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A Comprehensive
Guide to Sydney 2005
Review of the 10th International
Myeloma Workshop
International Myeloma Foundation
International Headquarters
12650 Riverside Drive, Suite 206
North Hollywood, California 91607
800 452 CURE (2873) Fax: 818 487 7454
TheIMF@myeloma.org
www.myeloma.org
A Publication of the International Myeloma Foundation
This activity is jointly sponsored by the Institute for Continuing Healthcare Education
Dedicated to improving the quality of life of myeloma patients while working toward prevention and a cure.
and the International Myeloma Foundation.
© 2005 International Myeloma Foundation
Release Date: September 2005 - Expiration Date: September 30, 2006
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Accreditation:
This activity has been planned and implemented in accordance with the Essential Areas and
Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the
joint sponsorship of the Institute for Continuing Healthcare Education and the International
Myeloma Foundation. The Institute for Continuing Healthcare Education is accredited by the
ACCME to provide continuing medical education for physicians.
The Institute for Continuing Healthcare Education designates this educational activity for a
maximum of 4.0 category 1 credits toward the AMA Physician's Recognition Award. Each
physician should claim only those credits that he/she actually spent in the activity.
Target Audience:
This activity has been designed to meet the educational needs of hematologists and hematologic
If you do not have the 2 DVDs that came with
oncologists treating patients with multiple myeloma.
this monograph please contact the
International Myeloma Foundation at
800 452 CURE (2873)
Commercial Support:
This activity is supported by educational grants from
Celgene Corporation, Millennium Pharmaceuticals, and Novartis.
The Institute for Continuing Healthcare Education recognizes and adheres to the
ACCME Standards for Commercial Support of Continuing Medical Education
Disclaimer:
The opinions expressed in this publication are those of the participating faculty and not
that of the Institute for Continuing Healthcare Education, the IMF or any manufactures of
products mentioned herein.
The information is provided for general medical education purposes only and is not meant to
substitute for the independent medical judgment of a health-care professional.
A Comprehensive
Guide to Sydney
2005
Review of the
10th International
Myeloma Workshop
This activity is jointly sponsored by the
Institute for Continuing Healthcare Education
and the
International Myeloma Foundation
A Publication of the International Myeloma Foundation
Dedicated to improving the quality of life of myeloma patients while working toward prevention and a cure.
© 2005 International Myeloma Foundation
Editor
John Gibson, MD, PhD
Deputy Director and Associate Professor of Medicine
Institute of Haematology
Douglas E. Joshua, MD, DPhil
Royal Prince Alfred Hospital
Professor and Head, Institute of Haematology
Camperdown, Australia
Royal Prince Alfred Hospital
Camperdown, Australia
P. Joy Ho, MD, DPhil
Senior Staff Specialist, Institute of Haematology
Faculty
Research Associate, Centenary Institute
Royal Prince Alfred Hospital
Kenneth C. Anderson, MD
Camperdown, Australia
Director, Jerome Lipper Multiple Myeloma Center
Kraft Family Professor of Medicine
Heinz Ludwig, MD
Harvard Medical School
Head, Department of Medicine and Medical Oncology
Dana-Farber Cancer Institute
Director, Myeloma Reference Center
Boston, Massachusetts, USA
Wilhelminen Hospital
Vienna, Austria
P. Leif Bergsagel, MD, FRCP
Associate Professor of Medicine
Gregory R. Mundy, MD
Mayo Clinic Cancer Center
Professor, Department of Medicine
Scottsdale, Arizona, USA
Chief, Division of Endocrinology
The University of Texas Health Science Center
Kathleen Boyle, PhD
at San Antonio
Medical Director
San Antonio, Texas, USA
Institute for Continuing Healthcare Education
Philadelphia, Pennsylvania, USA
Linda Pilarski, PhD
Professor and Senior Scientist
Meletios A. Dimopoulos, MD
Department of Oncology
Professor of Therapeutics
University of Alberta
University of Athens School of Medicine
Cross Cancer Institute
Athens, Greece
Edmonton, Alberta, Canada
Madhav Dhodapkar, MD
S. Vincent Rajkumar, MD
Irene Diamond Associate Professor
Associate Professor of Medicine
Laboratory of Tumor Immunology and Immunotherapy
Mayo Clinic
The Rockefeller University
Rochester, Minnesota, USA
New York, New York, USA
Pieter Sonneveld, MD, PhD
Brian G.M. Durie, MD
Professor of Hematology
Specialist in Multiple Myeloma and Related Disorders
Erasmus Medical Center
Cedars-Sinai Comprehensive Cancer Center
Rotterdam, The Netherlands
Los Angeles, California, USA
Ivan Van Riet, MD
Gösta Gahrton, MD
Academic Hospital Free University Brussels
Professor Emeritus in Hematology
Department of Medical Oncology and Hematology
Karolinska Institute
Stem Cell Laboratory
Stockholm, Sweden
Brussels, Belgium
Ramón García-Sanz, MD, PhD
Professor, Hematology Department
Hospital Universitario de Salamanca
Salamanca, Spain
Activity Instructions
Participants will review all accreditation information, disclosure information, and learning objectives before
reading all 16 articles including tables, figures, and references. Participants will then complete the post-test
questions at the end of each section. Participants must fill in their answers on the post-test answer key and
submit the form along with the registration for credit and evaluation form. To receive a certificate of credit, a
score of 80% or higher is required on the post-test. This activity is valid until September 30, 2006. It should
take approximately 4.0 hours to complete this activity as designed.
Learning Objective
Plenary Session 3
1. Identify the geographic variation in the
incidence of MM, and summarize possible
Plenary Session 1
risk factors in its etiology.
1. Describe the normal maturation of the
2. Discuss the differentiation between
B cell to the plasma cell and how this is
smoldering MM and the risk factors that
disarranged in multiple myeloma (MM).
increase the risk of transformation to active
2. Explain how plasma cells interact with
MM.
stromal cells and how the normal cell cycle
3. Describe the basis of the new international
of the plasma cell is controlled.
staging system (ISS) for MM.
3. Identify the phenotypic alterations that
4. Review the role of the new imaging
occur in plasma-cell development, and
procedures in MM and their importance in
explain how they are applicable to clinical
planning therapy.
monitoring of MM.
Focus Session 3
Plenary Session 2
1. Discuss the mechanism and role of somatic
1. Explain the molecular basis of MM and the
mutation and class switching in the normal
new molecular classification based on the
and malignant plasma cell.
translocation/cyclin D (TC) model.
2. Identify the signals that mediate interactions
2. Describe the cytogenetic abnormalities
between the MM plasma cell and the bone-
associated with MM.
marrow microenvironment.
3. Summarize the significance of cyclin D
3. Explain the role of the cell-surface molecule
dysregulation in MM.
CD45 in the malignant plasma cell.
4. Assess epigenetic changes that occur in MM
and their possible role in the progression of
Plenary Sessions 4 and 8
the disease.
1. Describe the role of autologous
transplantation and high-dose therapy in
Focus Session 2
MM.
1. Assess the incidence of response and side
2. Identify the place of tandem autologous
effects of thalidomide in MM.
transplants in MM.
2. Identify the role and mechanisms of action
3. List the important prognostic factors that
of bisphosphonates in preventing bone
relate to patients treated with high-dose
disease in MM.
therapy.
3. Review the incidence of anemia in MM and
4. Discuss the constraints and use of high-dose
its role in determining performance status.
therapy in older patients.
Focus Sessions 4 and 8
Plenary Session 9
1. Explain the new concepts of osteoclast
1. Define the role of allogeneic transplantation
activation and bone destruction in MM.
in MM.
2. Identify important cytokines involved in the
2. Assess the differences between myeloablative
bone disease of MM.
and nonmyeloablative transplantation
3. Discuss the potential role and complications
with respect to transplant-related toxicity,
of bisphosphonate therapy in MM.
response, and relapse rates.
Plenary Session 5
Focus Session 9
1. Describe the mechanism of action of the
1. Explain the mechanism of how MM cells
novel proteasome inhibitor bortezomib.
home to the bone marrow and which
2. Assess the significance of the pivotal
molecules are involved in the process.
trials of the novel agents bortezomib and
2. Define how IGF-1 acts as a growth factor
lenalidomide.
for MM cells.
3. Examine clinical significance of preclinical
3. Explain how Akt signaling is a critical
models of MM cell growth and the
pathway for cell survival.
interaction of the MM cell and the bone-
4. Recognize other signaling pathways that
marrow environment.
play a role in the survival of the malignant
plasma cell, and describe the potential for
Plenary Session 6
targeted therapies to block these pathways.
1. Describe the natural interaction between the
MM cell and the bone-marrow stroma.
2. Identify the cytokines and signaling
Plenary Session 11
pathways involved in cell adhesion-mediated
1. Explain the role of the immune system
drug resistance (CAMDR).
in the control of growth of the malignant
3. State the mechanism of action of agents that
clone.
interfere with angiogenesis in MM.
2. Identify which tumor reactive cells can be
4. List the key proteins involved in formation
recognized in patients with MM.
of new blood vessels.
3. Describe the biology of the dendritic cell
and its action in initiating the antitumor
Focus Session 6
immune response.
