include 2-methoxyestradiol (2ME2), -lapachone, and AE-941 (Neovastat), a multi-
functional anti-angiogenic compound.26 These agents are in late preclinical and clinical
trials.
To further identify molecular therapeutic targets, we have analyzed in vitro effects of var i-
ous therapeutic agents on the molecular profile of MM cells and cell lines. We have also
evaluated dif ferences between drug-resistant and drug-sensitive cell lines. In studies ana-
lyzing the effects of in vitro Dex treatment of MM cells on gene expression using high-den-
sity oligonucleotide microarray,14 we have observed early transient induction of the number
of genes involved in cell defense/repair machinery, followed by induction of genes known to
mediate cell death and repression of growth and survival. Our studies show that Dex
induces IBb transcripts. This is confirmed by northern blotting, as well as increased IBb
protein expression. The findings suggest that at least in part, Dex downregulates NF-B
activity in MM cells, by the induction of IBa. These data further support NF-B as a ther-
apeutic target, and also may, in part, account for the in vitro sensitivity and clinical respons-
es in MM to proteasome inhibitor PS-341. Conversely, in comparing gene expression pro-
files of Dex-sensitive versus Dex-resistant MM cells, increased gene and protein expression
of ubiquitin-related enzymes are observed. This is consistent with a potential role in con-
ferring drug resistance. In summary, novel agents that act on the MM cell and the BM
microenvironment represent a new treatment paradigm to overcome drug resistance and
improve patient outcome in MM. Understanding the in vivo molecular targets and mecha-
nisms of action of these agents will promote more specific, potent, and less toxic
therapies.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
REFERENCES
1. Teoh G, Anderson C. Interaction of tumor and host cells with adhesion and extracel-
lular matrix molecules in the development of multiple myeloma. Hematol/Oncol Clin
North Am.1997;11:27-42.
2. Chauhan D, Uchiyama H, Akbarali Y, et al. Multiple myeloma cell adhesion-induced
interleukin-6 expression in bone marrow stromal cells involves activation of NF-kappa
B. Blood. 1996;87:1104-1112.
3. Hideshima T, Chauhan D, Schlossman R, Richardson P, Anderson KC. The role of
tumor necrosis factor in the pathophysiology of human multiple myeloma: therapeu-
tic applications. Oncogene. 2001;20:4519-4527.
4. Urashima M, Ogata A, Chauhan D. Transforming growth factor-beta1: differential
effects on multiple myeloma versus normal B cells. Blood. 1996;87:1928-1938.
5. Podar K, Tai YT, Davies FE, et al. Vascular endothelial growth factor triggers signal-
ing cascades mediating multiple myeloma cell growth and migration. Blood.
2001;98:428-435.
6. Ogata A, Chauhan D, Teoh G, et al. Interleukin-6 triggers cell growth via the ras-
dependent mitogen-activated protein kinase cascade. J Immunol. 1997:2212-2221.
7. Chauhan D, Kharbanda S, Ogata A. Interleukin-6 inhibits Fas-induced apoptosis and
stress-activated protein kinase activation in multiple myeloma cells. Blood. 1997;89:
227-234.
8. Chauhan D, Pandey P, Ogata A, et al. Dexamethasone induces apoptosis of multiple
myeloma cells in a JNK/SAP kinase independent mechanism. Oncogene.1997;15:
837-843.
9. Chauhan D, Pandey P, Ogata A, et al. Cytochrome-c dependent and independent
induction of apoptosis in multiple myeloma cells. J Biol Chem. 1997;272:29995-
29997.
10. Chauhan D, Hideshima T, Pandey P. RAFTK/PYK2-dependent and -independent
apoptosis in multiple myeloma cells. Oncogene.1999;18:6733-6740.
11. Chauhan D, Hideshima T, Rosen S, Reed JC, Kharbanda S, Anderson KC. Apaf-
1/Cytochrome c-independent and Smac-dependent induction of apoptosis in multiple
myeloma cells. J Biol Chem. 2001;276:24453-24456.
12. Hideshima T, Nakamura N, Chauhan D, Anderson K. Biologic sequelae of interleukin-
6 induced PI3-K/AKT signaling in multiple myeloma. Oncogene. 2001. In press.
13. Chauhan D, Pandey P, Hideshima T, et al. SHP2 mediates the protective effect of
interleukin-6 against dexamethasone-induced apoptosis in multiple myeloma cells.
J Biol Chem. 2000;275:27845-27850.
14. Chauhan D, Auclair D, Robinson EK, et al. Identification of genes regulated by
dexamethasone in multiple myeloma cells using oligonucleotide arrays. Oncogene.
2001. Submitted for publication.
15. Urashima M, Chen BP, Chen S, et al. The development of a model for the homing of
multiple myeloma cells to human bone marrow. Blood.1997;90:754-765.
16. Lentzsch S, LeBlanc R, Podar K, et al. Thalidomide and its immunomodulatory
analogs inhibit human multiple myeloma cell growth and angiogenesis in vivo. Blood.
2001. Submitted for publication.

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PATHOGENESIS AND TREATMENT
17. Hideshima T, Chauhan D, Shima Y, et al. Thalidomide and its analogs overcome drug
resistance of human multiple myeloma cells to conventional therapy. Blood.
2000;96:2943-2950.
18. Gupta D, Treon SP, Shima Y, et al. Adherence of multiple myeloma cells to bone mar-
row stromal cells upregulates vascular endothelial growth factor secretion: thera-
peutic applications. Leukemia. 2001. In press.
19. Davies FE, Raje N, Hideshima T, et al. Thalidomide and immunomodulatory derivatives
augment natural killer cell cytotoxicity in multiple myeloma. Blood. 2001;98:210-216.
20. Mitsiades N, Mitsiades CS, Poulaki V, et al. Apoptotic signaling induced by
immunomodulatory thalidomide analogs (IMiDs) in human multiple myeloma:
therapeutic implications. Blood. 2001. Submitted for publication.
21. Hideshima T, Richardson P, Chauhan D, et al. The proteasome inhibitor PS-341
inhibits growth, induces apoptosis, and overcomes drug resistance in human multi-
ple myeloma cells. Cancer Res. 2001;61:3071-3076.
22. Hayashi T, Hideshima T, et al. Arsenic trioxide inhibits growth of human multiple
myeloma cells in the bone marrow microenvironment. Blood. 2001. In press.
23. Singhal S, Mehta J, Desikan R, et al. Anti-tumor activity of thalidomide in refractory
multiple myeloma. N Engl J Med. 1999;341:1565-1571.
