Leukemia (2010) 24, 1700­1712
& 2010 Macmillan Publishers Limited All rights reserved 0887-6924/10
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REVIEW
The use of biochemical markers of bone remodeling in multiple myeloma: a report of the
International Myeloma Working Group
E Terpos1, MA Dimopoulos1, O Sezer2, D Roodman3, N Abildgaard4, R Vescio5, P Tosi6, R Garcia-Sanz7, F Davies8,
A Chanan-Khan9, A Palumbo10, P Sonneveld11, MT Drake12, J-L Harousseau13, KC Anderson14 and BGM Durie5 on behalf
of the International Myeloma Working Group1
1Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; 2Department of Hematology,
Oncology and Stem cell Transplantation, University Medical Center Hamburg, Hamburg, Germany; 3Department of Medicine,
University of Pittsburgh Medical Center, Pittsburgh, PA, USA; 4Department of Hematology, Odense University, Odense,
Denmark; 5Cedars-Sinai Outpatient Cancer Center at the Samuel Oschin Comprehensive Cancer Institute, Los Angeles, CA, USA;
6Institute of Hematology and Oncology, University of Bologna, Bologna, Italy; 7Department of Hematology, Hospital
Universitario de Salamanca, Salamanca, Spain; 8Institute of Cancer Research and Royal Marsden Hospital, Section of
Haemato-oncology, Sutton, Surrey, UK; 9Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA; 10Divisione
di Ematologia, University of Torino, Torino, Italy; 11Department of Hematology, Erasmus Medical Center, Rotterdam,
The Netherlands; 12Division of Endocrinology, Mayo Clinic, Rochester, MN, USA; 13Institut de Biologie, Laboratoire
d'Hematologie, Nantes, France and 14Division of Hematologic Malignancies, Department of Medical Oncology, Dana-Farber
Cancer Institute, Boston, MA, USA
Lytic bone disease is a frequent complication of multiple
uncoupling of the bone remodeling process, in which
myeloma (MM). Lytic lesions rarely heal and X-rays are of
osteoclast-mediated bone resorption is normally tightly coupled
limited value in monitoring bone destruction during anti-
both temporally and spatially with osteoblast-mediated bone
myeloma or anti-resorptive treatment. Biochemical markers of
formation.2­4 Lytic lesions rarely heal even in patients at
bone resorption (amino- and carboxy-terminal cross-linking
telopeptide of type I collagen (NTX and CTX, respectively) or
complete remission.4 Further, owing to the marked decrease
CTX generated by matrix metalloproteinases (ICTP)) and bone
in osteoblast activity, bone scans are often negative in myeloma
formation provide information on bone dynamics and reflect
patients with extensive lytic lesions and offer very little in the
disease activity in bone. These markers have been investigated
follow-up of bone disease in these patients.5,6 Finally, sequential
as tools for evaluating the extent of bone disease, risk of
measurement of bone mineral density using Dual-energy X-ray
skeletal morbidity and response to anti-resorptive treatment in
Absorptiometry scans produce heterogeneous local bone
MM. Urinary NTX, serum CTX and serum ICTP are elevated in
myeloma patients with osteolytic lesions and correlate with
mineral density changes; as such the routine use of sequential
advanced disease stage. Furthermore, urinary NTX and serum
Dual-energy X-ray Absorptiometry scans is not recommended to
ICTP correlate with risk for skeletal complications, disease
assess bone disease in MM.6,7
progression and overall survival. Bone markers have also been
Although osteolytic lesions are usually assessed by plain
used for the early diagnosis of bone lesions. This International
radiographs, conventional radiography cannot provide informa-
Myeloma Working Group report summarizes the existing data
tion about ongoing bone remodeling.6 Accordingly, biochem-
for the role of bone markers in assessing the extent of MM bone
disease and in monitoring bone turnover during anti-myeloma
ical markers of bone metabolism have been used in MM to
therapies and provides information on novel markers that may
assess the rate of bone turnover (defined as the prevalent rates of
be of particular interest in the near future.
both bone formation and bone resorption) and to improve
Leukemia (2010) 24, 1700­1712; doi:10.1038/leu.2010.173;
monitoring of bone destruction in MM. Moreover, bone turnover
published online 2 September 2010
markers have been used to follow myeloma bone disease during
Keywords: myeloma; bone markers; NTX; CTX; ICTP
specific therapies.8­10 However, at present there is no consensus
for the use of bone turnover markers in MM. This report of the
International Myeloma Working Group summarizes the existing
Introduction
data for the role of markers of bone remodeling in assessing the
extent of myeloma bone disease and in monitoring bone
Multiple myeloma (MM) is characterized by the presence of
turnover during anti-myeloma treatment. It also proposes
osteolytic bone lesions that result in skeletal-related events
markers that can be used in clinical practice, and presents
(SREs), such as pathologic fractures, need for radiation or surgery
novel markers that may be of particular interest in the future.
