P. Leif Bergsagel, MD, FRCPC
Mayo Clinic Arizona
Molecular principles underlying
myeloma pathogenesis
Scottsdale,
Scottsdale Arizona
Rochester,
Rochester Minnesota
Jacksonville,
Jacksonville Florida
Continuous improvements in 5-year survival: 1950-1998
Melphalan (1962)
Prednisone (1968)
35%
35
C
l
yc ophosph
id
am e (1972)
High-dose Dex (1984)
ival
Bisphosphonates (1996)
v
Erythropoeitin (1996)
sur
High-dose melphalan with
stem cell support (1996)
ear
Thalidomide (1999)
5-y
Bortezomib (2003)
0
Tandem Transplant (2003)
1950
1960
1970
1980
1990
2000 Lenalidomide (2005)
Low-dose Dex (2007)
Year of diagnosis
Pegylated liposomal
doxorubicin (2007)
Myeloma: Long-lived, hypermutated, switched plasma cells
Lymph node
short lived
IgM
IgM
Plasma cell
Lymphoplasmacyte
G,A,E
Plasmablast
Submucosa
Germinal Center
Plasma
ll
ce
Pl
bl
asma
t
as
SOMATIC
G,A,E
G,A,E
Lymphoblast
HYPERMUTATION
Plasmablast
Isotype switch
recombination
Virgin B cell
G,A,E Plasmablast
VDJ
Bone
long lived
recombination
Marrow
G,A,E
Plasma cell
Pre-B cell
TC Classification: universal dysregulation of cyclin D
204379_s_at FGFGR3
FGFR3
209053_s_at MMSET
MMSET
206363_at MAF
C-MAF
218559_s_at MAFB
MAFB
201700_at cyclin D3
CCND3
208711_s_at cyclin D1
CCND1
208712_at cyclin D1
CCND1
200951_s_at cyclin D2
CCND2
RB 211540_s_at
RB1
4p16
Maf
11q13
D1
D1 N
+
D2
o
14%
8% 6p21 16%
32%
D2 n
19%
2%
e
2%
7% 2%
596 patients from UAMS - Shaughnessy & Barlogie
Supervised clustering identifies patients with shared gene expression profiles
11q13
hyperdiploid
other
4p16
maf
6p21)
p)
Bergsagel PL, Kuehl WM, Zhan F, Sawyer J, Barlogie B, Shaughnessy J. BLOOD 2005
Unsupervised clustering identifies recurrent Ig translocations,
hyperdiploidy and proliferation
D2
4p16
D1
11q13/6p21
1
maf
PR
LB
MS
HY
CD-1/CD-2 MF
Zhan, F. et al. Blood 2006;108:2020-2028
Timing of oncogenic events
?
Germinal
Intramedullary
Extramedullary
MGUS
center B cell
Myeloma
Myeloma
Karyotypic abnormalities
11q13
NON-
12p13
HYPER
62
6p 1
Secondary (Ig)
(Ig) TLC
21
TLC
DIPLOID
IgH tx
16q23
MAPK pathway
N-ras
20q11
K-ras
activating mutations
DEL13
FGFR3
8q24*
q
4p16
TRISOMY
p18INK4c
HYPER
RB1 pathway
HYPER
RB1
3, 5, 7, 9,
DIPLOID
inactivating mutations
11,15,19,21
MYC dysregulation
p53 pathway
TP53
inactivating mutation
Activation of MYC transforms MG to MM
· MYC translocated in 15% untreated MM, 40%
advanced MM and >90% of HMCL
· >80% of C57Bl/6 develop MG (<4g/l) by 18m
­ Radl. Immunology 1988 65:31
· Ongoing somatic hypermutation
hypermutation (SHM) in
in MGUS
MGUS
­ Sahota & Stevenson Blood 1996 87:746
· Activate MYC by SHM in C57Bl/6? (Vk*MYC)
· >80% of Vk*MYC in C57Bl/6 develop MM by 18m
­ MM: progressively increasing M-spike >10g/l, >10% BM
PC, End-organ damage
gg (Anemia, Bone disease)
9/2003