24. Treon SP, Mitsiades C, Mitsiades N, et al. Tumor cell expression of CD59 is
associated with resistance to CD20 serotherapy in B-cell malignancies.
J Immunother. 2001;24:263-271.
25. Hallek M, Bergsagel PL, Anderson KC. Multiple myeloma: increasing evidence for a
multistep transformation process. Blood.1998;91:3-21.
26. Gimgras. 4E-BP1, a repressor of mRNA translation, is phosphorylated and inactivat-
ed by the Akt(PKB) signaling pathway. Genes Development.1997;12:502-513.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
SELF-ASSESSMENT QUESTIONS
1. Interleukin-6 in myeloma:
a. Is the major growth factor
b. Is the major survival factor
c. Is secreted in bone mar row stromal cells
d. Is triggered by adhesion of myeloma cells to bone marrow stromal cells
e. All of the above
2. Cytokines:
a. Inhibit growth, survival, and migration of myeloma cells
b. Are secr eted by myeloma cells
c. Are insignificant in the pathogenesis of myeloma
d. Inhibit angiogenesis
e. None of the above
3. Which of the following is (are) correct:
a. Gamma
irradiation-,
Fas-,
and
dexamethasone-induced
myeloma
cell
apoptosis are mediated by distinct signaling cascades
b. Dexamethasone- but not gamma irradiation- or Fas-triggered apoptosis is medi-
ated via activation of related adhesion focal tyrosine kinase (RAFTK)
c. Dexamethasone-mediated myeloma cell apoptosis is associated with mitochon-
drial cytochrome c-release and is not mediated by second mitochondria activator
caspase (Smac) release from mitochondria
d. IL-6 promotes apoptosis triggered by dexamethasone
e. a and b
4. Thal/ImiDs:
a. Increase angiogenesis in myeloma
b. Inhibit angiogenesis in myeloma
c. Directly induce apoptosis or G1 growth arrest in myeloma cells
d. Abrogate adhesion of myeloma cells to bone marrow stromal cells
e. b, c, and d
5. Proteasome inhibitor PS-341:
a. Blocks NF-B
b. Increases paracrine IL-6 production in bone marrow stromal cells
c. Indirectly induces apoptosis
d. Promotes binding of myeloma cells to bone marrow stromal cells
e. None of the above

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
6. As O :
2
3
a. Induces apoptosis of drug-resis tant myeloma cells via caspase 9 activation
b. Is inhibited by the anti-apoptotic effects of IL-6 in vitro
c. Increases myeloma cell binding to bone marrow stromal cells
d. Promotes IL-6 and VEGF secretion in bone marrow stromal cells
e. Promotes proliferation of myeloma cells already adherent to bone marrow
stromal cells

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
Bart Barlogie, PhD, MD
Bart Barlogie, PhD, MD is Professor of Medicine and Pathology at the University of
Arkansas for Medical Sciences in Little Rock. In addition, he is Director of the Myeloma
Institute for Research Therapy, also in Little Rock.
Dr. Barlogie earned his MD at Heidelberg University Medical School in Heidelberg,
Germany, and his PhD magna cum laude at Max Planck Institute for Medical Research, also
in Germany. His internship and residency in internal medicine were conducted at the
University of Munich and the University of Muenster Medical School, respectively.
Dr. Barlogie has authored and co-authored more than 300 articles, 340 abstracts, and 70
book chapters devoted to autologous stem cell transplantation in multiple myeloma
patients, extended survival in advanced and refractory multiple myeloma after single-agent
thalidomide, risk of deep vein thrombosis in multiple myeloma patients treated with thalido-
mide and chemotherapy, and the critical importance of cytogenetics and molecular genet-
ics for prognosis, to name a few. His articles are published in prestigious journals such as
Blood, British Journal of Hematology, and the New England Journal of Medicine. Dr.
Barlogie is a committee member of the International Myeloma Foundation and the Multiple
Myeloma Research Foundation. His society memberships include the American
Association for Cancer Research, the American Society of Clinical Oncology, the American
Society of Hematology, and the International Society of Hematology, among others. He
serves on the editorial boards of Annals of Hematology, Blood, Clinical and
Experimental Medicine, Clinical Cancer Research, and the International Journal of
Oncology.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
HIGH-DOSE THERAPY AND IMMUNOMODULATORY DRUGS
IN MULTIPLE MYELOMA
Bart Barlogie, PhD, MD
LEARNING OBJECTIVES
Upon completion of this educational activity, participants should be able to:
· Discuss data and key developments in myeloma research and therapy, in particular,
Total Therapy I and II studies, the effects of single-agent thalidomide in the setting of
post-transplant relapses
· Discuss the ef ficacy of melphalan-based tandem transplants and the use of melpha-
lan in geriatric and renal failure patients
· Understand the adverse consequences of chromosome 13 deletion
· Describe the clinical benefit and toxicities associated with combination therapy of
thalidomide with dexamethasone and cytotoxic agents
· Recognize the higher incidence of deep venous thrombosis in the setting of
Adriamycin-containing therapy
· Recognize the feasibility and utility of performing serial gene expression profile
analyses as related to the molecular mechanisms of drug action and drug sensitivi-
ty and resis tance
ABSTRACT
Total Therapy I--employing vincristine, Adriamycin, and dexamethasone (VAD)based
remission induction, high-dose melphalan, and interferon maintenance--represented the
first tandem transplant approach in newly diagnosed multiple myeloma patients. Long-
term follow-up data (median, 8 years) indicate that 75% of 155 untreated patients pre-
senting without chromosome 13 abnormalities and normal LDH levels have 10-year event-
free survival rates of 29% (±9%) and overall survival rates of 47% (±14%) in comparison
with 0% and ±12% for the remaining patients (P=0.0003/0.001). When 76 previously
treated patients who were also enrolled in melphalan 200 mg/m2-based tandem trans-
plant trials were included, chromosome 13 abnormalities (CA 13) were confirmed as the
key adverse variable along with LDH, CRP, and creatinine. Importantly, less than 5%
remained event-free at 5 years and none survived 10 years.
Evaluation of melphalan-based tandem transplants in 70 patients (age 70 or older)
revealed the feasibility of adequate PBSC collection for 2 transplants and transplant-relat-
ed mortality of less than 10%. Event-free and overall survival (EFS and OS) rates were sig-

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
nificantly longer when prior standard therapy did not exceed 12 months. Eighty-one
patients with renal failure (creatinine >2 mg/dL) were scheduled for tandem transplants,
including 38 who were on hemodialysis. The incidence of CR increased from 26% after
first transplant to 30% after second. At 4 years, 50% of patients remain event-free and
55% remain alive, including 2 who became dialysis-independent.