1. Discuss the clinical manifestations of the
rare immunoglobulin diseases: amyloidosis,
Plenary Session 12
Waldenström's macroglobulinemia, and the
1. Recognize the fundamentals of dendritic cell
POEMS syndrome.
function.
2. Explain the differences in therapeutic
2. Describe the current options of tumor
approaches required for optimal treatments
vaccination in MM (dendritic cell, DNA,
of these conditions.
and idiotype vaccination).
Plenary Session 7
Focus Session 12
1. Identify the principles of gene-array analysis.
1. Examine the mechanism of acquired drug
2. Explain
the
basis
of
new
molecular
resistance in MM.
classifications of MM based on gene arrays.
2. Identify the different mechanisms of
3. Discuss the different clinical phenotypes
acquired versus de novo drug resistance.
associated with molecular subtypes of MM,
3. Discuss the major signaling pathways
especially the t(4:14) translocation.
involved in pro- and antiapoptosis.
4. Describe how patient factors influence
disease behavior and response to therapy
(pharmacogenomics).
General Disclosure
This review has been developed based on numerous presentations given at the Multiple Myeloma Confer-
ence in Sydney, Australia, on April 10­14, 2005. Sixteen expert faculty members who participated in this
conference have summarized the presentations given by their colleagues and have written comprehensive
overviews of the specific scientific sessions from the meeting. Therefore, this review includes the discussion
of unlabeled uses of commercial products and/or products that have not yet been approved by the FDA for
use in the United States for any purpose.
The education content for this activity has been independently reviewed and validated to ensure that it is a
fair and balanced representation of the topic, based on the best available evidence. Any relationships faculty
members may have with commercial entities have been disclosed and reviewed, and any potential conflicts
have been resolved.
The opinions expressed in this publication are those of the participating faculty and not those of the Insti-
tute for Continuing Healthcare Education, the International Myeloma Foundation, Celgene Corporation,
Millennium Pharmaceuticals, Novartis or any manufacturers of products mentioned herein.
The information is provided for general medical education purposes only and is not meant to substitute for
the independent medical judgment of health-care professionals regarding diagnostic and treatment options of
a specific patient's medical condition. In no event will the Institute for Continuing Healthcare Education be
responsible for any decisions made or action taken based upon the information provided through this activity.
Readers are encouraged to consult the package insert of all products for updated information and changes
regarding indications, dosages, and contraindications. This recommendation is particularly important with
new or infrequently used products.
Financial Disclosure
Dr. Dimopoulos has received honoraria related to
formal advisory activities from Novartis.
Dr. Anderson has received grant support
Dr. Durie has received honoraria related to the
related to research activities from Millennium
development of educational materials and grant
Pharmaceuticals, Inc., Celgene Corporation, and
support for research activities from Millenium
Novartis.
Pharmaceuticals, Inc. and Celgene Corporation. He
has received honoraria for speaker-bureau activities
Dr. Bergsagel has disclosed that he has no significant
from Millenium Pharmaceuticals, Inc. Dr. Durie
relationships with the grantors or any other
has also received honoraria for the development of
commercial company whose products and services
educational materials from Kyphon.
are discussed in his material.
Dr. Gahrton has disclosed that he has no significant
Dr. Boyle has disclosed that she has no significant
relationships with the grantors or any other
relationships with the grantors or any other
commercial company whose products and services
commercial company whose products and services
are discussed in his material.
are discussed in her materials.
Dr. Garcia-Sanz has disclosed that he has no
Dr. Dhodapkar has disclosed that he has no
significant relationships with the grantors or any
significant relationships with the grantors or any
other commercial company whose products and
other commercial company whose products and
services are discussed in his material.
services are discussed in his material.
Dr. Gibson has received grant support related to
Dr. Pilarski has disclosed that she has no significant
research activities from Johnson & Johnson.
relationships with the grantors or any other
commercial company whose products and services
Dr. Ho has disclosed that she has no significant
are discussed in her material.
relationships with the grantors or any other
commercial company whose products and services
Dr. Rajkumar has received grant support related to
are discussed in her material.
research activities from Celgene Corporation and
Millennium Pharmaceuticals, Inc.
Dr. Joshua has received honoraria related to formal
advisory activities from Novartis, Janssen-Cilag, and
Dr. Sonneveld has received honoraria related to
Pharmion.
formal advisory activities from Celgene Corporation
and Millennium Pharmaceuticals, Inc. He has
Dr. Ludwig has received honoraria related to formal
received honoraria related to speaker-bureau
advisory and speaker-bureau activities from Amgen
activities from Johnson & Johnson and Ortho
Inc. and Ortho Biotech Products, L.P.
Biotech Products, L.P.
Dr. Mundy has disclosed that he has no significant
Dr. Van Riet has disclosed that he has no significant
relationships with the grantors or any other
relationships with the grantors or any other
commercial company whose products and services
commercial company whose products and services
are discussed in his material.
are discussed in his material.
Table of Contents
Chapter
Page
Chapter
Page
Plenary Session:1
1
Focus Session 6:
45
The Malignant Clone
Waldenström's Symposium
Ramón García-Sanz
and Myeloma Variants
Meletios A. Dimopoulos
Plenary Session 2:
6
Cytogenetics and
Plenary Session 7:
51
Molecular Pathogenesis
How Do We Use Genomics
P. Leif Bergsagel
to Tailor Therapy?
P. Joy Ho
Focus Session 2:
10
Innovations in Standard and
Plenary Session 9:
56
Supportive Therapy
Allogeneic Transplantation
Heinz Ludwig
Gösta Gahrton
Plenary Session 3:
16
Focus Session 9:
61
Evolving Myeloma
Homing Mechanisms
Brian G.M. Durie
and Signal Transduction
Ivan Van Riet
Focus Session 3:
20
The Malignant Clone
Plenary Session 11:
65
Linda Pilarski
Immune Biology
Madhav Dhodapkar
Plenary Sessions 4 and 8:
24
Autologous Transplantation
Plenary Session 12:
69
John Gibson
Immunotherapy
Kathleen Boyle
Focus Sessions 4 and 8:
31
Bone Disease in Multiple Myeloma
Focus Session 12:
71
Gregory R. Mundy
Drug Resistance: Mechanisms
and Therapeutic Strategies
Plenary Session 5:
36
Pieter Sonneveld
New Therapeutic Agents
Kenneth C. Anderson
Plenary Session 6:
40
Tumor Microenvironment
and Angiogenesis
S. Vincent Rajkumar
Plenary Session 1:
Dr. MacLennan1 also noted that several studies
in mice have reported the possibility of an
The Malignant Clone
accumulation of somatic mutations outside the
germinal center, which also favors the hypothesis
Ramón García-Sanz
of the second way for producing PCs. In any case,
Hospital Universitario de Salamanca
MM PCs seem to have been produced from cells
Salamanca, Spain
that have undergone maturation in the germinal
center, but the possibility of an alternative cellular
The 10th International Workshop on Multiple
origin cannot be ruled out.
Myeloma held in Sydney last April 2005 started with
a wide overview of the current knowledge about the
In the second talk of the session, Dr. Selina
malignant clone in multiple myeloma (MM).
Chen-Kiang2 (Weill Medical College of Cornell
University, United States) spoke about cell-cycle
In the first talk, Dr. Ian MacLennan1 (MRC
control in MM. Myelomatous PCs have lost both
Centre for Immune Regulation, University of
cell-cycle and apoptotic controls at distinct stages
Birmingham, United Kingdom) focused on the
of malignant transformation. The mechanisms that
origin of neoplastic plasma cells (PCs) in MM.
lead cell-cycle dysregulation in MM, however, are
Normal PCs are usually produced in the follicular
still unknown, although they will contribute to
centers of secondary lymphoid organs through a
monoclonal expansion of MM cells in the initial
B-cell differentiation process that produces the
phases of the disease and to aggressive MM cell
so-called long-lived PC as well as memory B cells.
However, an alternative pathway occurring in the
proliferation during relapse.
bone marrow (BM) may generate the so-called
short-lived PC without the production of memory
With the current knowledge, cell-cycle alterations
B cells. The first findings to support the second
in MM mainly involve the dysregulation of the G1
hypothesis derive from the use of the anti-CD20
phase of the cycle, when the cell prepares for DNA
monoclonal antibody (MAB) (rituximab) in
synthesis. The G1 phase has a middle regulatory
autoimmune diseases. It is important to note that
checkpoint at the E2F protein and the control that
this therapy provides a quick decrease in B cells but,
RB protein (pRB) exerts in it. This checkpoint is
as PCs usually lack CD20 expression, no changes in
controlled by the aggregate balance between positive
the production of immunoglobulin (Ig) would be
regulators (cyclins and cyclin-dependent kinases
expected. This has been confirmed by measurement
[CDKs]) and negative regulators (CDK inhibitors
of IgG levels, which are little affected as they are
[CDKIs]). CDKIs are of 2 types: early CDKIs (p15,
produced by long-lived PCs. A similar effect has
p16, p18, and p19) and late inhibitors (p21, p27,
been observed in the titers of specific antibodies
and p57). Thanks to this checkpoint, normal PCs
such as those directed against the tetanus toxoid.