to bone, spinal cord compression and hypercalcemia. In the
absence of effective bisphosphonate therapy, more than 50% of
patients with Durie­Salmon stage III MM will experience at least
Markers of bone remodeling
one SRE over 2 years.1 The development of lytic bone lesions is
not only related to increased osseous breakdown but also to
Throughout life, bone undergoes continuous remodeling with
removal of old bone by osteoclasts and replacement with new
Correspondence: Dr E Terpos, Department of Clinical Therapeutics,
bone by osteoblasts; a process that is balanced under normal
University of Athens School of Medicine, Alexandra General Hospital,
conditions.11 However, in MM, there is increased activation of
80 Vas. Sofias Avenue, Athens 11528, Greece.
osteoclasts and suppression of osteoblast function.2­4 Over the
E-mail: eterpos@med.uoa.gr
1
past two decades, the isolation and characterization of cellular
See appendix
Received 9 April 2010; revised 20 June 2010; accepted 5 July 2010;
and extracellular components of the skeletal matrix have
published online 2 September 2010
resulted in the development of biochemical markers that reflect
Bone markers in multiple myeloma
E Terpos et al
1701
Table 1
Markers of bone resorption
Marker
Abbreviationa
Tissue of origin
Analytical method
Analytical specimen
Hydroxyproline
Hyp
All tissues and all genetic
Colorimetric, assay,
Urine
types of collagen
HPLC
Hydroxylysine
Hyl
All tissues and all genetic
Reversed-phase HPLC
Urine
types of collagen
Galactosyl-
Gal-Hyl
Both Gal-Hyl and Glc-Gal-
Reversed-phase HPLC
Urine
hydroxylysine
Hyl appears to be specific
for bone collagen
degradation
Glucosyl- galactosyl-
Glc-Gal-Hyl
Bone, cartilage, tendon,
Reversed-phase HPLC
Urine
hydroxylysine
blood vessels
Pyridinoline
PYD
Bone, dentin
HPLC, ELISA
Urine
Deoxypyridinoline
DPD
All tissues containing type-I
RIA
Urine (free DPD can be
collagen
also measured in serum
or plasma)
N-terminal cross-linking
NTX
All tissues containing type-I
ELISA, RIA
Urine, serum
telopeptide of type-I
collagen
collagen
C-terminal cross-linking
CTX
All tissues containing type-I
ELISA, RIA
Urine, serum (b-form
telopeptide of type-I
collagen
only)
collagen
C-terminal cross-linking
CTX-MMP or
All tissues containing type-I
RIA
Serum
telopeptide of type-I
ICTP
collagen
collagen generated by
MMPs
Tartrate-resistant acid
TRACP-5b
Bone (osteoclasts)
Colorimetric RIA, ELISA
Serum, plasma
phosphatase isoform 5b
Bone sialoprotein
BSP
Bone, dentin, hypertrophic
RIA, ELISA
Serum
cartilage, cancer cells
Abbreviations: ELISA, enzyme-linked immunosorbent assay; HPLC, high-performance liquid chromatography; MMP, matrix metalloproteinase;
RIA, radioimmunoassay.
aAccording to the bone marker nomenclature by the Committee of Scientific Advisors of the International Osteoporosis Foundation.16
Table 2
Markers of bone formation
Marker
Abbreviationa
Tissue of origin
Analytical method
Analytical specimen
Osteocalcin (or bone gla-protein)
OC
Bone, platelets
RIA, ELISA, IRMA
Serum
Bone-specific alkaline phosphatase
Bone ALP
Bone
ELISA, IRMA, colorimetric assay
Serum
Procollagen type-I N-propeptide
PINP
Bone, soft tissue, skin
RIA, ELISA
Serum
Procollagen type I C-propeptide
PICP
Bone, soft tissue, skin
RIA, ELISA
Serum
Abbreviations: ELISA, enzyme-linked immunosorbent assay; RIA, radioimmunoassay; IRMA, immunoradiometric assay.
aAccording to the bone marker nomenclature by the Committee of Scientific Advisors of the International Osteoporosis Foundation.16
either bone formation or bone resorption.12­15 Markers of bone
However, both Hyp and Hyl are also contained in certain serum
resorption and formation are depicted in Tables 1 and 2.
proteins, such as the C1q component of complement. This
Measurement of bone turnover markers is noninvasive, compara-
disadvantage, in combination with the effect of age and
tively inexpensive and when applied and interpreted correctly,
circadian rhythm (both Hyp and Hyl have their peak excretion
can be of significant help in the assessment of bone disorders.
after midnight) on their circulating levels, makes both Hyp and
However, factors that affect bone turnover marker levels,
Hyl less specific indices of bone resorption. As such, both have
including circadian rhythm, diet, age, gender, renal function
been largely replaced by newer markers.17­19
and drugs, should be clearly defined and appropriately adjusted
for whenever possible. It is also important to recognize that these
biochemical measurements reflect whole-body bone turnover
Pyridinoline (PYD) and deoxypyridinoline (DPD) cross-
and give little information about the function of local changes in
links of type I collagen. PYD and DPD are formed by the
skeletal homeostasis. All these issues are discussed below.
enzymatic action of lysyl oxidase on lysine and Hyl. PYD and
DPD act as mature cross-links in type I collagen of all major
connective tissues (Figure 1).20 The products of bone collagen
Biochemistry of bone markers
degradation by osteoclasts include amino- and carboxy-terminal
peptide fragments (NTX and CTX, respectively) of various sizes
Bone resorption markers
that remain attached to helical portions of nearby collagen
Hydroxyproline (Hyp) and hydroxylysine (Hyl). Hyp is
molecules by a pyridinium cross-link. These molecules are
formed in the cell from the post-translational hydroxylation of
released into the circulation. Further degradation occurs in the
proline and is the predominant amino acid within all collagens.
liver and kidney, where the fragments are finally degraded to
Hyl is another structural amino acid of collagenous proteins.11
their constituent amino acids and the pyridiniums, PYD and
Leukemia
Bone markers in multiple myeloma
E Terpos et al
1702
must be cross-linked, but can be imbedded into fragments of
the C-terminal telopeptide of variable size (1000­10 000 Da).
As half of the recognized antigens in normal sera are smaller
than 3000 Da, it is smaller than the ICTP antigen.
Owing to specificity for type I collagen and their unique
characteristics, the bone resorption markers NTX, ICTP and CTX
have almost completely replaced the use of older resorption
indices in the diagnostic assessment of bone disease.
Figure 1 Fibrils of collagen showing the N- and C-terminal ends
Tartrate-resistant acid phosphatase isoform 5b (TRACP-
bonding to helical areas of adjacent fibrils by pyridinoline and
5b). Two
forms
of
TRACP
circulate
in
human
deoxypyridinoline crosslinks.
serum, macrophage-derived TRACP-5a and osteoclast-derived
TRACP-5b.29­31 In human serum, TRACP-5b circulates in a
large complex that contains a2-microglobulin and calcium.32
DPD. The measurement of urinary DPD and PYD is not
Osteoclasts secrete TRACP-5b into the circulation as a cata-
influenced by the degradation of newly synthesized collagen
lytically active enzyme that is inactivated and degraded to
fibrils or by dietary collagen intake. Further, unlike Hyp, the
fragments in the circulation. Thus, TRACP-5b molecules mea-
PYD amino acids are fully excreted with no known pathway of
sured in serum are freshly liberated from osteoclasts, providing a
metabolic degradation.21
resorptive index that is useful as a surrogate marker for total
activated osteoclast numbers.29
Amino- and Carboxy-terminal cross-linking telopeptide
of type I collagen. During bone collagen degradation by
Bone formation markers
osteoclasts, NTX and CTX fragments are released into the
Bone-specific alkaline phosphatase (ALP). ALP is a
circulation.21 These fragments represent a spectrum of proteins
ubiquitously expressed, cell membrane-associated enzyme.33
of different molecular weights. The proteolytic activities of
Liver and bone (bALP) isoforms account for almost 95% of the
cathepsin K and matrix metalloproteinases result in the
total ALP activity in the serum. bALP is produced by osteoblasts
production of a variety of degradation peptides with different
and has been demonstrated in matrix vesicles deposited as
antigenic properties.22 The majority of these peptides is
`buds' derived from the cell membrane. These deposits have an
relatively small and is freely filtered by the glomerulus into the
important role in bone formation.15 bALP is produced in
urine. NTX fragments are considered specific for bone tissue
extremely high amounts during the bone formation phase of
breakdown, as other tissues that contain type I collagen, for
bone turnover, and is, therefore, an excellent indicator of total
example, skin, do not undergo osteoclast-mediated metabolism.