Single-agent thalidomide was recently identified by our group as the first new class of
agents with substantial antimyeloma activity following the introduction of glucocorticoids
and melphalan nearly 40 years ago. Mainly in the setting of post-transplant relapse, single-
agent thalidomide effected 50% paraprotein reduction in 30% of patients, with 2-year EFS
and OS 1 rates of 20% and 50%, respectively. Responses were higher and survival longer
when the daily thalidomide dose was at least 400 mg. The best distinguishers of high risk
associated with short survival were elevation of B2M, abnormal cytogenetics, and high
labeling index prior to thalidomide therapy.
Based on the lack of myelosuppressive toxicity, thalidomide has been combined with
dexamethasone or DCEP for post-transplant relapse in good and high-risk patients,
respectively. The incidence of CR and near-CR was 36% with dexamethasone plus thaldo-
mide among 14 patients receiving dexamethasone plus thalidomide versus zero of 11 with
dexamethasone alone. Similarly, 25% of the 38 patients treated with DCEP plus thalido-
mide achieved CR or near-CR compared with 10% of those receiving DCEP alone.
A program of dexamethasone, thalidomide, and 4-day continuous infusions of cisplatin 10
mg/m2, Adriamycin 10 mg/m2, cyclophosphamide 400 mg/m2, and etoposide 40 mg/m2
(DT PACE)--all daily times 4--was developed for previously treated patients with the objec-
tive to determine the efficacy of this 6-drug regimen not requiring stem cell support in
comparison to melphalan-based tandem transplants in patients responding after 2 cycles.
Results in 229 patients indicated lower CR but comparable CR plus near-CR rates with DT
PACE and the transplant arm and also identical 2-year event-free survival rates of 73% in
both arms. The frequent crossover to tandem transplant on the DT PACE arm in case of
lack of CR or disease progression prompted a new trial that randomized all patients after
a single cycle of DT PACE with subsequent PBSC collection to either standard melphalan
200 mg/m2 times 2 cycles vs a new hybrid regimen of melphalan 100 mg/m2 plus DT
PACE times 2, which had remarkable activity and less gastrointestinal toxicity than mel-
phalan 200 mg/m2 in a pilot trial of 20 patients.
Total Therapy II builds on the success of Total Therapy I by exploring further intensification
of induction therapy (VAD, DCEP, CAD with PBSC collection, DCEP) followed by a melphalan
200-mg/m2-based tandem transplant phase, followed by consolidation chemotherapy with
either DCEP or DCEP alternating with CAD for 4 cycles; followed by maintenance interfer-
on. All patients were randomized up front to thalidomide. A total of 380 patients had been
enrolled as of October 2001, 231 of whom have been followed for at least 1 year. Data indi-
cate a CR plus near-CR rate of 65% after 2 transplants (intent-to-treat). Event-free and
overall survival rates were significantly better in the absence of chromosome 13 abnor-
malities, with normal LDH and with age less than 65 years (47 65 years). Two-year esti-

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
mates of EFS and OS were 84% and 93% in the majority of patients without CA 13 and
normal LDH compared with 50% and 60%, respectively, in the presence of either CA 13
or LDH greater than 190 U/L. In a comparison with the 231 patients previously treated
on Total Therapy I, Total Therapy II is associated with significantly improved EFS and OS in
the good-risk group without CA 13 and normal LDH, whereas a discernable benefit is not
yet apparent in the remaining patients. Data have not been unblinded as to the role of
thalidomide to which Total Therapy II patients were randomized up front.
A higher than expected incidence of deep vein thrombosis (DVT) was documented in
patients randomized to thalidomide with a cumulative incidence within the first year of
entering Total Therapy II of 40% compared with 15% without thalidomide (P=0.0002). In
order to appreciate the potential role of certain chemotherapeutic agents in the causation
of DVT, DT PACE patients were compared with those receiving DCEP plus thalidomide post-
transplant relapse. None of the patients on DCEP plus thalidomide, compared with 31
(16%) on DT PACE, developed DVT, indicating that the presence of Adriamycin in thalido-
mide combination trials significantly adds to the generation of this thromboembolic event
(P<0.01).
Fifteen patients, 7 of whom were previously treated with thalidomide, all had received prior
autologous transplant, were enrolled in a phase I/II trial of an analog of thalidomide, the
immunomodulatory drug, IMiD. Dose escalation was performed every 3 patients from a
starting le vel of 5 mg to 10 mg to 25 mg, to a maximum of 50 mg, at which dose level 6
patients were treated. Responses were evaluated after 1 month and during an extension
phase when dose escalation was permitted depending on whether at least 3 patients had
completed the first month of therapy at the next higher dose level. Altogether 8 respond-
ed (25% or greater paraprotein reduction), except for one, all at a dose level of at least 25
mg, which included 2 responses in 7 patients who had previously either failed or respond-
ed and then relapsed while on thalidomide. There was negligible neurotoxicity, whereas
myelosuppression did appear to be dose related and dose limiting, especially among
patients enrolled with hematopoietic compromise (ie, platelets <100,000/mm3. These
data suggest that IMiD has anti-myeloma activity in the setting of far advanced disease.
Toward a comprehensive molecular genetic analysis in multiple myeloma, gene expression
profiling studies have been conducted in more than 300 patients in various stages of their
disease, including baseline samples on more than 100 enrolled in Total Therapy II. Using
appropriate statistical methods, 4 discrete myeloma subgroups were identified with MM1
resembling most closely monoclonal gammopathy of undetermined significance (MGUS)
and MM4 resembling most closely established myeloma cell lines. The 4 groups could be
distinguished on the basis of only 24 genes, with MM4 representing the category that
uniquely displayed up-regulation of genes involved in DNA metabolism (eg, Ku 70), cell cycle
progression, drug resistance (POH), and farnesyl transferase. Chromosomal abnormali-
ties were significantly more common in MM4 than in the other subgroups, and a signifi-
cant increase in B2M serum levels with the transition from MM1 to MM4 was also
observed. Longer follow-up will allow determination as to whether this gene-arraybased
classification of MM has prognostic implications.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
A total of 27 patients have been studied after 48-hour therapy with dexamethasone (n=5),
thalidomide (n=16), and IMiD (n=6). The objective of the study was to determine whether
there are unique changes in gene expression as a result of the specific agent employed
and subsequent response to therapy that included the test drug. In the case of dexam-
ethasone, 325 genes were up-regulated in all patients studied. In contrast, only 4 genes
were down-regulated in 3 of 5 patients (average fold changes, 2.8- to 12-fold). The average
fold change for the up-regulated genes ranged from 2- to 56-fold. Importantly, the gene
with a 56-fold up-regulation almost uniformly turned off in myeloma but highly expressed in
normal plasma cells and is intimately linked to B-cell development and apoptosis.