Conversely, autoantibody titers significantly fall in
are permanently withdrawn from the cell cycle.
a 1- to 2-month period. Although possible, it is not
It is thought that p18INK4c in normal PCs is
probable that PCs producing these autoantibodies
upregulated by interleukin-6 (IL-6) and required
would be affected by the anti-CD20; actually, it is
for cell-cycle termination and generation of G1-
more plausible that PCs producing autoantibodies
arrested functional PCs. In the absence of p18INK4c,
are relatively short-lived cells, whose renewal from
although CD138+ plasmacytoid cells are generated,
the B cells is affected by the MAB.
they fail to terminate the cell cycle or produce
terminally differentiated functional PCs. Although
1
bone-homing is affected, these plasmacytoid cells
The third talk given by Dr. Federico Caligaris-
are rapidly eliminated by apoptosis. This was the
Cappio3 (Universitŕ Vita-Salute, Istituto Scientifico
first demonstration of cell-cycle control of B-cell
San Raffaele, Italy) focused on the "cross-talks" that
immunity and provided a functional link between
are thought to take place in MM between tumor
CDKI-mediated cell-cycle control and apoptosis in
PCs and the microenvironment, which could
PC differentiation.
provide the basis for developing new treatment
modalities for treatment of MM by targeting these
Thus, loss of CDKI function may play a critical
triggering interactions.
role in pathogenesis of MM, but this possibility has
not been verified. Nevertheless, mutations in the
BM microenvironment is the specific external
p18 INK4c gene and methylation inactivation of p16
support that development of MM requires. This
and p15INK4b gene promoters have been described
can explain why peripheral lymphoid organs
in MM. Moreover, cyclin D1 or D3 overexpression
are unaffected by the malignancy, whereas BM
is frequently associated with MM in a mutually
is constantly involved, despite the peripheral
excluding manner. In addition, the selective
origin of the monoclonal founder cell. The
phosphorylation of the pRB protein by cyclin
D2-CDK4/6 is enhanced in advanced MM. These
BM microenvironment includes stromal cells,
observations would imply that gain of the cyclin
endothelial cells, and osteoclasts. All these cells
D function may contribute to the loss of cell-cycle
could deliver prosurvival and anti-apoptotic
control in MM cells. However, cyclin D1 and D3
signals to the malignant clone. This creates tight
protein levels have no relationship to the cell-cycle
interactions between MM PCs and the BM that
status of primary BM MM cells. Thus, the cyclin D
constitute a key element in behavior of MM.
involvement in MM cell-cycle dysregulation requires
additional experimental support.
Apparently, hypoxia can influence the relationship
Accordingly, the hypothesis is that the proliferative
between MM cells and BM microenvironment.
expansion of MM cells is preceded by the loss of
Hypoxia transiently upregulates the expression of
the mid-G1 cell-cycle checkpoint caused by an
HIF-1
and HIF-2 molecules. In endothelial
imbalance between positive and negative G1 cell-
cells under hypoxic conditions, HIF-1 and HIF-
cycle regulators. This hypothesis will be tested with
2 are upregulated and mediate the transcriptional
the so-called functional cell-cycle assay, which takes
activation of hypoxia-responsive genes including
into account the Ki67 expression of CD138+ cells
and the ex vivo BdrU uptake. This method has
vascular endothelial growth factor (VEGF). These
been calibrated according to the phosphorylation of
cells exposed to hypoxic conditions (HIF-1
specific cell-cycle proteins in CD138-purified cells
and HIF-2 positive) are induced to proliferate
from MM BM. Preliminary results of this functional
and migrate. This activating change is called
cell-cycle analysis have shown that remission and
the angiogenic switch. The HIF-1 molecule is
relapse are associated with deregulation of early
expressed by freshly isolated BM PCs from patients
and late G1 cell-cycle regulators. These studies
with MM at levels significantly higher than the PCs
will contribute to a better understanding of MM
from monoclonal gammopathies of undetermined
pathophysiology as well as different forms of disease
significance (MGUS). This suggests that MM and
evolution. In addition, it may also help in the design
stromal cells are under hypoxic conditions and
of cell-cycle inhibitors as a therapeutic strategy for
release proangiogenic factors that promote the
treatment of MM.
angiogenic switch of the endothelial cells present in
the BM blood vessels. Thus, the next question to
2
answer is if MM therapy can affect the regulation
was much higher in cells from MGUS than from
of the endothelial response to hypoxia, for example,
MM. A similar finding has also been reported for
by using the proteasome inhibitor MG-132.
indolent versus aggressive chronic lymphocytic
This therapeutic agent impairs the mitochondrial
leukemia. In U266 and LP1 cell lines, MICA
activity of human umbilical vein endothelial cells
expression was not sufficient to elicit killing or IFN-
(HUVECs) and PCs and inhibits the HUVECs
production by V 9/V 2 T-cell clones. However,
sprouting formation in vitro and the angiogenesis in
pamidronate is able to sensitize MICA+ MM
vivo. In addition, hypoxia plays a crucial role in these
cell lines to the
-cell lysis. In addition, MICA
effects, as MG-132 induces apoptosis of HUVEC
enhances the killing of MM PC from patients by
mainly when they are hypoxic. In conclusion, in
pamidronate-activated V 9/V 2 T-lymphocytes.
MM, endothelial cells receive stimulus to proliferate
Thus, although these functions mostly depended on
and migrate, but this also makes them more sensitive
T-cell receptor triggering, they also are influenced
to M-132­induced apoptosis.
by MICA engagement. All these interactions
support the existence of a possible involvement of
The second topic of this talk was the action that
lymphocytes in the immune surveillance of MM.
T cells can exert on MM BM microenvironment.
In MM, T cells have a specific recognition
The last talk of the session corresponded to Dr.
mechanism: CD8+ cells recognize PCs and CD4+
Jesús F. San Miguel4 (Hospital Universitario
cells recognize stromal cells. This is a consequence
Salamanca, Spain) who reviewed the
of CD80- and CD40L-mediated interactions.
immunophenotype of the malignant clone and its
Thus, MM-specific CD8+ T-lymphocytes that
implications on the management of the disease. The
recognize naďve tumor cells can be generated
use of multiparametric immunophenotyping by
by in vitro immunotherapeutic approaches.
flow cytometry in MM has been mainly restricted
However, anti-MM T-cell generation appears to
to research purposes and differential diagnosis of
be hampered in patients with high tumor burden.
unusual cases. Nevertheless, it would probably
By contrast, innate effector cells are thought to
be more useful in clinical practice than usually
be early defenders against tumors when damaged
thought to be. Immunophenotypic characterization
cells fail to repair DNA mutations. In this context,
of PCs requires a minimum panel of MABs
V 9/V 2 T-lymphocytes are a subset of interest
(CD19, CD20, CD28, CD33, CD45, CD56,
because they can be activated in hematologic tumors
CD117, and monotypic surface immunoglobulin
with phosphorylated nonpeptidic metabolites.
[sIg] together with CD38/CD138), preferably in
Among such compounds, amino-bisphosphonates
quadruple combinations. This type of panel allows
can activate the V 9/V 2 T-cell subset to favor
the identification of phenotypic aberrancies in
the killing of MM cells. These effector functions
myelomatous PCs as well as the discrimination
can be enhanced upon triggering the activating
between normal and malignant PCs. In a series
receptor NKG2D by MICA, a stress-inducible
with more than 800 untreated patients with MM,
antigen expressed by a number of epithelial and
more than 90% of them had malignant PC-
hematopoietic tumors. MICA was expressed in the
expressing phenotypic aberrancies such as antigen
surface of MM cell lines (ie, U266 and LP1) as
underexpression (decreased CD38 intensity),
well as in freshly isolated PCs from 10/10 patients
overexpression (increased reactivity for CD28,
with newly diagnosed MM and 6/6 patients with
CD33, CD56), or asynchronous antigen expression
MGUS. Moreover, the mean expression of MICA
(presence of sIg, CD20, CD45, CD117). Within
3
all the above-mentioned antigens, the lack of
considered, as it is already used in other disorders
expression of CD56 or CD117 or the presence of
such as chronic lymphocytic B-leukemia (B-CLL).
CD28 is associated with relatively poor prognoses.
Other potential applications for immuno-
Moreover, the association among different antigenic
phenotyping include differential diagnosis between
expressions (antigenic profile) has a higher impact
MGUS and MM, assessment of the degree of BM
on the prognosis. Thus patterns such as CD56-
infiltration, and contamination of apheresis and the
CD117- and CD56-CD28+ are associated
specific analysis of the DNA-cell content (DNA
with poor prognoses, whereas CD117+CD28-
ploidy) and cell-cycle distribution (proportion of
patients have favorable prognoses. In multivariate
S-phase PCs) of the myelomatous tumor clone.
analysis, the CD56-CD117- antigenic profile was
These latter parameters afford relevant prognostic
independently associated with poor prognoses. The
information. All together, these data illustrate the
expression of CD56, CD117, and CD33 antigens
potential clinical value of immunophenotypic
is more frequently associated with hyperdiploid
studies in MM.
DNA-cell content of PCs. By contrast, positivity
for CD20 and CD28 is usually associated with
References
diploid DNA-cell content. Patients with deletion of
13q as well as those with IgH rearrangements, were
1.