bone formation activity.33
Thus, different type I collagen fragments are formed during the
breakdown of non-skeletal tissues.15
An enzyme-linked immunosorbent assay method has been
Osteocalcin (OC). OC is one of the most abundant non-
developed to recognize a discrete pool of NTX isolated from
collagenous proteins within bone. It is produced by osteoblasts,
urine, namely the a2-chain N-telopeptide fragment.23 Although
odontoblasts and hypertrophic chondrocytes. Most of the
this fragment contains the pyridinium cross-links, the assay does
circulating OC is a product of osteoblast activity. OC is
not recognize the PYD and DPD per se. This confers bone
incorporated into bone matrix, where it serves to bind calcium;
specificity, as the PYD cross-link in bone primarily involves the
as such, OC is considered a marker of bone formation. OC is a
a2-chain, whereas in other tissues the a1-chain predominates.23
small protein of 49 amino acids. In serum, OC is degraded so
NTX contains the cross-linked a2 N-telopeptide sequence
that both the intact peptide and fragments coexist in the
QYDGKGVG, which is a product of osteoclastic proteolysis,
circulation.34­38 Thus, assays that evaluate both intact OC and
in which lysine (K) is embodied in a trivalent cross-linkage.
OC fragments are more accurate for the measurement of serum
Collagen must be degraded to small cross-linked peptides that
OC. Serum levels of OC are significantly influenced by gender,
contain this exact sequence before the antibody will recognize
age and renal function.36
the NTX antigen. This ensures that the NTX peptide is a direct
product of osteoclastic proteolysis that does not require further
metabolism in the liver or kidney for generation, and is rapidly
Type I procollagen propeptides. Collagen type I is a
cleared by the kidney.24 Urinary NTX results are expressed
300-kDa protein that comprises 90% of the organic bone matrix.
relative to creatinine as nM of bone collagen equivalent per mM
It is synthesized by osteoblasts in the form of procollagen.
of creatinine.
Extracellular processing of procollagen before collagen fiber
Other assays have also been developed for the measurement
assembly includes cleavage of the amino- and carboxy-terminal
of epitopes associated with CTX (a-CTX, b-CTX and CTX
extension propeptides (termed procollagen type I N-propeptide
generated by matrix metalloproteinases (ICTP)) in both serum
(PINP) and C-propeptide (PICP)).39 Circulating PINP is cleared
and urine.25,26 These include a radioimmunoassay that detects
by the scavenger endothelial system in the liver, whereas PICP is
ICTP by rabbit polyclonal antibodies directed against a large
removed from the circulation by the mannose receptors on liver
antigen (10 000 Da) with a preserved trivalent cross-linked
endothelial cells.40 Because PINP and PICP peptides are
structure.27 This antigen is liberated when type I collagen is
generated in a stoichiometric 1:1 ratio with newly formed
degraded by matrix metalloproteinases.22,28 In contrast to the
collagen molecules, their serum levels are considered an index
approach used in the ICTP assay, the CTX-I (b-CTX) antigen is
of collagen synthesis and thus of bone formation.41 Most studies
liberated when type I collagen is degraded by cathepsin K, but
suggest that the PINP has a greater diagnostic validity than PICP
not by matrix metalloproteinases.26 The recognized antigen
in metastatic bone disease.42
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Bone markers in multiple myeloma
E Terpos et al
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Markers of bone remodeling in myeloma bone disease
Po0.001).57 Terpos et al. showed that OC levels were reduced
in myeloma patients and correlated with the extent of bone
Bone turnover markers and extent of myeloma
disease, whereas bALP levels were not.55 Why differences
bone disease
between the studies exist is not clear, but may reflect different
Markers of both resorption and formation have been used in
study populations and/or different phases of bone turnover in
attempts to better evaluate the extent of bone disease in MM.
each population. PICP values do not seem to reflect the extent of
Table 3 summarizes the results of the most important studies to
myeloma bone disease.43­46,48 As shown in Table 3, although
date regarding the levels of bone markers in MM patients.43­60
markers of bone formation may be of some value in myeloma,
As has been shown in multiple studies, urine levels of PYD,
they do not appear to reflect the extent of myeloma bone
DPD and NTX and serum levels of CTX, ICTP and TRACP-5b
destruction. Thus at present, their clinical utility is doubtful.
were elevated in MM patients compared with healthy controls,
and correlated with the extent of osteolytic disease.46,48,51­56,58­60
Urinary NTX levels were increased even in myeloma patients
Correlations of bone turnover markers with myeloma
who had reached a clinical plateau phase of their disease,61
activity and survival
whereas PYD, DPD and NTX were also elevated in myeloma
In several studies, biochemical markers of bone resorption
patients before autologous transplantation.62,63
strongly correlated with stage of MM. Serum ICTP and urinary
A histomorphometric study in bone marrow biopsies of
NTX were higher in myeloma stage II/III than in stage I
myeloma patients showed that urinary NTX correlated most
disease.44,48,53 High DPD urinary levels also correlated with
positively with dynamic histomorphometric indices of bone
advanced myeloma stage.51,52 In 121 newly diagnosed myelo-
resorption, followed by serum ICTP and urine DPD; urine PYD
ma patients, NTX and TRACP-5b, but not OC or bALP, strongly
did not correlate with the histomorphometric findings.64 More-
correlated with disease stage.55 Two additional studies also
over, comparison between these four markers (PYD, DPD, NTX
failed to show a correlation between OC and bALP with
and ICTP) revealed that serum ICTP and urinary NTX
myeloma stage.48,51
better reflected the extent of myeloma bone disease and could
Markers of bone remodeling have also correlated with well-
better predict early progression of the bone disease after
characterized markers of disease activity, such as b2-micro-
conventional chemotherapy (CC).6,54 However, serum ICTP
globulin and interleukin-648,51,55,64 and also with overall
remained more sensitive than the urinary assays when
survival (OS).44,46,48,52,68,69 Fonseca et al. showed that the
patients with impaired renal function were excluded from that
median survival was 4.1 and 3.5 years for patients who received
analysis.54
CC and had low or high ICTP levels, respectively (P ¼ 0.02).48
Jakob et al. demonstrated that serum ICTP was elevated in
Jakob et al. also reported that ICTP is a prognostic factor for OS
MM patients who did not have detectable osteolytic lesions by
in MM patients treated with CC (Po0.03), whereas urinary NTX
plain radiograph, but had abnormal bone magnetic resonance
was only of borderline prognostic value (P ¼ 0.05).52 The same
imaging scans.65 Urinary NTX also correlated with the overall
group showed in 100 patients with newly diagnosed sympto-
score of skeletal involvement as measured by Tc-99m-MIBI
matic MM that disease stage, according to International Staging
scintigraphy and bone marrow infiltration by plasma cells.66
System, del(13q14), high dose therapy and ICTP independently
Coleman et al. showed in 210 MM patients that high or
predicted for OS, with ICTP having the most powerful
intermediate urinary NTX correlated with an increased risk for
prognostic value (hazard ratio: nine-fold increase; Po0.001).
