Early pathogenic events determine MM biology and clinical course
P. Leif Bergsagel, MD, FRCPC
Mayo Clinic
Scottsdale Arizona
International Myeloma Workshop 2005

Evidence for familial clustering of MM
International Myeloma Workshop 2005

DNA Breaks During B Cell Development Can Lead to Chromosomal
Translocations and Tumors
Lymph Nodes, Spleen,
Peyer's Patches
Plasma cell
Switch Recombination
· Multiple myeloma
· Sporadic Burkitt's lymphoma
· Diffuse large cell lymphoma
Bone
Germinal
Marrow
Center
Somatic Hypermutation
· Endemic Burkitt's lymphoma
Naive B cell
· Diffuse large cell lymphoma
· Multiple myeloma
Receptor Editing and Revision
V(D)J Recombination
· Mantle cell lymphoma
· Follicular lymphoma
International Myeloma Workshop 2005

Turning on Oncogenes by Somatic Hypermutation
Somatic Hypermutation
· c-MYC
· BCL6
International Myeloma Workshop 2005

Engineering Oncogene Activation by Somatic Hypermutation
Kappa locus
Vk
Jk5-Ck intron with IE
3'RR with 3'E
L
VJ
C segment
Transgenes
Vk21.E
L
V
HA
CMYC/BCL6
Wild type HA (HA):
ATG GGA TCG GCC ATT ...
Mutated HA (*HA):
ATG GGA TAG TCA GCC ATT ...
stop codon
SH-hotspot (RGYW)
International Myeloma Workshop 2005

Summary of phenotypes
c-MYC
BCL6
HA
pro-B lymphoma
block in B-cell
(Positive control)
development
HA*
Multiple myeloma
Diffuse Large
B-cell Lymphoma
International Myeloma Workshop 2005

Multiple Myeloma in Vk*HAMYC tg Mice
WT
TG
WT
TG38
TG18
Albumin
Ig-fraction
week
50
10
20
30
20
30
40
International Myeloma Workshop 2005

Vk*MYC develop spikes as early as 30 weeks
Incidence of spikes
n=14
n=5
100%
n=39
90%
n=41
n=48
80%
TG
70%
n=5
60%
n=42
n=4
wt
50%
n=7
tg
40%
n=24
30%
WT
20%
n=27
n=23
10%
n=12
0%
20w
30w
40w
50w
60w
70w
80w
age (weeks)
International Myeloma Workshop 2005

Multiple Myeloma in Vk*HAMYC tg Mice
International Myeloma Workshop 2005

Identification of Translocation and Cyclin D (TC) groups
FGFR3
MMSET
C-MAF
ITGB7
CCND3
CCND1
CCND2
PI
CI
PB PC
4p16
maf 6p21
11q13
D1
D1+D2
D2
HMCL
NONE
International Myeloma Workshop 2005

Microarray based Proliferation Index (PI) vs PCLI
8.0
7.0
6.0
5.0
PI
R2 = 0.63
4.0
3.0
2.0
1.0
0.0
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
PCLI
International Myeloma Workshop 2005

Different TC distribution of MM&MGUS versus Relapsed versus HMCL
4p16
maf
6p21
11q13
D1
D1+D2 NONE
D2
CCND1
CCND2
CCND3
MM
rel
MGUS
HMCL
8
7
6
CCND1 long
5
4
3
2
1
0
11q13
D1
D1+D2
International Myeloma Workshop 2005

Reproducibility of TC groups in other data sets: Mayo
4p16 maf 6p21
11q13
D1
D1+D2
D2
FGFR3
MMSET
ITGB7
CCND3
D1 total
D1 long
CCND2
PC
MM
MGUS
SMM
International Myeloma Workshop 2005

Expression of TRAIL in TC groups
20
10
0
4p16 maf 6p21 11q13 d1 d1+d2 d2 none
International Myeloma Workshop 2005

Bone disease correlates with molecular subgroup
% MRI positive for lytic lesions
100%
90%
80%
70%
60%
50%
Total
4p16
16q23 20q11
11q13 6p21
D1
D2
136/172
16/28
6/11
30/32
62/70
22/31
N/A
0.002
0.039
0.024
0.011
0.221
p-value
International Myeloma Workshop 2005

Which patients respond to
· Melphalan
A
· Glucocorticoids
·Thalidomide
·Bortezomib
B
A&B
A&B
International Myeloma Workshop 2005

Bortezomib - Summit 025 PGx analysis
· 202 relapsed, refractory MM treated with
bortezomib
· 126 enrolled on companion pharmacogenomic study
· 45 successful microarray data (Affymetrix
Hu133A+B)
· Arrayed group differed from total group
Increased PC infiltration of BM
Increased deletion 13
Increased cytogenetic abnormality
International Myeloma Workshop 2005

TC classification of Summit 025
32%
23%
18%
22%
5%
FGFR3
MMSET
MAFB
CCND3
CCND1 total
CCND1 long
CCND2
4p16
6p21+11q13
D1
D2
maf
PD
NC
MR
PR
CR/NCR
71% p=0.002
17% p=0.01
32%
RR 39% overall
International Myeloma Workshop 2005

t(4;14): longer TTP, shorter OS
Time to progression
Overall survival
100
100
t(4;14)
other
75
75
50
50
25
25
0
0
0
90
180 270 360 450 540 630 720
0
90
180 270 360 450 540 630 720
Days
Days
median 296 vs 84 days (p=0.065)
median 405 vs 598 days (p=0.041)
International Myeloma Workshop 2005

E1A00: Thal/Dex vs Dex
· ECOG Phase III randomized study in newly diagnosed patients
· 207 pts enrolled in the trial
· 103 randomized to Thal/Dex and 104 to Dex
· 74 BM samples obtained for research studies
· 46 adequate microarray hybridizations
· 35 evaluable for response
International Myeloma Workshop 2005

E1A00: Upfront Thal/Dex vs Dex
4p16
m 6 11
d1
d1+d2
d2
FGFR3
MMSET
MAFB
CCND3
CCND1 total
CCND1 long
CCND2
PD
NC
PR
Thalidomide
CR
38%
69%
50%
p=0.07
International Myeloma Workshop 2005

Differential response to dex
4 & m & 6 &11
d1 & d1+d2
Thal & Dex
4/7 (57%)
7/9 (78%)
Dex
1/7 (14%)
4/7 (57%)
p=0.09
p=0.09
International Myeloma Workshop 2005

Acknowledgements
Marco
Matteo
Mike
Kuehl
Marta
Chesi
Maurizio Affer, Davide Robbiani
Rafael Fonseca, Keith Stewart
Vincent Rajkumar, Phil Greipp
Paul Richardson, Ken Anderson
John Shaughnessy, Bart Barlogie
International Myeloma Workshop 2005

Identification of trisomies in TC D1 and D1+D2 groups
1.3
1.2
1.2
ALL
1.1
1.0
1.0
TEL
T
Normal
MLL
Hyperdiploid >50
E2A
BCR
0.9
0.9
MM
0.8
0.8
0.7
0.7
BMPC
6p21
11q13
D1
D1+D2
D2
None
4p16
maf
HMCL
International Myeloma Workshop 2005

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