3/2004
+1, dup(1)(q11q32)x2
-3,add(3)(q13.2)
-5
-6, -6
-8,-8
-10,-10,-10
-14,
-13,-13
-15
add(16)(p11.2)x2
-17
+18
-20
-21
Add(14)(q32)
-X,-X
87-89,XX,-X,-X, +1, dup(1)(q11q32)x2,-3,add(3)(q13.2),-5,-6,-6,-8,-8,-10,-10,-10,-12,-13, -13, -14, add(14)(q32),-15,
add16(p11.2)x2,-17,+18,-20,-21,+ 14-17mar[cp4]/46,XX[16]
Detection of activation of the non-canonical NFkB pathway:
nuclear vs cytoplasmic localization of NFKB2 (p52)
Inactivation of TRAF3
· Inactivating point mutations in 50% of patients with LOH of
TRAF3
· ~13% of patients and ~18% of cell lines have TRAF3
TRAF3
inactivation
· Inactivation predicted to abrogate TRAF3 interaction with
NIK
· TRAF3 inactivation is known to activate the non-canonical
NFKB pathway (p100 to p52 processing)
TRAF3 inactivation associated with increased processing of NFKB2 p100 to p52
p100
p52
TRAF3
Association of TRAF3 inactivation with primary genetics
40
35
*
*
30
25
sesac 20
of
%
15
*
10
*
5
0
11q13
6p12
4p16
Maf
D1
D1+D2
D2
None
Overall
TRAF3<0.6
37
3
44
8
26
18
62
4
202
Total Cases 143
22
133
66
328
67
181
21
961
TRAF3<0.6 is more common in non-hyperdiploid MM (27% v 10%,
Fisher's Exact p=0.02)
DEXAMETHASONE
BORT
BOR EZOMIB
T
BORT
BOR EZOMIB
T
Resistance to Dex in HMCL with NFkB mutations
1.20
1.00
TRAF3
0.80
TRAF3
BIRC
TRAF3
NIK
none
0.60
NFKB1
none
none
none
0.40
none
none
0.20
0.00
d0
0
1
5
20
78
313
1250
nM dexamethasone
Patients with low TRAF3 mRNA are resistant to Dex and sensitive to Bortezomib
CR+PR
PFS
2/20
10%
83d
17/19
89%
193d
17/50
30%
140d
41/104
40%
145d
APEX (039 & 040) pharmacogenomic data courtesy of George Mulligan and Barb Bryant
Conclusion
· Mutations activate the non-canonical
NFkB pathway
py in ~20% of patients
p
· The activity of proteasome inhibitors
may be
be in
in part through
through inhibition of
NFKB2 p52 proteasomal processing
· Inhibitors of
of NIK
NIK or IKK1 are predicted
predicted
to be more specific
Timing of oncogenic events
?
Germinal
Intramedullary
Extramedullary
MGUS
center B cell
Myeloma
Myeloma
Karyotypic abnormalities
11q13
NON-
12p13
HYPER
62
6p 1
Secondary (Ig)
(Ig) TLC
21
TLC
DIPLOID
IgH tx
16q23
MAPK pathway
N-ras
20q11
K-ras
activating mutations
DEL13
FGFR3
8q24*
q
4p16
TRAF3
NFkB pathway
cIAP1/2
activating mutations CYLD
NIK
TRISOMY
p18INK4c
HYPER
RB1 pathway
HYPER
RB1
3, 5, 7, 9,
DIPLOID
inactivating mutations
11,15,19,21
MYC dysregulation
p53 pathway
TP53
inactivating mutation
Acknowledgements
Mouse model
model
Hd
Human model
Marta Chesi
Jonathan Keats
Michael Sebag
Marta Chesi
Michael Sebag
Wee-Joo Chng
Rafael Fonseca
Keith Stewart
Stewart
Mayo MM Team
Laurakay Bruhn (Agilent)
Michael Barrett (Agilent)
John Carpten (Tgen)
Jeff Trent
Trent (Tgen)
George Mulligan (Millenium)
Barb Bryant (Millenium)
Mike Kuehl (NCI)