MacLennan ICM. Unconventional switched
more frequently positive for CD20 and negative for
bone marrow plasma cells with Ig V-region
CD56, CD45, and CD117 markers.
mutations [abstract]. Haematologica.
2005;90(suppl 1):1. Abstract PL1.01.
The second area of interest for immunophenotyping
2.
Ely S, Di Biberto M, Niesvizky R, et al.
in MM is investigation of minimal residual disease
Cell cycle control in multiple myeloma
(MRD). This is based on the discrimination
[abstract]. Haematologica. 2005;90(suppl
between normal and myelomatous PCs according
1):1-2. Abstract PL1.02.
to the presence of the above-mentioned phenotypic
3.
Caligaris-Cappio F, Ferrarini M, Ferrero
aberrancies, present in more than 95% of patients
E, Sitia R. Cross-talk between plasma cells
with MM. In this area, immunophenotype provided
and the microenvironment: triggering
higher predictive information of risk of relapse than
and targeting [abstract]. Haematologica.
conventional electrophoresis. In the evaluation of
2005;90(suppl 1):2-3. Abstract PL1.03.
BM obtained 3 months after autologous stem-cell
4.
Mateo G, Gutierrez NC, Lopez-Berges MC,
transplantation (ASCT), immunophenotyping can
et al. Immunophenotype of the malignant
distinguish among 3 different groups according to
clone: implications for management
the levels of MRD: 1%, 1%­0.01%, and 0.01%,
[abstract]. Haematologica. 2005;90(suppl
whose medians of event-free survival are 23 months,
1):3. Abstract PL1.04.
40 months, and not reached, respectively. Moreover,
within patients achieving a negative electrophoresis
after transplant, immunophenotype distinguished
between patients with high and low risk of relapse
according to the presence of more or less than 0.01%
tumor cells or according to the presence of more
or less than 75% normal PCs. Based on these data,
the term immunophenotypical remission should be
4
Post-test Questions
1.
The immunoglobulin gene in the plasma
cell of multiple myeloma (MM) has
undergone somatic hypermutation.
True
False
2.
Cyclins and cyclin dependent kinases are
involved in cell-cycle checkpoints in the
plasma cell.
True
False
3.
Ninety percent of plasma cells in MM have
phenotypic abnormalities.
True
False
5
The pathogenetic pathways that lead to the
Plenary Session 2:
formation of plasma-cell neoplasms are evident
in monoclonal gammopathy of undetermined
Cytogenetics and
significance (MGUS). Patients with MGUS harbor
the same chromosome abnormalities as in MM
Molecular Pathogenesis
and in similar prevalence; for instance, all IgH-
P. Leif Bergsagel
TRX observed in MM are also observed in MGUS.
Mayo Clinic Cancer Center
Uncertainty existed regarding the presence of
t(4;14) in patients with MGUS, and others have
Scottsdale, Arizona, USA
suggested that its presence would invariably lead
to MM. Dr. Fonseca reported that he has observed
Summary
t(4;14) in patients with MGUS and smoldering
Multiple myeloma (MM) is a heterogeneous disease.
MM at a similar prevalence as in MM, with no
From a genetic standpoint, there are 2 main types.
evidence of an increased risk of progression to MM.
One has recurrent chromosome translocations of
The proportion of t(11;14) MGUS is higher than
the immunoglobulin genes, and the other has an
in MM (25% vs 16%) and even higher in patients
extra copy of several chromosomes (3, 5, 7, 9, 11,
with earlier plasma-cell proliferations such as light-
15, 19, and 21). Genetic subclassification identifies
chain amyloidosis (~50%).
subtly different diseases with important differences
in biology, prognosis, and response to therapy.
Dysregulation of a Cyclin D Gene: An Early and
Epigenetic and alternative RNA splicing provide
Unifying Event in MGUS and MM
additional mechanisms for gene dysregulation and
There is a paradox in MM that was pointed out
tumor progression.
by Dr. Michael Kuehl2 (National Cancer Institute,
United States). Despite the fact that MM cells have
Integration of Genetics in a Comprehensive
a very low proliferative rate, they are characterized
Pathogenesis Model for MGUS/MM
by almost universal overexpression of 1 of the
The session started with a review of the importance
3 members of the cyclin D gene family that are
of ploidy (the number of chromosome copies
normally associated with proliferation. He was to
per cell). A normal diploid cell has 23 pairs of
correlate the individual cyclin D gene expressed
chromosomes. When cells have more than 47
with the underlying genetics. Patients with
chromosomes, they are called hyperdiploid. Dr.
t(11;14) expressed cyclin D1, t(6;14) expressed
Rafael Fonseca1 (Mayo Clinic, United States)
cyclin D3, both because of juxtaposition of the
pointed out that there are 2 major subtypes of MM:
immunoglobulin heavy chain with the cyclin D
one harboring immunoglobulin gene translocations
gene at the chromosome translocation breakpoint.
(IgH-TRX) and having nonhyperdiploid (NH)
The t(14;16) and t(14;20) translocations dysregulate
chromosome content, the other with hyperdiploid
maf transcription factors that can directly upregulate
(HYP) chromosome content. MM with HYP and
cyclin D2. The HYP patients were found to
low prevalence of IgH-TRX is characterized by the
have ectopic expression of cyclin D1 by an as yet
presence of multiple trisomies (3 copies) of the odd-
undetermined mechanism. Finally, the remaining
number chromosomes (3, 5, 7, 9, 11, 15, 19, and
patients overexpress cyclin D2. The combination
21). These patients have a lower prevalence of IgH-
of IgH-TRX and cyclin D expression allows one to
TRX than patients with NH MM (20% vs 80%).
divide MM patients into 1 of 8 distinct TC groups:
HYP MM is less aggressive, and patients have better
TC 4p16, TC maf, TC 6p21, TC 11q13, TC D1,
overall prognoses.
TC D1+D2, TC D2, and TC NONE.
6
Cyclin D works together with partner proteins
able to show that there are important biologic and
to regulate the cell cycle. Even though cyclin
clinical differences among patients in the different
D appears to be universally dysregulated, it
TC groups. For example, patients in TC 4p16 and
seems that its partner proteins can be targeted
TC maf have a lower incidence of bone disease
by genetic mutations. These include the cyclin-
(55%), whereas it is higher for those in TC D1 and
dependent kinase inhibitors p16 and p18. This
TC 11q13 (90%). Furthermore, there are important
genetic evidence highlights the importance of
prognostic implications, with a poor prognosis for
this pathway to the development of MM and
TC 4p16 and TC maf.
suggests that targeting this pathway may have
possible therapeutic potential. It appears that
Regardless of the method used to identify patients
the chromosome translocations and cyclin D
with 4p16, they have uniformly poor survival. This
dysregulation are very early genetic events (present
applies to both patients treated with conventional or
in the earliest stages of MGUS). These early events
high-dose therapy, suggesting that novel treatment
are followed by a common series of secondary
approaches are required. Dr. Bergsagel reported
genetic events that contribute to progression of
that t(4;14) is associated with ectopic expression
disease. These include secondary translocations of
of fibroblast growth factor receptor 3 (FGFR3),
the MYC gene and point to mutations of the RAS,
which is located at the translocation breakpoint.3
p53, and PTEN genes. These secondary changes are
With Dr. Suzanne Trudel (Princess Margaret
not seen in MGUS.
Hospital, Canada), he was able to show that a
selective tyrosine kinase inhibitor of FGFR3 was
Clinical Implications of Classifying MM Based on
able to induce cell-cycle arrest and cell death in
Translocation and Cyclin D
MM cells that express an activated FGFR3. These
The patterns of progression from MGUS to MM
preclinical studies have provided the scientific basis
are likely to follow the specific pathways that
for proceeding with a clinical trial of an FGFR3
are preferred based on the unique cytogenetic
inhibitor, CHIR-258, in patients with 4p16 MM.
background of the MGUS cells. Dr. Fonseca
This kind of targeted therapy with a tyrosine kinase
reported that although mutations of the RAS
inhibitor has been extremely successful in chronic
genes are seen in approximately 30% of patients
myelogenous leukemia, and holds great promise for
with MM overall, they are far more common in
effective and nontoxic therapy of MM.
patients with t(11;14) (~50%) than in patients with
t(4;14) (~<5%).3 Further support for this concept
To make more rapid progress in targeted drug
of distinct diseases identified by cytogenetics
development, it is critical to have preclinical models
came from an analysis by Dr. Kuehl and Dr.
that reflect the genetics of human MM. To this end,
Bergsagel of the gene-expression profiles of 250
Dr. Bergsagel reported on his efforts to use mice to
newly diagnosed patients performed by Dr. John
model the genetic events that give rise to human
Shaughnessy3 (University of Arkansas for Medical
MM. He generated mice that expressed FGFR3
Sciences, United States). Dr. Bergsagel reported
in plasma cells, and they remained healthy and
that the underlying genetics, as reflected in the TC
free of cancer. In contrast, mice that expressed the
classification, accounted for most of the variability
other partner protein in the t(4;14) translocation,
in gene expression among patients. He was able
MMSET, developed lymphomas, suggesting that
to apply the TC classification successfully to
it is also important in the pathogenesis of t(4;14)
patients with gene-expression profiles generated in
MM. Finally, he presented a novel mouse model of
different institutions and using different platforms,
MGUS/MM that depends on exactly mimicking
suggesting that it is a valid and robust method to
the timing of genetic transformation. These mice
classify patients. Using this classification, he was
reproducibly developed MGUS at 40 weeks of
7
age and can now be used to study the mechanisms
Alternative Gene Splicing in MM: An Important
of progression and the effects of therapeutic
Prognostic Event
interventions.