After treatment with thalidomide, 2 genes were down-regulated greater than 2-fold in 8 of
16 patients (average 5-fold; range, 2.2 to 9.4). On the other hand, 131 genes were up-reg-
ulated greater than 2-fold in more than 9 patients; their products function in an array of
biological pathways ranging from DNA repair, growth arrest, adhesion, signaling, and
metabolism, with an interesting preponderance of ubiquination and proteasome functions.
Gene expression profiling before and after IMiD treatment was performed on 6 patients.
Six genes were down-regulated in 3 of 6 patients (average range 2.43- to 6.4-fold; histone
and early growth response genes). A total of 51 genes were up-regulated including 14
genes in 5 of 6 patients by an average of 2.46- to 9.72-fold; 1 gene was up-regulated in all
6 patients (4.58-fold). Comparison of thalidomide and IMiD effects identified 21 common-
ly up-regulated genes, several of which are tightly linked to apoptosis and, hence, probably
involved in the drugs' actions. The lower number (51 vs 131) of up-regulated genes in the
case of IMiD vs thalidomide may be indicative of the more specific action of IMiDs and
fewer clinical side effects. Algorithms are being developed to determine which genes are
specifically involved in the drugs' antitumor effects. Short-term in vivo effects on gene
expression are now being investigated systematically in all untreated patients in an
attempt to understand the molecular mechanisms of sensitivity and resistance to the key
agents used for myeloma therapy and eventually to develop individualized therapy.
Thus, gene expression profiling can be used in the classification of disease, understanding
of mechanisms of drug action, including the mechanisms of sensitivity or resistance, and,
importantly, also help identify new pathways for more selective therapeutic intervention.
The poor prognosis of patients with chromosome 13 abnormalities has led us to investi-
gate mini-allogeneic transplants in such patients, initially during far advanced disease for
postautologous transplant relapse and subsequently by design for consolidation in remis-
sion following a first melphalan 200 mg/m2-based autologous transplant. The mini-allo-
geneic transplant regimen consisted of melphalan 100 mg/m2 in the 25 related trans-
plants and of melphalan 100 mg/m2 plus total body irradiation (200 cGy) plus fludarabine
in 5 of the 6 unrelated transplants. Full chimerism was documented by day 30 in 20 of the
25 related transplants and in 5 of the 6 unrelated transplants, reaching 22 of 24 evalu-
able among the 25 related and 3 of 4 evaluable among the unrelated groups. Of the 17
patients with progression af ter prior autologous transplantation, 7 achieved CR or near-
CR after mini-allotransplant, compared with 12 of 14 in PR prior to allo-transplants

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
(P=0.02). Nine of the 17 with disease progression experienced treatment-related mortal-
ity compared with 3 of the 14 in CR, near-CR, or PR (P=0.02). TRM during the first 100
days was only 10%. Acute GVHD greater than grade II was noted in 58% of patients who
received cyclosporin A and prednisone as immunosuppressive regimen. Overall, the medi-
an duration of EFS and OS was 15 months. Two-year EFS and OS rates were superior in the
setting of prior responsiveness to therapy and when only 1 prior autotransplant had been
administered. In that setting, none of the 9 patients have relapsed or died. By contrast,
patients with 2 or more autotransplants or progressive disease prior to administration of
mini-allotransplants (22 patients), 15 patients have relapsed (P=0.005) and 12 have died
(P=0.01). Responses after mini-allotransplant were associated with the onset of GVHD in
all patients. Thirty of the 31 patients had abnormal cytogenetics and 12 had abnormalities
of chromosome 13. Four additional had both myeloma and myelodysplastic syndrome.
These data indicate remarkable antitumor activity from melphalan 100 mg/m2-based mini-
allotransplants, a high incidence of full chimerism, markedly reduced morbidity and mor-
tality, and clinical benefit when this intervention was limited to patients with fewer than 2
prior autotransplants. This approach is currently offered to all patients with chromosome
13 deletion within 4 to 6 months after an autologous transplant.
The principle of alkylating agent dose intensity with melphalan has been effective in increas-
ing the incidence of complete remission beyond 60% and effecting 10-year survivorship in
about 40% of the three quarters of patients presenting without cytogenetic abnormalities.
Further dose escalation and duration of cytotoxic therapy as practiced with Total Therapy
II seems to benefit those not presenting with chromosome 13 abnormalities and without
LDH elevation. The contribution of thalidomide in this protocol has not y et been disclosed.
Phase III trials for post-transplant relapse indicate significantly higher CR and near-CR
rates among patients randomized to thalidomide. The systematic application of gene
expression profiling to our patients enrolled on Total Therapy II will help dissect the genet-
ic basis for durable response or resistance. Re-evaluation at the time of relapse will help
discern whether originally low-grade presentations, such as MM1, will present with high-
risk MM3 or MM4 gene expression profile patterns at the time of relapse. Given the avail-
ability of a larger treatment armamentarium (eg, thalidomide, IMiD, the proteasome
inhibitor PS-341, farnesyl transferase inhibitors), gene expression profiling is anticipated t o
help in the selection of agents toward individualized treatment with the greatest probabili-
ty of activity. Careful scrutiny of gene expression will also help in the identification of hither-
to unrecognized tar gets for therapeutic intervention.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
SELECTED READINGS
Badros A, Barlogie B, Morris C, et al. High response rate in refractory and poor-risk
multiple myeloma after allotransplantation using a nonmyeloablative conditioning
regimen and donor lymphocyte infusions. Blood. 2001;97:2574-2579.
Badros A, Barlogie B, Siegel E, et al. Autologous stem cell transplantation in elderly
multiple myeloma patients over the age of 70 years. Br J Hematol. 2001;114:1-9.
Badros A, Barlogie B, Siegel E, et al. Results of autologous stem cell transplant in
multiple myeloma patients with renal failure. Br J Haematol. 2001;114(4):822-829.