SRE development compared with low NTX values (risk ratio (RR)
Incorporation of ICTP in the International Staging System
2.25, P ¼ 0.032 and RR 1.75, P ¼ 0.016, respectively).57 High
separated four risk groups with a 5-year OS rate of 95, 65, 46
NTX values also correlated with a three-fold increased risk for
and 22%, respectively.60
developing a first SRE (Figure 2), whereas there was also a trend
Abildgaard et al., using sequential measurements of both ICTP
toward increased risk for progression of osteolytic lesions in the
and NTX showed that high levels of ICTP and NTX correlated
high NTX group (P ¼ 0.08).57 A recent study by Terpos et al.in
with an increased risk for early progression of bone lesions
282 myeloma patients who participated in a randomized phase
during CC, suggesting that their measurements are clinically
III study comparing zoledronic acid and pamidronate showed
useful for identifying patients with increased risk of early disease
that high urinary NTX was independently associated with
progression.7 In a recent study, Terpos et al. analyzed the effect
elevated risk for the development of first SRE (68% increase in
of urinary NTX on survival in 210 patients participating in a
risk for SRE development per 100-unit increase of NTX;
randomized study comparing treatment with either zoledronic
P ¼ 0.005).67 In summary, these results suggest that serum ICTP
acid or pamidronate. Increased baseline levels of urinary NTX
and urinary NTX strongly correlate with the extent of MM bone
(X50 nM bone collagen equivalent per mM creatinine) corre-
disease, the risk for the development of SREs, and possibly with
lated with an 88% increased risk of death and a 67% increased
risk for MM progression.
risk of first SRE (Figure 3).70 The update of this study in 282
Markers of bone formation have been evaluated in several
patients confirmed that high urinary NTX independently
studies, but the results have been more variable than those
predicted for poor survival (RR ¼ 1.60; P ¼ 0.017).67 These data
found with bone resorption markers.43­46,48­51,53,55,56 In some
suggest that the bone resorption markers serum ICTP and urinary
studies, bALP and OC were elevated in myeloma patients
NTX have prognostic significance for disease progression and
compared with controls, whereas in others they were either
survival in MM under CC, and that their routine measurement in
reduced or within normal limits. In a study by Fonseca et al.,
future clinical trials may be of prognostic value in the current era
which included a large number of myeloma patients (n ¼ 313),
of novel anti-MM agents. In contrast, measurement of bone
serum bALP correlated with bone pain, lesions and fractures,
formation markers seem to be of limited prognostic value.71
whereas OC levels were lower in myeloma patients than in
controls but did not correlate with the extent of bone disease.48
Furthermore, Coleman et al. showed that myeloma patients
Bone markers during anti-resorptive therapy
with high bALP levels are at increased risk for developing a SRE
Biochemical markers of bone turnover have been used in MM
(RR 3.29; Po0.001) and for disease progression (RR 2.42;
both to monitor bisphosphonate treatment, and to determine
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Bone markers in multiple myeloma
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Table 3
Markers of bone remodeling in myeloma patients and correlations with clinical data
Authors (year)
No. of
Parameter
Comparison with controls
Correlation with
Correlation with
patients
studied
(symbol refers
extent of bone
survival (in multivariate
to MM patients)
disease
models)
Nawawi et al., 199643
17
DPD
m
NA
NA
TRACP
NS
OC
NS
bALP
NS
PICP
NS
Abildgaard et al., 199744
109
ICTP
m
NA
Yes
OC
NS
Yes
bALP
m
No
PICP
NS
No
PIIINP
m
No
Withold et al., 199845
15
DPD, PYD
m
NA
NA
bALP, PICP
k
Carlson et al., 199946
73
DPD
m
Yes
No
ICTP
m
Yes
Yes
OC
NS
No
No
PICP
NS
No
No
Woitge et al., 199947
18
PYD
m
NA
NA
DPD
m
NTX
m
CTX
m
BSP
m
Fonseca et al., 200048
313
ICTP
m
Yes
Yes
TRACP
m
No
No
OC
k
No
No
bALP
NS
Yes
No
PICP
NS
No
No
Terpos et al., 200049
62
NTX
m
NA
NA
OC
k
bALP
k
Woitge et al., 200150
43
OC
NS
NA
NA
bALP
k
Corso et al., 200151
52
DPD
m
Yes
NA
OC
k
No
bALP
NS
No
Jakob et al., 200252a
57
DPD
m
Yes
No
NTX
NS
No
P ¼ 0.05
ICTP
m
Yes
Yes
Alexandrakis et al., 200253
38
PYD
m
Yes
NA
DPD
m
Yes
NTX
m
Yes
OC
m
No
bALP
NS
No
Abildgaard et al., 200354
34
PYD
m
Yes
NA
DPD
m
Yes
ICTP
m
Yes
NTX
m
Yes
Terpos et al., 200355,56
121
NTX
m
Yes
No
TRACP-5b
m
Yes
No
OC
k
Yes
No
bALP
k
No
No
sRANKL/OPG
m
Yes
Yes
Coleman et al., 200557
318
NTX
m
Yesb
Yes
Kuliszkiewicz-Janus et al., 200558
75
ICTP
m
Yes
NA
OC
NS
No
Dizdar et al., 200759
25
CTX
m
Yes
NA
DPD
m
Yes
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Table 3 (Continued )
Authors (year)
No. of
Parameter
Comparison with controls
Correlation with
Correlation with
patients
studied
(symbol refers
extent of bone
survival (in multivariate
to MM patients)
disease
models)
Jakob et al., 200860
100
ICTP
ma
Yes
Yes
Terpos et al., 201067
282
NTX
NA
NA
Yesc
DPD
NA
NA
No
Abbreviations: bALP, bone-specific alkaline phosphatase; BSP, bone sialoprotein; CTX, carboxy-terminal cross-linking telopeptide of type I
collagen; DPD, deoxypyridinoline; ICTP, carboxy-terminal cross-linking telopeptide of type I collagen generated by matrix metalloproteinases;
NA, not assessed; NS, non significant; NTX, amino-terminal cross-linking telopeptide of type I collagen; OC, osteocalcin; OPG, osteoprotegerin;
PICP, procollagen type I C-propeptide; PIIINP, N-terminal propeptide of procollagen type III; PYD, pyridinoline; sRANKL, soluble receptor activator
of nuclear factor-kB ligand; TRACP-5b, tartrate-resistant acid phosphatase isoform 5b.
aMM compared with MGUS patients.
bCorrelation with SREs.
cIn this study high NTX also independently predicted for high risk for development of first SRE.