A final mechanism controlling gene expression is the
regulation of mRNA splicing, which governs how
Epigenetic Changes in the Molecular Pathology of
genes are finally put together. Overexpression of
MM
genes with dysregulated cellular function promotes
The regulation of gene expression is complex and
cancer. Aberrant splicing is another mechanism to
is governed not only by the structure of the genes
dysregulate a gene's cellular function. Dr. Linda
themselves but secondary modifications of the
Pilarski5 (University of Alberta and Cross Cancer
nucleic acids in the gene promoters (methylation)
Institute, Canada) described the impact on MM of
and of the proteins that hold chromosomes together
aberrant splicing in hyaluronan synthase 1 (HAS1)
(chromatin). These changes are called epigenetic,
and abnormal regulation of alternative splicing in
and are perhaps most familiar as the mechanism by
RHAMM: 2 proteins functionally linked as ligand
which all cells in women inactivate 1 of the 2 copies
and receptor, respectively. Three aberrant splice
of the X chromosome. Unlike genetic changes,
variants were detected in MM and 1 in particular
epigenetic changes are not always permanent, and
(HAS1Vb) in MGUS. The expression of HAS1Vb
they can sometimes be reversed. Epigenetic changes
either alone or in combination with HAS1 and its
are important in tumor progression as an efficient
variants in the peripheral blood B cells correlates
mechanism to silence the expression of many
with poor survival. HAS1Vb is the only variant
tumor-suppressor genes. Identification of these
with prognostic impact that appears to produce
changes, and their reversal, holds great therapeutic
intracellular HA, a form that may modulate
potential. Dr. Johannes Drach4 (Medical University
RHAMM association with the mitotic spindle.
of Vienna, Austria) compared the aberrant promoter
HAS1 and its variants, in concert with RHAMM,
methylation profile of known or suspected tumor-
may be key contributors to chromosomal instability
suppressor genes in MGUS with that in MM. He
in MM.
found that several genes were frequently methylated
in MM including p16, p15, E-cadherin, DAPK,
References
and DcRI, whereas methylation of other genes was
infrequent (RASSF1A, MGMT, RAR ). In MGUS,
1.
Fonseca R, Bergsagel PL, Chesi M, et al.
abnormal methylation was observed as well, and
Integration of genetics in a comprehensive
the percentage of MGUS cases with at least 1 gene
pathogenesis model for myeloma [abstract].
methylated was similar to that of MM (80%).
Haematologica. 2005;90(suppl 1):4-5.
However, the mean methylation index (a reflection
Abstract PL2.01.
of the methylation status of all of the genes tested)
2.
Kuehl M, Brents L, Cultraro C, et al.
of MGUS cases was lower than that of MM (0.15
Pathogenesis of myeloma: IG translocations,
cyclin D dysregulation, other events
vs 0.30; P<0.001). For most of the genes, the
[abstract]. Haematologica. 2005;90(suppl
methylation frequencies were higher in MM cases
1):6. Abstract PL2.03.
compared with MGUS, which was particularly
3.
Bergsagel PL, Chesi M, Affer M, et al.
evident for CDH1. Although critical chromosomal
Early pathogenic events identified by
abnormalities (14q translocations, deletion of 13q)
chromosome translocation and cyclin D
are identical in MGUS and MM, methylation of
expression determine myeloma biology and
certain genes may be associated with transition from
clinical course [abstract]. Haematologica.
MGUS to MM.
2005;90(suppl 1):5. Abstract PL2.02.
8
4.
Drach J, Seidl S, Ackermann J, Zöchbauer-
Müller S. Epigenetic changes in the
molecular pathology of multiple myeloma
[abstract]. Haematologica. 2005;90(suppl
1):6-7. Abstract PL2.04.
5.
Pilarski LM, Adamia S, Mant MJ, Reiman
T, Belch AR. Alternative gene splicing in
myeloma: aberrant splicing of hyaluronan
synthase 1 predicts for poor survival
[abstract]. Haematologica. 2005;90(suppl
1):7. Abstract PL2.05.
Post-test Questions
4.
The presence of hyperdiploidy is associated
with a better prognosis in MM.
True
False
5.
Cytogenetic changes similar to those found
in MM are found in MGUS.
True
False
6.
Abnormal methylation is not found in
MGUS.
True
False
9
Focus Session 2:
Waldenström's disease.1 Ten percent of patients
achieved a complete remission and 64% a partial
Innovations in Standard
remission. Dr. Meletios Dimopoulos (University
of Athens, Greece), the host of the next Myeloma
and Supportive Therapy
Workshop in 2007 in Corfu, Greece, presented
results of an intermittent melphalan-thalidomide-
Heinz Ludwig
dexamethasone treatment in previously untreated
Wilhelminen Hospital
elderly patients. Seven percent achieved a complete
Vienna, Austria
remission and 61% a partial remission (overall
response rate: 68%). Responses were obtained
The symposium covered various clinically relevant
fast with a median time to remission of 2 months.
topics from the present state of thalidomide
These data are remarkable, as thalidomide
treatment in newly diagnosed patients and
(300 mg) and dexamethasone were given only
important side effects of thalidomide to treatment
on days 1 to 4 and 14 to 18 of a 5-week cycle,
of multiple myeloma (MM) bone disease with
keeping side effects, particularly deep venous
bisphosphonates; the role of plasmapheresis in renal
thromboembolism (DVT) and neuropathy, at
failure in MM; and the prevalence, incidence, and
low frequencies. Other combinations used were
treatment of anemia in MM.
doxorubicin, vincristine, dexamethasone, and
thalidomide (DVD-T); thalidomide, vincristine,
Dr. Donna Weber (M.D. Anderson Cancer
epirubicin, and dexamethasone (TVED); and
Center, United States) presented a comprehensive
bortezomib, thalidomide, and dexamethasone
review on the results of thalidomide combination
(BTD). The results of a phase 2 study with
therapies for previously untreated patients with
pegylated doxorubicin, vincristine, dexamethasone,
MM. Thalidomide-dexamethasone (TD) first-line
and thalidomide (DVd-T) (every 4 weeks x 6) have
treatment has been shown to yield responses in 64%
previously been reported in abstract form.2 Forty-
to 76% of patients. Responses have been achieved
six percent of patients received a complete or near
much faster (median time to response: 5 weeks)
complete remission and 84% stabilization of their
than with conventional treatment, and median
disease. TVED (every 3 weeks until plateau, then
duration of remission has not been reached after 12
thalidomide alone) rendered responses in 80% (19%
months. TD compared favorably with single-agent
CR and 61% PR) of the patients.3 Dr. Raymond
dexamethasone, which yielded responses in 43% of
Alexanian and colleagues (M.D. Anderson Cancer
patients. A retrospective study of an Italian group
Center, United States) reported the incorporation
(Cavo and associates, Myeloma Workshop 2005)
of bortezomib in a TD regimen. The dose of
compared TD with vincristine, doxorubicin, and
bortezomib was escalated from 1.1 mg/m2 to 1.9
dexamethasone (VAD) showing a response rate of
mg/m2. Response rate was 64% in patients on
76% with the former and of 52% with the latter
bortezomib doses up to 1.3 mg/m2 and 94% in those
regimen. Stem-cell collection was successful in 83%
treated with bortezomib in doses between 1.5 and
and 88% of patients, respectively, and stem-cell
1.9 mg/m2, yielding an overall response rate of 80%.
yield was only insignificantly lower with TD (7.58 x
106/kg vs 10.5 x 106/kg).
Two groups used TP plus melphalan and conducted
prospective comparisons with other regimens. Italian
Several groups studied TD or thalidomide plus
investigators (Palumbo and colleagues Myeloma
prednisone (TP) in combination with other
Workshop 2005) compared melphalan-prednisone-
drugs. A previously published study used TD
thalidomide (MPT) with melphalan-prednisone
plus clarithromycin in patients with MM and
(MP), and the French Intergroupe Francophone du
10
Myélome (IFM) compared MP with MPT and with
DVTs in 535 patients treated with thalidomide and
melphalan 100 mg/m2 plus stem-cell support. Both
thalidomide combinations was 15%. The incidence
studies enrolled elderly patients, and both studies
rate was considerably higher in patients treated with
are still ongoing; hence, interim results only were
doxorubicin (4.3-fold increase in risk) and in those
presented. In the Italian study, 80% of patients
with newly diagnosed disease (2.5-fold increased
achieved a response with MPT, but only 48% with
risk). In his series, abnormalities of chromosome 11
MP. Of note, complete remissions were seen in 26%
were also associated with increased rates of DVT.
of patients with the former but only in 4% with the
In other studies, the DVT rate was found to be
latter therapy. Event-free survival at 26 months was
only marginally increased in patients on single-
68% and 32%, respectively. In the IFM study, 3
agent thalidomide treatment. Incidence increased
arms were compared: A) 12 courses of MP, B) 12
significantly when thalidomide was combined with
courses of MPT, and C) 2 cycles of VAD followed
dexamethasone and increased further by combining
by stem-cell priming with cyclophosphamide (3
TD with cytotoxic drugs. The incidence rates
g/m2) and by intermediate-dose melphalan (100
reported vary between 2% and 6%, 8% and 18%,
mg/m2) with stem-cell support. The overall response
and 15% and 30%, respectively.
rates (>50% paraprotein reduction) were 34%,
84%, and 71%, respectively; 3%, 14%, and 18%
This high complication rate makes prophylaxis
achieved complete remissions.
mandatory. Three approaches are used: aspirin,
warfarin, and low-molecular-weight heparin
The data obtained with TD or combinations with
(LMWH). At present, there is no consensus about
TD or with TP in newly diagnosed patients provide
the optimal approach. LMWH is effective and
substantial evidence for the use of thalidomide-
safe, but requires daily injection and is expensive.
containing regimens as first-line treatment.