Badros A, Morris C, Barlogie B, et al. Preliminary results of non-myeloablative
allogeneic transplantation in multiple myeloma. JCO. 2001. In press.
Barlogie B, Desikan R, Eddlemon P, et al. Extended survival in advanced and refractory mul-
tiple myeloma after single-agent thalidomide: identification of prognostic factors in a phase
2 study of 169 patients. Blood. 2001;98:492-494.
Barlogie B, Jagannath S, Desikan R, et al. Total therapy with tandem transplants for newly
diagnosed multiple myeloma. Blood. 1999;93:55-65.
Barlogie B, Jagannath S, Vesole D, et al. Superiority of tandem autologous
transplantation over standard therapy for previously untreated multiple myeloma. Blood.
1997;89:789-793.
Desikan R, Barlogie B, Sawyer J, et al. Results of high dose therapy for 1,000 patients with
multiple myeloma: durable complete remissions and superior survival in the absence of
chromosome 13 abnormalities. Blood. 2000;95:4008-4010.
Fenghuang A, Hardin H, Bumm K, et al. Molecular profiling of multiple myeloma. Blood.
2001. In press.
Singhal S, Mehta J, Desikan R, et al. Antitumor activity of thalidomide in refractory multiple
myeloma. N Engl J Med. 1999;341:1565-1571.
Shaughnessy J, Barlogie B, McCoy J, et al. Early relapse after t otal therapy II for multiple
myeloma (MM) is significantly associated with cytogenetic abnormalities of chromosome
13 (CA13) but not interphase FISH-del 13 or plasma cell labeling index (PCLI) [abstract].
ASH Abstract, 2001.
Tricot G, Barlogie B, Jagannath S, et al. Poor prognosis in multiple myeloma is
associated only with partial or complete deletions of chromosome 13 or abnormalities
involving 11q and not with other karyotype abnormalities. Blood. 1995;86:4250-4256.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
Zangari M, Anaissie E, Badros A, et al. High risk of deep vein thrombosis in multiple myelo-
ma patients receiving thalidomide in combination with chemotherapy. Blood. 2001;
98:1614-1615.
Zangari M, Tricot G, Zeldis J, Eddlemon P, Saghafifar F, Barlogie B. Results of phase I study
of CC-5013 for the treatment of multiple myeloma (MM) patients who relapse after high
dose chemotherapy (HDCT) [abstract]. ASH Abstract, 2001.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
SELF-ASSESSMENT QUESTIONS
1. A complete workup of multiple myeloma should include:
a. Cytogenetic anal ysis
b. Interphase FISH for chromosome 13
c. Serum 2-microglobulin levels
d. Level of C-reactive protein
e. Plasma cell labeling index
f. All of the above
2. Consideration of autologous peripheral blood stem cell transplantation during the
initial workup of a patient with symptomatic myeloma calls for the following:
a. Assuring the patient that stem cells can be obtained once relapse from standard
melphalan prednisone has occur red
b. Collection of a sufficient minimum dose of 2 million CD34 cells
c. No difference in outcome whether high-dose therapy is applied early or late in the
disease course
d. Avoidance of cytotoxic chemotherapy, especially stem celltar geting melphalan,
nitrosoureas and ionizing radiation, until an adequate number of stem cells
(preferably 10 x 106 CD34/kg cells) have been procured
3. Adverse prognostic factors, especially with high-dose therapy but also with standard
therapy, have recently been recognized, including:
a. Chromosome 13 deletion
b. Plasma cell labeling index >1%
c. CRP >4 mg/L
d. -Microglobulin >3 mg/L
2
e. IgA isotype
f. Deletion 13 by interphase FISH
g. All of the above
4. The following is true for thalidomide:
a. Is ef fective in one third of far advanced myeloma
b. Dose-limiting toxicity is peripheral neuropathy, which is dose related
c. Thromboembolic e vents are more common in the case of combination therapy
that includes adriamycin (age >60) and in the presence of chromosome 11
abnormalities
d. The myelosuppressive activity of thalidomide makes combination with chemother-
apy difficult
e. Hypothyroidism occurs in one third of patients receiving thalidomide
f. Only a, b, c, and e

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
5. The following statements are true for the use of mini-allogeneic transplants in
multiple myeloma:
a. High incidence of graft versus myeloma effect in >60% of those with advanced
disease
b. Morbidity and mortality are low, regardless of the number of prior autologous
transplants and whether patients have progressive disease
c. Complete chimerism can be obtained routinely even with melphalan alone
100 mg/m2 without TBI and without fludarabine
d. Low morbidity and mortality call for mini-allotransplants in more patients with
newly diagnosed myeloma and sibling donor availability, without consideration of
prognostic factors and without preceding autograft
e. Only a and c
6. Gene expression profiling is useful for the following:
a. Distinction from myeloma versus normal donor bone marrow plasma cells
b. Distinction of m yeloma plasma cells from plasma cells of patients with MGUS
c. Distinction of distinct subgroups within ne wly diagnosed myeloma
d. Identification of translocations
e. Understanding of drug action and predicting sensitivity or resistance
f. Identification of previously unknown molecular targets for "smart molecule
therapy"
g. All of the above

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
William S. Dalton, PhD, MD
William S. Dalton, PhD, MD, is Professor of Oncology, Medicine, and Biochemistry at the
University of South Florida in Tampa. In addition, he is Deputy Director of the H. Lee Moffitt
Cancer Center and Research Institute, and Chair of the Interdisciplinary Oncology Program
in Tampa.
Dr. Dalton earned his PhD in toxicology/medical life sciences and his MD at Indiana
University in Bloomington. After graduating, he completed his internship in medicine at
Indiana University and his residency in medicine at the University of Arizona in Tucson. His
fellowships in oncology and clinical pharmacology were conducted at the University of
Arizona.
Dr. Dalton's research interests include the biochemical mechanisms of drug resistance
and novel medications. An expert in the biology and treatment of multiple myeloma, Dr.