Figure 2 Relative risk for experiencing any skeletal-related event (SRE) and a first SRE for multiple myeloma patients with high levels of
N-telopeptide of type I collagen (NTX; X100 nM bone collagen equivalent (BCE)/mM creatinine) or moderate NTX (50­99 nM BCE/mM creatinine)
versus patients with low NTX (o50 nM BCE/mM creatinine) treated with zoledronic acid. Length of horizontal lines represents 95% confidence
intervals.57,77
Figure 3 Kaplan­Meier Curves for (a) survival and (b) first on-study SRE by baseline NTX levels in 210 myeloma patients treated with
conventional chemotherapy and zoledronic acid.70 NTX, N-terminal cross-linking telopeptide of type l collagen; E, elevated; N, normal; RR, risk
ratio; CI, confidence interval; SRE, skeletal-related event.
those subjects who would benefit most from bisphosphonate
study, monthly pamidronate (90 mg, IV) produced a greater
therapy.45,49,57,61,71­75 Clodronate administration resulted in a
reduction of NTX and TRACP-5b compared with monthly
significant reduction of ICTP and PINP in 244 MM patients
ibandronate (4 mg, IV).56,75 In a large, randomized study
compared with controls.71 Terpos et al. showed that the addition
comparing 4 mg zoledronic acid with 90 mg pamidronate, given
of pamidronate to CC significantly reduced urinary NTX and
IV every 3­4 weeks in patients with bone metastases from breast
disease-related pain compared with CC alone,49 and that
cancer or with MM osteolytic disease, urinary NTX was strongly
pamidronate in combination with interferon-a induced bone
suppressed (up to 64% below baseline in both treatment groups)
formation in MM patients at plateau phase.61 Ibandronate at a
for the duration of the study.73 Bone marker data from this and
dose of 2 mg showed a substantial reduction of CTX and OC in
other bisphosphonate studies clearly demonstrate that there is a
only one-third of MM patients,74 whereas in a randomized
subset of myeloma patients who do not respond to, or who
Leukemia
Bone markers in multiple myeloma
E Terpos et al
1706
become refractory to bisphosphonate therapy.76 Patients with
skeletal involvement and tumor cell burden.14 However, further
persistently elevated bone marker levels are at higher risk for
evaluation is needed to support its value in MM bone disease.
SREs and disease progression compared with patients who
Dickkopf-1 (Dkk-1) protein is an inhibitor of the Wingless-
respond to bisphosphonate therapy and have normalized bone
type and Int (Wnt) pathway, a pathway crucial for stimulation of
resorption. Lipton et al. showed that among breast cancer or
osteoblast activity. Tian et al. were the first to describe that
myeloma patients (n ¼ 170) who had high baseline NTX levels
increased expression of Dkk-1 in plasma cells correlates with
(X64 nM bone collagen equivalent per mM creatinine), those
the presence of lytic lesions both by plain radiography and
with persistently elevated NTX levels after 3 months of
magnetic resonance imaging.85 Bone marrow plasma Dkk-1
zoledronic acid therapy (n ¼ 26, 15%) had a significantly
levels were increased in MM patients, and associated with Dkk-1
increased risk of developing a first SRE (RR ¼ 1.71; P ¼ 0.035)
concentrations in peripheral blood, levels of Dkk-1 transcripts in
and shorter SRE-free survival (RR ¼ 1.65; P ¼ 0.039) compared
myeloma cells and the presence of osteolytic lesions.86­88 Gene
with subjects who normalized NTX in response to bispho-
expression studies in 171 newly diagnosed MM patients showed
sphonate treatment (n ¼ 137, 81%).77 In this study, among
that overexpression of Dkk-1 correlated with the degree of
patients with high NTX at baseline, 15% treated with zoledronic
osteolytic bone disease.89 Similarly, serum Dkk-1 levels were
acid and 30% treated with pamidronate did not normalize NTX
elevated in myeloma patients with lytic bone disease compared
levels after 3 months of bisphosphonate therapy. Although
with those without lytic lesions by conventional radiography,
unknown, one might speculate that patients who did not have
and also correlated with the number of bone lesions.87 In
biochemical improvement in their NTX levels may have an
contrast, patients with monoclonal gammopathy of undeter-
osteoclast-independent mechanism of bone resorption and
mined significance had lower serum levels of Dkk-1 compared
might, therefore, benefit from additional therapies.77
with MM subjects, with levels similar to those found in control
Denosumab is a fully human monoclonal antibody against
subjects. High values of serum Dkk-1 also correlated with
receptor activator of nuclear factor-kB ligand (RANKL), the most
advanced ISS stage.87 It is interesting that, a recent report from
potent osteoclast activator to-date (see below). In a recent study,
Yaccoby and colleagues demonstrated that Dkk-1-negative
1776 adult patients with solid tumors or MM (n ¼ 10% of the
myeloma cells in trephine biopsies had more aggressive features
total) who were naive to intravenous bisphosphonates were
and plasmablastic morphology, whereas Dkk-1 was rarely
randomized to receive either subcutaneous denosumab 120 mg
expressed by plasma cells of plasma cell leukemia.90 The
or intravenous zoledronic acid every 4 weeks. Denosumab
current role of Dkk-1 in the clinical assessment of myeloma
produced similar results regarding the delay in time to first on-
bone disease, however, remains to be determined.
study SRE or subsequent SREs compared with zoledronic acid,
whereas it also rapidly and potently reduced (by more than 80%
within the first month) urinary NTX levels.78
The effect of novel anti-myeloma agents on markers of bone
remodeling
Novel molecules related to bone remodeling and
During the last decade, immunomodulatory drugs, including
myeloma bone disease
thalidomide and lenalidomide and proteasome inhibitors, such
RANKL and Osteoprotegerin (OPG). RANKL and OPG
as bortezomib, have been increasingly used for the treatment of
have crucial roles in the development of myeloma bone disease.
MM. Thalidomide, lenalidomide and bortezomib are effective
Although RANKL increases osteoclastogenesis and osteoclast
agents for the treatment of both newly-diagnosed and relapsed/
activity, OPG serves as a soluble inhibitor of RANKL activity.
refractory MM. The role of these drugs in bone metabolism has
Within the myeloma bone marrow microenvironment, the
been evaluated in several studies.