It seems to halve the risk for DVT. Dr. Zangari
Thalidomide treatment, however, is associated with
previously observed a 34% rate of DVT with a
important side effects. The most frequent and severe
thalidomide-doxorubicin regimen without LMWH
are DVT, neuropathy, and constipation and have
prophylaxis. This rate has come down to 15% with
been seen in all the above-cited studies.
respective prophylactic therapy. Low-dose warfarin
therapy seems to be ineffective. The rate of DVT
was 25% and 15% in patients treated with TD
Dr. Maurizio Zangari (University of Arkansas,
by Weber and by Cavo, respectively. But applying
United States) devoted his presentation to the
warfarin doses that induce therapeutic INR levels
discussion of thromboembolic complications of
(2­3) seems to protect against thalidomide-induced
thalidomide treatment. He presented data on the
DVTs according to a small study on 46 patients
increased prevalence of activated protein C
reported by Weber. Aspirin, according to common
(APC) resistance in cancer and particularly in
understanding, should not be very effective in
MM. Even newly diagnosed patients with MM
preventing venous thrombosis. In a randomized
present with an already hypercoagulable state that
trial in patients without MM, aspirin was only
is deemed to contribute to the increased incidence
slightly better than placebo. A study on 103 patients
of DVT in MM, although the precise mechanism
on aspirin prophylaxis while on TD therapy
of the thalidomide-associated high DVT rate is still
reported a DVT rate of 18%.4 In most studies
unknown. In his studies, 8.5% of patients presented
with thalidomide therapy, DVTs seem to occur
with APC resistance; a third of those had factor V
primarily within the first 3 to 6 months of therapy.
Leiden mutations. Patients with APC resistance
Interestingly, overall survival is not compromised
had roughly twice as many DVTs and a shorter
by DVTs in patients with MM. This is different
time to DVT compared with patients without
from other cancers, in which DVT is an unfavorable
this abnormality. Overall, the 1-year estimate of
prognostic factor.
11
Dr. Zangari presented data on sinus bradycardia
seen in the time to first creatinine increase. In
as a side effect of thalidomide treatment. He
case of rise in creatinine levels, Dr. Berenson
showed a 19% incidence of grade 2 bradycardia
recommended careful investigation of the patient,
in patients on total therapy 2 (TT2). Five patients
checking for possible causes of renal impairment
(2.5%) required pacemaker implementation. The
such as the disease itself, nephrotoxic medications
occurrence of bradycardia could not be anticipated
(NSAIDs, COX2 inhibitors, statins, etc), and other
by electrocardiographic (ECG) abnormalities,
comorbidities (diabetes, hypertension, etc). In case
such as increased PR interval, QRS duration, or
treatment with bisphosphonate is the most likely
QTc interval, and was not associated with the
cause, treatment should be withheld until creatinine
use of beta blockers, calcium channel blockers, or
levels return to baseline. Treatment should be
digoxin. Reports about the frequency of bradycardia
restored with increased infusion times, as high peak
vary widely among individual studies (0.25% in
bisphosphonate levels are nephrotoxic. Zoledronic
postmarketing studies to 53% in TT2 when all
acid should be given over a 60-minute infusion and
grades are included).
pamidronate over a 4-hour infusion. If problems
persist, another intravenous bisphosphonate should
Dr. James Berenson (Institute for Myeloma and
be selected. Should this not resolve the problem,
Bone Cancer Research, United States) reported
parenteral bisphosphonates should be discontinued
about novel developments in the treatment of MM
and an oral bisphosphonate used such as alendronate
bone disease. Skeletal complications are frequent
in the United States or alendronate or clodronate
in MM and one of the hallmarks of this disease.
in Europe. He also cited data that indicate that the
Actually, more than 80% of patients present at
nephrotoxic potential of pamidronate may primarily
diagnosis with skeletal manifestations. The most
affect the glomeruli, whereas zoledronic acid is
common complications are osteolytic lesions,
thought to have a greater effect on renal tubuli. This
predominantly in the vertebral column, pelvis, skull,
may be important, as many patients present with
and thoracic cage. Osteoporosis is seen in almost
subclinical tubular impairment due to secretion of
all patients, and fractures often occur in the ribs,
nephrotoxic light chains.
vertebrae, or long bones. Compression fractures,
hypercalcemia, and spinal-cord compression are
Another recently described complication of
severe complications of MM bone disease. The
bisphosphonate therapy is the occurrence of
occurrence of these complications, bone pain,
osteonecrosis of the jaw (ONJ). The development
the initiation of radiotherapy, and surgery can
of ONJ seems to be caused by poor dental hygiene,
be delayed by treatment with bisphosphonates.
dental procedures, the general impairment of the
Dr. Berenson pointed to zoledronic acid as the
immune system frequently associated with MM,
bisphosphonate with the highest in vitro potency
and the use of either pamidronate or, possibly more
and the advantage of short infusion time. He
frequently, therapy with zoledronic acid. ONJ
presented data from a previous study comparing
has only rarely been encountered with treatment
24 months of therapy with pamidronate and
with oral bisphosphonates, and its relationship
zoledronate in patients with breast cancer and
with bisphosphonate treatment is unclear at
MM.5 All patients were given vitamin D (400 IU)
present. However, treatment with intravenous
and 500 mg calcium per day as well. Zoledronic
bisphosphonates should be discontinued when ONJ
acid was given over a 15-minute infusion and
develops. For prophylaxis, good oral hygiene, use
pamidronate over a 120-minute infusion every
of chlorhexidine-containing rinse, dental workup,
3 to 4 weeks. The mean skeletal morbidity rate
and appropriate treatment and use of antibiotics for
was slightly lower with zoledronic acid (1.04
periodontal pockets are recommended before start
vs 1.39, P<0.084), although no difference was
of bisphosphonate treatment.
12
Kyphoplasty is an innovative treatment for
Table 1. Possible Causes of Renal Failure in MM
painful collapsed vertebral bodies. An introducer
is percutaneously inserted under local or general
§ Light chain damage
anesthesia into the collapsed body of the vertebra
§ Hypercalcemia
(Fig. 1). Thereafter, a small ball is inflated that
§ Dehydration
elevates the collapsed body and its endplates. This
§ Nephrotoxic drugs, particularly NSAIDs
leaves a defined cavity and trabecular dam that
§ Infection
subsequently is filled with bone void filler. This
§ Hyperuricemia
stabilizes the vertebra and results in immediate
§ Renal vein thrombosis
resolution or reduction of pain. Kyphoplasty is now
§ Plasma cell infiltration
frequently performed, mainly in the vertebral bodies
§ Amyloid
of thoracic and lumbar spine. Rare complications
are infections, particularly osteomyelitis and discitis.
may aggregate with other proteins to intratubular
casts, which obstruct tubuli and further damage
Dr. Graham Jackson (UK Myeloma Forum and the
tubular cells. This process results in atrophy of the
UK National Cancer Research Network) discussed
tubular cells, increase of the lumen of the tubuli
the various causes that may lead or contribute to
(intrarenal hydronephrosis), and is accompanied by
renal failure in MM (Table 1). Among those, the
the development of giant polynuclear phagocytic
production of nephrotoxic light chains is the most
cells that try to degrade and eliminate the damaging
frequent and persistent cause. Physiologically,
proteins. The peritubular tissue shows inflammation
free light chains are produced in excess to whole
and, in advanced cases, increased fibrosis.
immunoglobulin molecules. They circulate in
the blood, are filtrated through glomeruli and are
Light chain­induced renal failure is reversible if
partly reabsorbed by the epithelial cells of the distal
the toxic light chains are removed quickly after the
tubuli. In MM, light chains frequently are produced
start of renal impairment. This can be attempted
in large excess, and some of these are particularly
by the use of rapidly effective MM treatment
nephrotoxic. They damage tubular epithelial cells
and possibly by the active removal of circulating
and induce their apoptosis. In addition, light chains
Figure 1. Principles of kyphoplasty. An introducer is inserted into the collapsed vertebral body. Subsequently,
a balloon is inflated; this elevates the collapsed body and bone cement is introduced to stabilize the cavity.