Dalton has authored and co-authored numerous articles concerning topics in his field. His
articles are published in Cancer Research, Blood, and Journal of Biochemistry, to name
a few.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
DRUG RESISTANCE AND DRUG DEVELOPMENT IN MULTIPLE MYELOMA
William S. Dalton, PhD, MD
LEARNING OBJECTIVES
Upon completion of this educational activity, participants should be able to:
· Discuss the influence of tumor microenvironment on drug response and resistance
· Describe tumor microenvironment interactions that influence drug response in
cancer
· Discuss mechanisms of de novo drug resistance and their implications as targeted
therapies
ABSTRACT
Circumvention of drug resistance in multiple myeloma is a major obstacle to improving clin-
ical outcome for myeloma patients. Identification of several mechanisms of acquired drug
resistance has led to the development of chemosensitizing agents that counter specific
drug resistance mechanisms. Initial successes in therapy using chemosensitizers often
culminate in relapse due to the multifactorial nature of acquired multidrug resistance
(MDR). Therefore, it may be important to design therapeutic strategies that focus on
mechanisms that allow for cell survival following initial treatments, prior to the acquisition
of MDR. It has been proposed that extracellular effectors such as cytokines, matrix com-
ponents, and adjacent cells may provide a sanctuary for cancer cells by preventing stress-
induced cell death. This review focuses on research implicating the cancer cell environ-
ment as a particularly important determinant in the emergence of drug resistance. There
are 2 general categories by which the bone marrow microenvironment may influence drug
response and the development of drug resistance. The first form is mediated by soluble
factors, or cytokines, generated by bone marrow stroma. Interleukin-6 (IL-6) is the most
well-characterized cytokine known to promote myeloma survival and progression. At least
1 mechanism by which IL-6 promotes cell survival is by the upregulation of anti-apoptotic
genes, in particular, Bcl-Xl. This is accomplished by the JAK2/STAT3 pathway; inhibition of
this pathway results in reduced cellular levels of Bcl-Xl and increased apoptotic cell death.
Cell adhesion also has been demonstrated to prevent cell death through a number of
mechanisms. Identification of cell adhesion mediated drug resistance (CAM-DR) as an ini-
tial or de novo effector of multidrug resistance suggests that therapies targeting interac-
tions between cancer cells and their environment may lead to the sensitization of cancer
cells to chemotherapy or radiotherapy prior to the emergence of acquired mechanisms of
MDR.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
We have classified mechanisms of de novo drug resistance under 4 general categories:
1) decreased cellular proliferation, 2) alterations in drug target, 3) decreased apoptosis,
and 4) integrin signaling cascades and cytoskeletal rearrangements. Importantly, the de
novo nature of CAM-DR suggests that we may be able to target early effectors of cell sur-
vival that prevent treatment-induced apoptosis. Doing so should enhance the efficacy of ini-
tial cancer treatment and prevent the acquisition of MDR. These data indicate that the can-
cer cell microenvironment provides a sanctuary conferring resistance to cancer therapy.
Therefore, interactions between myeloma cells and their environment may be critical tar-
gets for impr oving many therapeutic regimens used in the treatment of myeloma.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
SELECTED READINGS
Catlett-Falcone R, Landowski TH, Oshiro MM, et al. Constitutive activation of Stat3 signal-
ing confers resistance to apoptosis in human U266 myeloma cells. Immunity.
1999;10:105-115.
Damiano JS, Cress AE, Hazlehurst LA, Shtil AA, Dalton WS. Cell adhesion mediated drug
resistance (CAM-DR): role of integrins and resistance to apoptosis in human myeloma cell
lines. Blood.1999;93:1658-1667.
Damiano JS, Dalton WS. Integrin-mediated drug resistance in multiple myeloma. Leuk
Lymphoma. 2000;38:71-81.
Damiano JS, Hazlehurst LA, Dalton WS. Cell adhesion-mediated drug resistance (CAM-DR)
protects the K562 chronic myelogenous leukemia cell line from apoptosis induced by
BCR/ABL inhibition, cytotoxic drugs, and gamma-irradiation. Leukemia.2001;15:1232-
1239.
Hazlehurst LA, Damiano JS, Buyuksal I, Pledger WJ, Dalton WS. Adhesion to fibronectin via
beta1 integrins regulates p27kip1 levels and contributes to cell adhesion mediated drug
resistance (CAM-DR). Oncogene. 2000;19:4319-4327.
Dalton WS. Alternative (non-P-glycoprotein) mechanisms of drug resistance in non-
Hodgkin's lymphoma. Hematol Oncol Clin North Am. 1997;11:975-986.
Shain KH, Landowski TH, Dalton WS. The tumor microenvironment as a determinant of
cancer cell survival: a possible mechanism for de novo drug resis tance. Curr Opin Oncol.
2000;12:557-563.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
SELF-ASSESSMENT QUESTIONS
1. Extracellular effectors such as cytokines, matrix components, and adjacent cells
influence drug response and development of drug resistance.
a. True
b. False
2. Interleukin-6:
a. Promotes myeloma cell survival and progression
b. Upregulates anti-apop totic genes such as Bcl-Xl
c. Decreases myeloma cell survival and progression
d. Down-regulates anti-apoptotic genes such as Bcl-Xl
e. a and b
3. Cell adhesion:
a. Prevents cell death
b. Prevents cell growth
c. Promotes cells death
d. Has no influence on drug resistance
e. None of the above
4. Mechanisms of de novo drug resis tance include:
a. Decreased cellular proliferation
b. Alterations in drug target
c. Decreased apoptosis
d. Integrin signaling cascades and cytoskeletal rearrangement
e. All of the above

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
BRIAN G.M. DURIE, MD
Brian G.M. Durie, MD, is Chairman and Medical Director of the International Myeloma
Foundation, based in Los Angeles, California.
Born and raised in Scotland, Dr. Durie graduated from the University of Edinburgh
Medical School. Following internships at the University of Edinburgh, Dr. Durie completed
his residencies and fellowships in hematology and oncology at the Mayo Clinic and the
University of Minnesota in Rochester.
Upon completion of his fellowship, Dr. Durie moved to Tucson, Arizona, and began working
in the Department of Hematology/Oncology at the University of Arizona. It was there that
he, along with Dr. Sydney Salmon, developed the Durie/Salmon Staging Sy stem, which is
used worldwide for the evaluation of patients with myeloma. He earned the appointment
of Professor of Medicine (Hematology/Oncology).
Dr. Durie holds numerous honors and has been the recipient of many awards, including the
Leukemia Society of America Scholar and the US Hematologic Research Foundation
Annual Award. He is also the international patent holder for scintillation autoradiography.
Dr. Durie is listed in Who's Who in America and The Best Doctors in America. Ongoing
areas of interest and research include staging and prognostic factors; imaging (FDG/PET
scanning); thalidomide and other biologic therapies; virology (the role of stealth virus infec-
tions); molecular studies, especially the selective functions of plasma RNA; epidemiology,
particularly environmental factors; and genetic predisposition. He has written more than
300 research papers, including over 150 research papers focusing on myeloma, plus
numerous book chapters. He has published 2 books, one of which is a multi-author myelo-
ma text that will be republished in 2002.