RANKL/OPG ratio is shifted in favor of RANKL, leading to
increased osteoclastogenesis and increased bone resorption.2­4
Multiple studies have now documented that in MM, serum OPG
Immunomodulatory drugs
levels are reduced, whereas the soluble RANKL/OPG ratio is
Two clinical phase II trials have studied the effect of thalidomide
increased.63,79­82 This altered ratio correlates with extent of
on bone metabolism of MM patients (Table 4). In the first study,
bone disease, markers of bone resorption, such as NTX and
Terpos et al showed that in relapsed/refractory MM patients, the
TRACP-5b and myeloma stage.63,81 The administration of
combination of thalidomide (200 mg per day) with dexametha-
zoledronic acid in patients with asymptomatic myeloma was
sone (TD) produced a significant reduction of serum levels of
found to increase serum levels of OPG and thus reduce the
CTX, TRACP-5b and sRANKL/OPG after 6 months of therapy.
RANKL/OPG ratio, likely accounting for the effect of zoledronic
There was a strong correlation between changes in the sRANKL/
acid on osteoblast and/or bone marrow stromal cells together
OPG ratio and changes in TRACP-5b and CTX, suggesting that
with its direct effect on osteoclasts.83 The RANKL/OPG ratio has
the reduction of bone resorption by TD is at least in part due to
been found to correlate with OS in MM. This result has not been
the reduction of RANKL. TD showed no effect on bone
confirmed in all reported studies to date,63,69,83,84 may be due to
formation in that study.76 In the second study, Tosi et al showed
differences in patient populations and/or therapies administered.
in newly diagnosed MM patients that the combination of TD and
Further studies are needed before measurement of serum
zoledronic acid for 4 months produced a significant reduction of
RANKL and OPG levels in the everyday clinical setting should
urinary NTX and serum CTX, but only in patients who
be considered.
responded to therapy. This reduction was accompanied by a
reduction in bone pain in 60% of the patients, and also by a
Other potential molecules reflecting bone destruction in
reduction of bALP and OC levels in both responding and
MM. Bone sialoprotein is a phosphorylated 70­80 kDA
refractory patients. This negative effect of TD on bone formation
glycoprotein that accounts for 5­10% of the non-collagenous
may be due to the concomitant use of high-dose dexamethasone
bone matrix. Bone sialoprotein is involved in the adhesion of
in these patients.91
bone resorbing cells to the extracellular bone matrix.82 In one
Limited data exists for the effects of lenalidomide on bone
study of MM, bone sialoprotein levels were associated with
remodeling in myeloma patients. In a small study, lenalidomide
Leukemia
Bone markers in multiple myeloma
E Terpos et al
1707
Table 4
Clinical studies for the effect of novel anti-myeloma agents on bone metabolism
Agent
MM study
No. of
Results
Subpopulation
population
patients
analysis
Thalidomide (+Dexa)
Tosi et al.91a
Newly diagnosed
40
k Bone resorption markers (CTX & NTX)
In responders
k bone formation markers (bALP & OC)
In all patients
Terpos et al. 76a
Refractory/relapsed
35
k Bone resorption markers (CTX & TRACP-5b)
In all patients
k osteoclast stimulators (sRANKL, sRANKL/OPG ratio)
In all patients
2 bone formation markers (bALP & OC)
In all patients
Lenalidomide
Breitkreutz et al.92
Refractory/relapsed
11
k osteoclast numbers
ND
k osteoclast differentiation
k bone resorption
Bortezomib (±Dexa)
Heider et al.95a
Refractory/relapsed
58
m bone formation markers (bALP & OC)
In all patients
Terpos et al.97a
Refractory/relapsed
34
k bone resorption markers (CTX & TRACP-5b)
In all patients
k osteoclast stimulators (sRANKL, sRANKL/OPG ratio)
In all patients
m bone formation markers (bALP & OC)
In respondersb
k osteoblast inhibitors (Dkk-1)
In all patients
Giuliani et al.96a
Refractory/relapsed
21
k bone resorption markers (CTX)
In all patientsc
m osteoblast numbers
In responders
Terpos et al.83a
Refractory/relapsed
62
k bone resorption markers (CTX & TRACP-5b)
In all patients
(VMDT regimen)
k osteoclast stimulators (sRANKL, sRANKL/OPG, MIP-1a)
In all patients
2 bone formation markers (bALP & OC)
In all patients
k osteoblast inhibitors (Dkk-1)
In all patients
Abbreviations: bALP, bone alkaline phosphatase; CTX, carboxy-terminal cross-linking telopeptide of type I collagen; Dkk-1, dickkopf-1;
MIP-1a, macrophage inflammatory protein 1a; NTX, amino-terminal cross-linking telopeptide of type I collagen; OC, osteocalcin;
OPG, osteoprotegerin; RANKL, receptor activator of nuclear factor-kB ligand; TRACP-5b, tartrate-resistant acid phosphatase isoform type 5b.
aConcomitant bisphosphonates administration in majority of patients.
bbALP was increased only in responders whereas OC was elevated in all patients.
cThis reduction did not reach statistical significance.
reduced serum RANKL and increased serum OPG levels,
compared with those who received bortezomib monotherapy.95
leading to a reduction of the RANKL/OPG ratio.92 From the
Thus, although different effective anti-myeloma regimens in
available data, it seems that immunomodulatory drugs reduce
combination with bisphosphonates can reduce bone resorption
osteoclast function but have little or no effect on osteoblast
through reduction of tumor burden and inhibition of osteoclast
activity.
function,63 to-date only bortezomib has clearly shown an
anabolic bone effect in MM.
Bortezomib
An increasing number of studies have now reported the
beneficial effects of bortezomib on bone formation in the
Conclusions and future directions
clinical setting, confirming preclinical observations.93,94 As
described by Heider et al., the combination of bortezomib±
Biochemical markers of bone resorption faithfully reflect
dexamethasone produced significant increases in serum bALP
changes in bone metabolism associated with the malignant
and OC in both responders and non-responders.95 Giuliani et al.
process in myeloma. Serum ICTP and urinary NTX seem to be
found significant increases in the number of osteoblasts per mm2
more accurate than other bone resorption markers in reflecting
of bone tissue in trephine biopsies of patients responding to
both the severity of bone destruction and the efficacy of
bortezomib, but not in subjects who did not respond.96 Terpos
response to bisphosphonate treatment. To date, data on CTX
et al. showed that, in 34 patients bortezomib monotherapy
remain sparse, but studies are ongoing. There is also a strong
reduced serum Dkk-1 and RANKL levels. This was asso-
correlation between serum ICTP and urinary NTX with
ciated with a concomitant reduction in bone resorption (serum
increased risk for progressive bone disease, development of
TRACP-5b and CTX) and increase in markers of bone formation
SREs and OS (Table 5). However, it should be kept in mind that
(serum bALP and OC), changes that occurred irrespective of
ICTP and CTX undergo renal elimination, a fact that will affect
response to therapy.97
the potential utility of these measurements in many patients
However, when bortezomib was combined with other anti-
because of the high prevalence of renal dysfunction in MM.
myeloma agents (VMDT regimen, combination of bortezomib,
Symptomatic patients who continue to have increased levels
melphalan, dexamethasone and thalidomide), the reduction of
of NTX after 3 months of anti-myeloma and anti-resorptive
Dkk-1, sRANKL and CTX was not accompanied by increases in
therapy remain at high risk for both SREs and shortened OS;
bALP and OC.83 This observation suggests that bortezomib may
accordingly such patients may require more aggressive therapy.
lose its beneficial effect on osteoblasts when it is combined with
The value of bone markers in the setting of asymptomatic
other anti-myeloma agents. Indeed, Heider et al. found an
myeloma has also to be evaluated as it may reveal patients at
attenuated increase in bALP in patients who received VD
high risk for progression (Table 5).