Dudeney S, Lieberman IH, Reinhardt MK, Hussein M. Kyphoplasty in the treatment of osteolytic vertebral
compression fractures as a result of multiple myeloma. J Clin Oncol. 2002;20(9):2382-2387.
13
light chains through plasmapheresis. Dr. Jackson
treatment. Results of this study were presented for
reviewed the existing evidence for the use of
the first time and were part of the European Cancer
plasmapheresis. A small randomized trial by Italian
Anemia Survey, which enrolled 15,367 patients.
researchers6 enrolled 29 patients with acute renal
In the MM subset, 704 patients with a median age
failure (ARF). All received the same chemotherapy,
of 66 years have been included. The patients were
but half were randomized to 5 plasma exchanges
studied at baseline and were followed for up to 6
followed by hemodialysis, if required. The other
months. Prevalence of anemia (hemoglobin <12 g/
patients were immediately treated by peritoneal
dL) was 69%, and low hemoglobin levels correlated
dialysis. After the end of the study, 11 of the 15
with poor performance status. During further
patients treated by plasma exchange, but only 2
follow-up, anemia was found in 85% of patients at
of the 14 treated by peritoneal dialysis, were off
least once during the survey. Prevalence of anemia
further renal substitution therapy. One-year survival
in this cohort migrated with age and was found in
was 66% in the patients with plasma exchange but
60% of patients younger than 40 years but in 90%
only 28% in those without. Another prospective
of those older than 70 years. As 7 of 10 patients
trail that randomized 21 patients with ARF to
had already presented with anemia, incidence of
forced diuresis plus hemodialysis or to the same
anemia could only be studied in the subgroup with
procedure plus plasmapheresis 3 times weekly for 1
normal hemoglobin at enrollment that was started
to 4 weeks was unable to show a benefit for plasma
on or already receiving chemotherapy. Overall, 75%
exchange.7 Notably, the mean time from diagnosis
of patients developed anemia with an incidence of
of renal impairment to dialysis was 1.21 months
60% in those younger than 60 years and of 90% in
(range 0­7), which may be far too long for saving
those older than 60 years.
renal tubular cells from damage by nephrotoxic
The authors also identified risk factors for the
light chains. The largest hitherto-conducted study
development of anemia in MM. To increase the
has been presented at the workshop by Clark
statistical power of the analysis, patients with MM
and colleagues. They subjected 97 patients with
and with lymphoma were analyzed together. A low
newly diagnosed disease and renal failure to a
initial hemoglobin (OR 4.2), female gender (OR
1:2 randomization; 58 patients received standard
2.8), persistent or recurrent disease (OR 1.5), and
care plus 5 plasma exchanges, whereas 39 were
platinum treatment (OR 5.5) were found to confer
treated with standard care only. Results showed
a high risk for developing anemia.
no difference in outcome between both groups,
as defined by death rate, dialysis dependence, or
Forty-seven percent of the patients who were ever
creatinine clearance <30 mL/min. Then Dr. Jackson
anemic received treatment for anemia. Twenty-
went on to present his study, which had already
four percent were treated with erythropoietin,
been activated before the report of Dr. Clerke's
21% received transfusions, and 3% iron only.
data. Actually, 16 patients have already been entered
Previous studies have substantiated the benefits
since February 2004. In total, 286 patients will
of erythropoietin treatment, which, in essence,
be randomized to 7 plasmaphereses or to control
provides improvement in quality of life and
within the first 14 days after diagnosis. All patients
reduction in transfusion need. Only 1 study in MM
will be started on dexamethasone on day 1 (day 1­4
investigated the impact of erythropoietin treatment
and 9­12) followed by VAD on day 17.
on survival. Patients were randomized to treatment
with darbepoetin or placebo for up to 4 months
Dr. Ludwig reported the results of a prospective
and followed for 27 months. Survival was similar in
epidemiologic survey on the prevalence and
both groups. When the author analyzed survival in
incidence of anemia and of its relation to
a group of 32 patients with MM who were treated
performance status as well as on patterns of anemia
at his institution, response to erythropoietin was
14
found to be a strong prognostic factor. Patients with
6.
Zucchelli P, Pasquali S, Cagnoli L, Ferrari
response to erythropoietin survived for 28 months,
G. Controlled plasma exchange trial in
whereas survival was only 4 months in those who
acute renal failure due to multiple myeloma.
failed treatment. Overall, Dr. Ludwig recommended
Kidney Int. 1988;33(6):1175-1180.
exploiting the benefits of erythropoietin treatment
7.
Johnson WJ, Kyle RA, Pineda AA,
in patients with MM who are symptomatic due to
O'Brien PC, Holley KE. Treatment of
renal failure associated with multiple
anemia.
myeloma: plasmapheresis, hemodialysis,
and chemotherapy. Arch Intern Med.
1990;150(4):863-869.
References
Post-test Questions
1.
Coleman M, Leonard J, Lyons L,
Szelenyi H, Niesvizky R. Treatment of
7.
Thalidomide-dexamethasone therapy as
Waldenstrom's macroglobulinemia with
first-line treatment in MM has a response
clarithromycin, low-dose thalidomide,
rate of approximately 30%.
and dexamethasone. Semin Oncol.
True
False
2003;30(2):270-274.
2.
Agrawal NR, Hussein MA, Elson P, et
8.
Sinus bradycardia is a side effect of
al. Pegylated doxorubicin (D), vincristine
thalidomide seen in the total therapy
(V), reduced frequency dexamethasone (D)
program (TT2) combination therapy
and thalidomide (T) (DVd-T) in newly
program.
diagnosed (Nmm) and relapsed/refractory
True
False
(Rmm) multiple myeloma patients
[abstract]. Blood. 2003;102:237a. Abstract
9.
In the European cancer anemia survey, the
831.
prevalence of anemia in MM was 50%.
3.
Schutt P, Ebeling P, Buttkereit U, et
True
False
al. Thalidomide in combination with
vincristine, epirubicin and dexamethasone
(VED) for previously untreated patients
with multiple myeloma. Eur J Haematol.
2005;74(1):40-46.
4.
Baz R, Marchant K, Yiannaki EO, et
al. Aspirin decreases the thrombotic
complications (DVT) of liposomal
doxorubicin, vincristine, decreased
frequency dexamethasone and thalidomide
(DVd-T) treatment of multiple myeloma
(MM) [abstract]. Blood. 2004;104:658a.
Abstract 2397.
5.
Rosen LS, Gordon D, Kaminski M, et al.
Long-term efficacy and safety of zoledronic
acid compared with pamidronate disodium
in the treatment of skeletal complications in
patients with advanced multiple myeloma
or breast carcinoma: a randomized, double-
blind, multicenter, comparative trial.
Cancer. 2003;98(8):1735-1744.
15
Plenary Session 3:
increased MM incidence in both men and women,
and more strikingly in blacks. What remains to be
Evolving Myeloma
explained is why.
Brian G.M. Durie
Figure 2.
Cedars-Sinai Comprehensive Cancer Center
Los Angeles, California, USA
The session on "Evolving Myeloma" covered diverse
topics related to the etiology, early evolution, and
staging of multiple myeloma (MM).
Dr. Dalsu Baris (Occupational and Environmental
Epidemiology Branch at National Institutes of
Health, United States) led off with an overview
discussion of the epidemiology of MM and
provided an excellent overview of current
epidemiologic studies. Although it is well known
that MM is more common in men and among
black populations,1 the international variation in
Those and many other associations were discussed;
MM incidence by geographic continent and sex,
for example, the link between increased incidence
as illustrated and discussed by Dr. Baris, is quite
and lower socioeconomic class raise many questions
revealing (Fig. 1)2; for example, the prevalence in
for further study.5 The underlying causes and
Oceania vs most parts of Asia, where the incidence
mechanisms remain largely unexplored.
is generally low.
A model for further studies was presented. Clearly,
Figure 1.
studies at the genetic level need to be combined
with epidemiologic trials considering both the
macro- and microenvironment (Fig. 3).
Figure 3.
Attention was also drawn to the relationships
between obesity and MM, as shown in Fig. 2.3,4
There is a definite correlation between obesity and
16
Evolving Myeloma, MGUS, and Smoldering
Figure 4.
Myeloma
Dr. Robert Kyle and Drs. Blade, Rosinol, and
Cibeira; Barcelona, Spain
Results from both groups were presented and
proved to complement each other. The long-
term studies from the Mayo Clinic focused on the
discrimination between monoclonal gammopathy
of undetermined significance (MGUS) and
smoldering MM (SMM).6 The most reliable
indicator of likelihood of progression of disease is
the percentage of plasma cells in the bone marrow.
A bone marrow plasma-cell percentage of 10% or
greater, irrespective of the serum M-component
level (ie, < 3 or > 3 g/dL), predicts earlier transition
New Approaches to Staging and Monitoring of
to active MM. This conclusion was affirmed by
MM
several univariate and multivariate analyses. SMM
Dr. Philip Greipp (Mayo Clinic, United States)
is distinguished from active myeloma by the absence
provided an update of the new International Staging
of any end-organ dysfunction or "CRAB" features
System (ISS) recently published in the May 20,
(hypercalcemia, renal insufficiency, anemia, or bone
2005, Journal of Clinical Oncology (23:3412-3420).9
disease).6,7
The new system is shown in Figure 5.