From 1989 to 1992, Dr. Durie was Professor and Head of the Clinical Laboratory of
Hematology, Charing Cross and Westminster School of Medicine, University of London in
the United Kingdom. He returned to the United States to fulfill his position with the
International Myeloma Foundation, a California-based, nonprofit organization.
Dr. Durie has a hematology and oncology practice specializing in myeloma and related
diseases, with offices located at the Cedars-Sinai Comprehensive Cancer Center, where he
is Chairman of the Myeloma and Basic Science Liaison Committees for the Salick Health
Care, Inc Research Department.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
LOW-DOSE THALIDOMIDE IN MYELOMA:
EFFICACY AND BIOLOGIC SIGNIFICANCE
Brian G.M. Durie, MD
LEARNING OBJECTIVES
Upon completion of this educational activity, participants should be able to:
· Discuss studies of various disorders in which low-dose thalidomide has been
successful
· Discuss duration of low-dose thalidomide maintenance therapy in various disorders
· Describe thalidomide's mechanism of action and its specific effects on
macrophages
· Discuss the cur rent approaches to single-agent and combination therapy
ABSTRACT
Introduction
The efficacy of thalidomide at doses <200 mg/day was first reported at the VII
International Multiple Myeloma Workshop in Stockholm in September 1999.1 This was in
contrast to the efficacy with the Q 2 week dose escalation schedule achieving doses of
800-1200 mg/day.2 Results with the low dose protocol were subsequently published3 and
the long-term follow-up will be presented at the American Society of Hematology (ASH)
Meeting this year (2001).4 The overall response rate with low dose thalidomide as a single
agent in patients with relapsing and refractory myeloma was 44% with 25% having sus-
tained remission with at least 50% regression.4 With long term follow-up, 20% are in
remission for over 2 years.
Dose/Response Relationships
In the rapid dose escalation protocol,2 long-term follow-up indicated some added benefit for
those patients receiving higher doses of thalidomide. Conversely, in the low dose study,
remission duration was inversely related to dose required to achieve remission, i.e.,
patients taking lower doses (eg, 50 or 100 mg/day) stayed in remission longer. This is con-
sistent with data in patients with a range of infectious, inflammatory and autoimmune dis-
eases as well as some studies in patients with cancer.5-16 For example, in patients with lep-
rosy: thalidomide at <100 mg/day, complete responses 83%; thalidomide 100-200

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
mg/day, complete responses 68.4%; thalidomide >200-300 mg/day, complete respons-
es 67.8%; thalidomide >300 mg/day, complete response 50%. In Behcet's syndrome
patients, a randomized, double-blind, placebo-controlled trial8 indicated that efficacy was
equivalent for 100 mg/day versus 300 mg/day. In Behcet's, response has been reported
with as little as 25 mg/day, as it has in both chronic discoid lupus and cutaneous/pul-
monary sarcoidosis.11,14 Continuous low dose thalidomide (100 mg/day) has been reported
effective in a phase II trial in advanced melanoma, renal cell, ovarian and breast cancer.16
Duration of Therapy
In the low-dose myeloma study,4 thalidomide was continued as a low-dose maintenance
ranging from 50 mg daily to as little as 50 mg weekly, which was shown to be necessary
to sustain remission in some patients. In the treatment of cutaneous and pulmonary sar-
coidosis, 100 mg every other day was found to be an effective maintenance. However, in
patients with leprosy and rheumatoid ar thritis thalidomide is frequently discontinued when
response is achieved (eg, after 4-6 months). In this setting, long remissions have occurred
in responding patients lasting from 8 months to 6 years.15 There is, therefore, an urgent
need to evaluate both the dose and duration of therapy in patients with myeloma.
Mechanisms of Ef fect of Thalidomide: Central Role of Macrophages
The fact that low doses of thalidomide can be effective strongly suggests an anti-inflam-
matory and/or immunomodulatory mechanism of action. At low doses, thalidomide has
selective inhibitory effects upon macrophage derived TNFa and IL-12.17-20 It is impor tant to
note that partial inhibition of TNFa and IL-12 production by low doses of thalidomide is
preferable to total inhibition, in that TNFa plays a positive role in host resistance17 and IL-
12 is required for viral specific, NK cell mediated immunity.18 This explains the paradoxical
effects in HIV patients in whom thalidomide can directly inhibit replication of HIV,21 but also
suppresses the required IL-12 mediated immune response to HIV.22
Specific Effects Upon Macrophages: Relevance of Myeloma Cell Growth Inhibition to
Hypercoagulability
The exact thalidomide effects most relevant to anti-myeloma efficacy remain controversial.
However, the selective binding of thalidomide to a1-acid glycoprotein (AAG) may be involved
in its inhibition of TNFa production. AAG is an acute phase protein (also known as oroso-
mucoid) produced in soluble form by both hepatocytes and monocytes/macrophages.25
The ultimate critical effect is most likely decreased NFkB levels and binding activity. The
NFkB cascade is central to the activation of monocyte/macrophages re: cytokine produc-
tion, adhesion molecule expression, and viral activation.26-37 Of interest, the proteasome
activity and NFkB activation in monocytes/macrophages may also be the target for PS-
341, which has recently shown such dramatic benefit in relapsing and refractory
myeloma.38 In addition, monocyte/macrophage cells are known to be important, if not
essential, for active myeloma cell growth.39

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
AAG also has profound effects upon platelet aggregation25 and blood clot formation. This
may account for recent reports of hypercoagulability with thalidomide use especially com-
bined with chemotherapy.40 Of note, this is rarely observed with low doses of thalidomide
either alone or in combination.
Another macrophage-derived factor of potential interest and impor tance is MIF (Migraton
Inhibitory Factor.41 MIF is also triggered by NFkB and has several properties, including pro-
motion of neoangiogenesis, inhibition of p53 tumor suppression activity and antagonism to
glucocorticoid anti-inflammatory effects.41-43
Current Approaches to Single Agent and Combined Therapy
Thalidomide as a single agent is effective at doses of 50-200 mg/day. Most myeloma
patients have difficulty tolerating more than 300-400 mg/day. However, a subset of
patients both require and can tolerate these and even higher doses (800-1200 mg/day).