Leukemia
Bone markers in multiple myeloma
E Terpos et al
1708
Table 5
Summary of the role of markers of bone metabolism in multiple myeloma
Parameter
Reflection of the
Prediction for
Prediction for OS
Future possible use
extend of myeloma
SRE
bone disease
Bone resorption markers
Urinary NTX
+++
+++
+++
1. Symptomatic patients to drive initial therapy (NTX)
Serum ICTP
+++
++
++
2. Asymptomatic patients to drive decision for anti-
resorptive therapy (NTX, ICTP, CTX)
Serum CTX
++
ÀÀ
3. Symptomatic patients under bisphosphonates to decide
the duration and intervals of therapy (NTX, ICTP, CTX)
Serum TRACP-5b
+
ÀÀ
Bone formation markers
Serum bALP
+/ÀÀ
À
1. Use for the evaluation of bone anabolic agents, such as
bortezomib, anti-Dkk1, anti-SOST antibodies (bALP only)
Serum OC
+/ÀÀ
À
2. No future use is seen for other bone formation markers
Serum PINP or PICP
ÀÀ
À
Osteoclast/osteoblast
regulators
Serum sRANKL or
+/ÀÀ
+/À
1. Use for the follow-up of novel therapies (denosumab-anti-
tRANKL
RANKL, anti-Dkk1 etc)
Serum OPG
+/ÀÀ
À
Serum Dkk-1
+
ÀÀ
Abbreviations: (À), no evidence; (+/À), conflicting evidence; (+), low evidence; (++), intermediate evidence; (+++), strong evidence; bALP, bone
alkaline phosphatase; CTX, carboxy-terminal cross-linking telopeptide of type I collagen; Dkk-1, dickkopf-1; ICTP, carboxy-terminal cross-linking
telopeptide of type I collagen generated by matrix metalloproteinases; NTX, amino-terminal cross-linking telopeptide of type I collagen; OC,
osteocalcin; OPG, osteoprotegerin; PICP, procollagen type I carboxy-propeptide; PINP, procollagen type I amino-propeptide; SOST, sclerostin;
sRANKL, soluble receptor activator of nuclear factor-kB ligand; TRACP-5b, tartrate resistant acid phosphatase isoform 5b; tRANKL, total RANKL.
In the current era of concern about bisphosphonate-
edited paper; KCA contributed comments and edited paper;
associated adverse side-effects (that is, renal impairment,
BGMD contributed comments and edited paper
osteonecrosis of the jaw, subtrochanteric femoral fractures),
bone turnover markers may be of particular use: that is, low
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Appendix
Hermann Einsele, Universita¨tsklinik Wu¨rzburg, Wu¨rzburg,
Germany
International myeloma working group
Theirry Facon, Centre Hospitalier Regional Universitaire de
Lille, Lille, France
Rafat Abonour, Indiana University School of Medicine,
Dorotea Fantl, Socieded Argentinade Hematolgia, Buenos Aires,
Indianapolis, Indiana, USA
Argentina
Ray Alexanian, MD Anderson, Houston, Texas, USA
Jean-Paul Fermand, Hopitaux de Paris, Paris, France
Kenneth C. Anderson, DFCI, Boston, Massachusetts, USA
Rafael Fonseca, Mayo Clinic Arizona, Scottsdale, Arizona, USA
Michael Attal, Purpan Hospital, Toulouse, France
Gosta Gahrton, Karolinska Institute for Medicine, Huddinge,
Herve Avet-Loiseau, Institute de Biologie, Nantes, France
Sweden
Ashraf Badros, University of Maryland, Baltimore, Maryland, USA
Christina Gasparetto, Duke University Medical Center, Durham,
Bart Barlogie, M.I.R.T. UAMS Little Rock, Arkanas, USA
North Carolina, USA
Regis Batille, Institute de Biologie, Nantes, France
Morie Gertz, Mayo Clinic, Rochester, Minnesota, USA
Meral Beksac, Ankara University, Ankara, Turkey
John Gibson, Royal Prince Alfred Hospital, Sydney, Australia
Andrew Belch, Cross Cancer Institute, Alberta, Canada
Sergio Giralt, MD Anderson Cancer Center, Houston, Texas,
Bill Bensinger, Fred Hutchinson Cancer Center, Seattle,
USA
Washington, USA
Hartmut
Goldschmidt,
University
Hospital
Heidelberg,
P. Leif Bergsagel, Mayo Clinic Scottsdale, Scottsdale, Arizona,
Heidelberg, Germany
USA
Philip Greipp, Mayo Clinic, Rochester, Minnesota, USA
Jenny Bird, Bristol Haematology and Oncology Center, Bristol,
Roman Hajek, Brno University, Brno, Czech Republic
UK
Izhar Hardan, Tel Aviv University, Tel Aviv, Israel
Joan Blade´, Hospital Clinica, Barcelona, Spain
Jean-Luc Harousseau, Institute de Biologie, Nantes, France
Mario Boccadoro, University of Torino, Torino, Italy
Hiroyuki Hata, Kumamoto University Hospital, Kumamoto,
Michele Cavo, Universita di Bologna, Bologna, Italy
Japan
Wen Ming Chen, MM Research Center of Beijing, Beijing,
Yutaka Hattori, Keio University School of Medicine, Tokyo,
China
Japan
Tony Child, Leeds General Hospital, Leeds, United Kingdom
Tom Heffner, Emory University, Atlanta, Georgia, USA
James Chim, Department of Medicine, Queen Mary Hospital,
Joy Ho, Royal Prince Alfred Hospital, Sydney, Australia
Hong Kong
Vania Hungria, Clinica San Germano, Sao Paolo, Brazil
Wee-Joo Chng, National University Health System, Singapore
Shinsuke Ida, Nagoya City University Medical School, Nagoya,
Ray Comenzo, Tufts Medical School, Boston, Massachusetts,
Japan
USA
Peter Jacobs, Constantiaberg Medi-Clinic, Plumstead, South
John Crowley, Cancer Research and Biostatistics, Seattle,
Africa
Washington, USA
Sundar Jagannath, St. Vincent's Comprehensive Cancer Center,
William Dalton, H. Lee Moffitt, Tampa, Florida, USA
New York, New York, USA