With the documentation of substantial synergy between thalidomide and dexamethasone,
the role of higher dose thalidomide monotherapy has come into question. Therapy using
thalidomide doses of 50-200 mg/day combined with pulse dexamethasone is an attractive
alternative. Comparative studies are required to assess relative efficacy both in terms of
response and remission duration. Because of concerns about thrombophlebitis and skin
reactions, the thalidomide/dexamethasone combination must be used with some caution.
The severe skin reactions appear to be dose-related occurring with thalidomide 400 mg
(or higher), but rarely with 200 mg. Of note, thalidomide 50 mg-200 mg/day combined
with dexamethasone has a very low incidence of both thrombophlebitic and skin problems.
Combining thalidomide/dexamethasone with Biaxin to create a 3-drug combination (eg,
BLT-D) also has potential advantages. Both in vitro and clinical synergy has been reported.44
A very high response rate (>80%) in patients with relapsing/refractory disease has been
reported.45 However, thrombophlebitic and cardiovascular complications have been report-
ed and require careful clinical management. Again, comparative studies are urgently
required to assess both efficacy and toxicity.
Overall, it is clear that low doses of thalidomide (50-200 mg) are remarkably effective both
alone and in combination. Careful comparative studies are required to assess the relative
efficacy and toxicity of dif ferent doses/schedules for both induction and maintenance.

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
REFERENCES
1. Durie BGM, Stepan DE. Low dose thalidomide in myeloma. Proceedings of the VIIth
International Multiple Myeloma Workshop; September 1999; Stockholm, Sweden.
2. Singhal S, Mehta J, Desikan R, et al. Antitumor activity of thalidomide in refractory
multiple myeloma. Engl J Med. 1999;341:1565-1572.
3. Durie BGM, Stepan DE. Ef ficacy of low dose thalidomide in multiple myeloma. Elect J
Oncol. 2000;1:1-8.
4. Durie BGM, Stepan DE. Low dose thalidomide in myeloma: long term follow-up. Blood.
2001.
5. Richardson P, Hideshima T, Anderson K. Thalidomide: the revival of a drug with
therapeutic promise in the treatment of cancer. PPO Updates. 2001;15:1-18.
6. Stirling D. Pharmacology of thalidomide. Semin Hematol. 2000; 37(suppl 3):5-14.
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408-414.
8. Hamuryudan V, Mat C, Saip S, et al. Thalidomide in the treatment of the mucocuta-
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trial. J Intern Med.1998;128:443-450.
9. Jacobson JM, Greenspan JS, Spritzler J, et al. Thalidomide for the treatment of oral
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10. Tsenova L, Sokol K, Freedman VH, Kaplan G. A combination of thalidomide plus antibi-
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11. Atra E, Sato EI. Treatment of the cutaneous lesions of sy stemic lupus erythematosus
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13. Haslett P, Hempstead M, Seidman C, et al. The metabolic and immunologic effects of
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14. Carlesimo M, Giustini S, Rossi A, Bonaccorsi P, Calyieri S. Treatment of cutaneous and
pulmonary sarcoidosis with thalidomide. J Am Acad Dermatol. 1995;32:866-869.
15. Gutierrez-Rodriguez O, Starusta-Bacal P, Gutierrez-Montes O. Treatment of refract o-
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16. Eisen T, Boshoff C, Mak I, et al. Continuous low dose thalidomide: a phase II study in
advanced melanoma, renal cell, ovarian and breast cancer. Br J Cancer. 2000;82:
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17. Moreira AL, Sampaio EP, Zmuidzinas A, Frindt P, Smith KA, Kaplan G. Thalidomide
exerts its inhibitory action on tumor necrosis factor alpha by enhancing mRNA degra-
dation. J Exp Med. 1993;177:1675-1680.

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PATHOGENESIS AND TREATMENT
18. Moller DR, Wysocka M, Greenlee BM, et al. Inhibition of IL-12 production by thalido-
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19. Kubin M, Chow JM, Trinchieri G. Differential regulation of interleukin-12 (IL-12), tumor
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22. Clerici M, Lucey DR, Berzofsky JA, et al. Restoration of HIV-specific cell-mediated
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24. Libert C, Brouchaert P, Fiers W. Protection by a1-acid glycoprotein against tumor
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26. Klein B, Bataille R. Cytokine network in human multiple myeloma. Hematol Oncol Clin
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27. Carter A, Merchav S, Silvian-Draxler I, Tatarsky I. The role of interleukin-1 and tumour
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28. Bataille R, Manolagas SC, Bereson Jr. Pathogenesis and management of bone
lesions in multiple myeloma. Hematol Oncol Clin North Am. 1997;11:349-361.
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30. Sen R, Baltimore D. Inducibility of k immunoglobulin enhancer-binding protein NKkB by
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32. Kirillov A, Kistler B, Mos toslavsky R, Cedar H, Wirth T, Bergman Y. A role for nuclear
NFkB in B-cell specific demethylation of the Igk locus. Nat Genet.1996;13:435-441.
33. Darnay BG, Ni J, Moore PA, Aggarwal BB. Activation of NFkB by RANK requires
tumor necrosis factor receptor-associated factor (TRAF) 6 and NFkB-inducing
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ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT

ADVANCES IN MULTIPLE MYELOMA:
PATHOGENESIS AND TREATMENT
SELF-ASSESSMENT QUESTIONS
1. Low doses of thalidomide for induction:
a. Have been shown to increase remission duration
b. Are considered to be 50 mg/d to 200 mg/d
c. Are effective in other neoplasms, infectious, inflammatory, and autoimmune
diseases
d. Produced complete responses in 68% to 83% of patients with leprosy
e. All of the above
2. Which of the following is correct?
a. Total inhibition of TNF-a is preferred over partial inhibition
b. At low doses, thalidomide has selective excitatory ef fects on macrophage-derived
TNF-a and IL-12
c. Macrophages do not play a central role in the effects of thalidomide
d. At low doses, thalidomide has selective inhibitory effects on macrophage-derived
TNF-a and IL-12
e. None of the above
3. Which of the following is (are) correct?
a. Thalidomide selectively binds to a1-acid glycoprotein
b. a1-acid glycoprotein may be in volved in its inhibition of TNF-a production
c. NF-kB cascade is central to the activation of monocyte/macrophages
d. a,-acid glycoprotein has no effects on platelet aggregation and blood clot formation
e. a, b, and c only
4. Thalidomide/dexamethasone combination must be used with caution because of
concerns about thrombophlebitis and skin reactions.
a. True
b. False
5. Combining thalidomide/dexamethasone with clarithromycin (BLT-D) also has poten-
tial advantages for patients with myeloma.
a. True
b. False