Faith Davies, Royal Marsden Hospital, London, England
Hou Jian, Shanghai Chang Zheng Hospital, Shanghai, China
Ca´rmino de Souza, Univeridade de Campinas, Caminas, Brazil
Douglas Joshua, Royal Prince Alfred Hospital, Sydney, Australia
Michel Delforge, University Hospital Gasthuisberg, Leuven,
Artur Jurczyszyn, The Myeloma Treatment Foundation, Poland
Belgium
Asher Chanan Kahn, Roswell Park Cancer Institute, Buffalo,
Meletios Dimopoulos, University of Athens School of Medicine,
New York, USA
Athens, Greece
Michio Kawano, Yamaguchi University, Ube, Japan
Angela Dispenzieri, Mayo Clinic, Rochester, Minnesota, USA
Nicolaus Kro¨ger, University Hospital Hamburg, Hamburg,
Matthew Drake, Mayo Clinic, Rochester, Minnesota, USA
Germany
Brian G.M. Durie, Cedars-Sinai Outpatient Cancer Center, Los
Shaji Kumar, Department of Hematology, Mayo Clinic,
Angeles, California, USA
Minnesota, USA
Johannes Drach, University of Vienna, First Dept. of Internal
Robert Kyle, Department of Laboratory Med. and Pathology,
Medicine, Vienna, Austria
Mayo Clinic, Minnesota, USA
Leukemia
Bone markers in multiple myeloma
E Terpos et al
1712
Juan Lahuerta, Grupo Espanol di Mieloma, Hospital Universi-
Laura Rosinol, Hospital Clinic, Barcelona, Spain
tario, Madrid, Spain
Jesus San Miguel, University of Salamanca, Salamanca, Spain
Ola Landgren, National Cancer Institute, Bethesda, Maryland,
Orhan Sezer, Universita¨t Hamburg, Hamburg, Germany
USA
Jatin Shah, MD Anderson Cancer Institute, Houston, Texas, USA
Jacob
Laubach,
Dana-Farber
Cancer
Institute,
Boston,
John Shaughnessy, M.I.R.T. UAMS, Little Rock, Arkansas, USA
Massachusetts, USA
Kazuyuki Shimizu, Nagoya City Midori General Hospital,
Jae Hoon Lee, Gachon University Gil Hospital, Incheon, Korea
Nagoya, Japan
Xavier LeLeu, Hospital Huriez, CHRU Lille, France
Chaim Shustik, McGill University, Montreal, Canada
Suzanne
Lentzsch,
University
of
Pittsburgh,
Pittsburgh,
David Siegel, Hackensack, Cancer Center, Hackensack, New
Pennsylvania, USA
Jersey, USA
Henk Lokhorst, University Medical CenterUtrecht, Utrecht, The
Seema Singhal, Northwestern University, Chicago, Illinois, USA
Netherlands
Pieter Sonneveld, Erasmus MC, Rotterdam, The Netherlands
Sagar Lonial, Emory University Medical School, Atlanta,
Andrew Spencer, The Alfred Hospital, Melbourne, Australia
Georgia, USA
Edward Stadtmauer, University of Pennsylvania, Philadelphia,
Heinz Ludwig, Wilhelminenspital Der Stat Wien, Vienna,
Pennsylvania, USA
Austria
Keith Stewart, Mayo Clinic Arizona, Scottsdale, Arizona, USA
Angelo Maiolino, Rua fonte da Saudade, Rio de Janeiro, Brazil
Evangelos Terpos, University of Athens School of Medicine,
Maria Mateos, University of Salamanca, Salamanca, Spain
Athens, Greece
Jayesh Mehta, Northwestern University, Chicago, Illinois, USA
Patrizia Tosi, Italian Cooperative Group, Istituto di Ematologia
GiamPaolo Merlini, University of Pavia, Pavia, Italy
Seragnoli, Bologna, Italy
Joseph Mikhael, Mayo Clinic Arizona, Scottsdale, Arizona, USA
Guido Tricot, Huntsman Cancer Institute, Salt Lake City, Utah,
Angelina Rodriquez Morales, Bonco Metro Politano de Sangre,
USA
Caracas, Venezuela
Ingemar Turesson, Department of Hematology, Malmo Uni-
Philippe Moreau, University Hospital, Nantes, France
versity, Malmo, Sweden
Gareth Morgan, Royal Marsden Hospital, London, England
Karin Vanderkerken, Vrije University Brussels VUB, Brussels,
Nikhil Munshi, Diane Farber Cancer Institute, Boston, Massa-
Belgium
chusetts, USA
Brian Van Ness, University of Minnesota, Minneapolis, Minne-
Ruben Niesvizky, Weill Medical College of Cornell University,
sota, USA
New York, New York, USA
Ivan Van Riet, Brussels Vrija University, Brussels, Belgium
Amara Nouel, Hospital Rutz y Paez, Bolivar, Venezuela
Robert Vescio, Cedars-Sinai Cancer Center, Los Angeles,
Yana Novis, Hospital Si´rioLibane^s, Bela Vista, Brazil
California, USA
Robert Orlowski, MD Anderson Cancer Center, Houston, Texas,
David Vesole, Hackensack Cancer Center, Hackensack, New
USA
Jersey, USA
Antonio Palumbo, Cathedra Ematologia, Torino, Italy
Anders Waage, University Hospital, Trondheim, Norway NSMG
Santiago Pavlovsky, Fundaleu, Buenos Aires, Argentina
Michael Wang, M.D. Anderson, Houston, Texas, USA
Linda Pilarski, University of Alberta, Alberta, Canada
Donna Weber, MD Anderson, Houston, Texas, USA
Raymond Powles, Leukemia & Myeloma, Wimbledon, England
Jan Westin, Sahlgrenska University Hospital, Gothenburg,
S. Vincent Rajkumar, Mayo Clinic, Rochester, Minnesota, USA
Sweden
Donna Reece, Princess Margaret Hospital, Toronto, Canada
Keith Wheatley, University of Birmingham, Birmingham, United
Tony Reiman, Cross Cancer Institute, Alberta, Canada
Kingdom
Paul G. Richardson, Dana Farber Cancer Institute, Boston,
Dina B. Yehuda, Department of Hematology, Hadassah
Massachusetts, USA
University Hospital, Hadassah, Israel
David Roodman, University of Pittsburgh Medical Center,
Jeffrey Zonder, Karmanos Cancer Institute, Detroit, Michigan,
Pittsburgh, PA, USA
USA
Leukemia

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