The Barcelona group, represented by Dr. Blade,
presented data related to the whole range of
Figure 5.
parameters, which may predict disease progression.
They specifically raised the possibility to delineate a
International Staging System
discrete disease entity of "evolving" vs "nonevolving"
M / S. Alb
2
SMM.8
Low
M<3.5* plus
Stage I
2
Factors correlated with "evolving" disease with a
S.Albumin**
3.5 G/DL
median time-to-progression of 1.6 years vs 4.3
M<3.5 but low albumin<3.5 or
years for "nonevolving" were presence of previous
Stage II
2M : 3.5 ­ <5.5
2
MGUS, IgA M-component subtype, M-component
Stage III
High
M
5.5mg/DL
level > 1.5 g/dL (See Fig. 4) and perhaps a different
2
pattern of chromosomal abnormalities, including
* mg/DL
presence of 1q+ changes in 57%.
Based upon 10 - 15 years follow-up
**Gm/DL
Further studies are required and are under way to
evaluate immunophenotypes, angiogenic factors,
This prognostic factor-based staging system is now
and gene-expression profiling.
recommended for widespread use and provides
a reliable and systematic method to stage and
classify patients with MM in trials conducted
around the world.
17
Dr. Greipp provided an example of prospective
2.
Parkin DM, Whelan SL, Ferlay J, Teppo
evaluation of the new ISS system in SWOG trial
L, Thomas DB. Cancer incidence in five
9321, an intergroup transplant trial. The ISS
continents: Volume VIII. IARC Sci Publ.
system provided excellent separation by stage. In
2003.
addition, classification by ISS stage correlated with
3.
Brown LM, Gridley G, Pottern LM. Diet
progression-free survival differences.
and nutrition as risk factors for multiple
myeloma among blacks and whites in
the United States. Cancer Causes Control.
Dr. Durie discussed the role of imaging in providing
2001;12(2):117-125.
direct anatomic staging for MM.10 The Durie/
4.
Calle EE, Rodriguez C, Walker-Thurmond
Salmon "PLUS" system was presented to illustrate
K, Thun MJ. Overweight, obesity, and
the integration of both MRI and FDG-PET
mortality from cancer in a prospectively
imaging into a new type of anatomic/functional
studied cohort of US adults. N Engl J Med.
staging system, shown in Figure 6.
2003;348:1625-1638.
5.
Baris D, Brown LM, Silverman DT.
Figure 6.
Socioeconomic status and multiple myeloma
among US blacks and whites. Am J Public
Health. 2000;90(8):1277-1281.
Durie / Salmon "PLUS" System
6.
Kyle RA, Greipp PR. Smoldering
Integration of Imaging
multiple myeloma. N Engl J Med.
1980;302(24):1347-1349.
Durie / Salmon
PLUS
MRI/PET*
7.
Durie BG, Kyle RA, Belch A, et al.
Stage
upstage
Number of lesions
Myeloma management guidelines: a
consensus report from the Scientific
I B
I 0 - 4
Advisors of the International Myeloma
II A or B
II 5 - 20
Foundation. Hematol J. 2003;(4):379-398.
III A or B
III > 20
8.
Montoto S, Rozman M, Rosinol L, et
al. Malignant transformation in IgM
*Bauer
2002
B: creatinine > 2
Durie 2002
monoclonal gammopathy of undetermined
Walker 2003
and/or EMD on PET
significance. Semin Oncol. 2003;30(2):178-
181.
The future role of other molecular techniques
9.
Greipp P, San Miguel J, Durie BG, et al.
for patient classification was also presented and
International staging system for multiple
discussed. Examples using gene-expression profiling,
myeloma. J Clin Oncol. 2005;23(15):3412-
3420.
circulating nucleic acids, and proteomics were
10.
Durie BG, Waxman AD, D'Agnolo A,
provided.11
Williams CM. Whole-body (18)F-FDG
PET identifies high-risk myeloma. J Nucl
Overall, this session provided an excellent summary
Med. 2002;43(11):1457-1463.
of the current status of research concerning both
11.
Durie BG, Urnovitz HB, Murphy WH. RT-
etiology and newer approaches to classifying
PCR amplicons in the plasma of multiple
evolving and symptomatic MM.
myeloma patients--clinical relevance
and molecular pathology. Acta Oncol.
References
2000;39(7):789-796.
1.
Gahrton G, Durie BGM, Samson D.
Multiple Myeloma and Related Disorders.
2004:Arnold Press.
18
Post-test Questions
10.
Obesity and low socioeconomic status are
risk factors for the development of MM.
True
False
11.
Evidence of end organ dysfunction includes
anemia, hypercalcemia, renal insufficiency,
and bone lesions.
True
False
12.
The ISS is based on the hemoglobin and
B2M.
True
False
13.
MRI-PET provide means to stage MM.
True
False
19
Focus Session 3:
from 1 abnormal B cell. The immunoglobulin
gene rearrangement that characterizes the original
The Malignant Clone
transformed B cell provides a unique molecular
marker (termed clonotypic) for identification of all
Linda Pilarski
progeny of that B cell and thus, in the case of MM,
University of Alberta, Cross Cancer
for unequivocal identification of all members of the
Institute
MM clone. Many laboratories have confirmed that
MM PCs are derived from somatically mutated,
Edmonton, Alberta, Canada
post-switch B cells.
This session focused on the genetic and phenotypic
Dr. Suhinder Sahota (University of Southampton,
characteristics of the malignant clone in multiple
United Kingdom) presented an analysis of somatic
myeloma (MM), including comparisons among
mutation in the DNA encoding the antibody
normal, monoclonal gammopathy of undetermined
combining site of the immunoglobulin heavy
significance (MGUS), and MM B lineage cells.1-5
chain gene (IgH) and IgH class switching of
Such comparisons provide a window within which
B cells from normal donors and persons with
to view changes that may have occurred during
MGUS.1 He described a set of normal B cells that
progression from normal to malignant status.
in tissue culture conditions are able to generate
To more effectively attack malignant cells in this
plasmablasts (early-stage PCs) in the absence of
difficult disease, a fuller understanding is needed
any deliberate stimulation with antigen. Analysis
of the biologic properties that make malignant
of these plasmablasts revealed evidence for ongoing
cells resistant to therapy or that may provide novel
events associated with class switching, including
targets for the design of new therapeutics.
the presence of a key enzyme that is known to
be essential for both somatic mutation and class
During normal B lineage differentiation, B cells
switching (activation-induced cytidine deaminase
proliferate in response to antigen, which triggers
or AID). Furthermore, these plasmablasts may
somatic mutation to generate antibody diversity.
also continue to undergo somatic mutation. Dr.
These B cells, called memory B cells, respond more
Sahota suggested that somatic mutation and class
quickly and effectively to protect the body from
switching, both thought to be restricted to an
attack by foreign invaders. They undergo class-
earlier stage of B-cell development, may persist
switch recombination, a process that recombines
in cells at the plasmablast stage. The role of AID
the DNA encoding the somatically mutated
at this late stage of normal, post-switch B lineage
combining site of the antibody, with DNA
differentiation remains to be resolved. He speculated
encoding a new constant region. This programmed
that this system may provide a model for early
breakage and rejoining of DNA gives rise to a
events in MM and a means to begin identification
post-switch B cell secreting an antibody that is
of the originating cell in MM.
able to more effectively mediate clearance of the
invading antigen. Prolonged exposure to antigen
Dr. Thomas Rasmussen (University of Copenhagen,
stimulates differentiation of stimulated B cells to
Denmark) addressed the involvement of a subset
plasma cells (PCs). PCs are, in essence, biologic
of clonotypic memory B cells in MM.2 Clonotypic
factories for high-rate secretion of antibodies,
memory B cells share the defining IgH VDJ of MM
most frequently of IgG or IgA antibodies (termed
PCs. If memory cells contribute to MM, analysis
post-switch isotypes of immunoglobulin). MM is
of the genetic abnormalities that they share or do
an accumulation of monoclonal PCs, signifying
not share with the MM PCs from the same patient
that all the MM PCs in a given patient originate
may provide insight into the origins of MM. In 4/4
20
patients with MM and in 2/3 patients with MGUS,
at either higher or lower levels in the populations
a particular set of purified memory B cells expressed
from malignant cells compared with their normal
the same genetic abnormalities as did the PCs
counterparts. Statistical analysis is then used to
from the same patient. The abnormalities analyzed
determine which genes are likely to be significantly
included IgH translocations, thought by some to be
deregulated. He found that heparin-binding factors
originating molecular events in MM, overexpression
of the EGF family are expressed at higher-than-
of the fibroblast growth factor receptor 3 (FGFR3)
normal levels by MM PCs from 65 patients with
and of cyclin D1. However, the B cells with these
MM. For MM PCs, no expression was detected for
abnormal expression patterns comprised less than
EGF members that lack heparin sulfate binding.
1% of the B- cell subset analyzed. As a further
Interestingly, only those EGF family members that
marker of malignancy, selected memory B cells from
bind to syndecan-1 had MM cell growth activity,
2 patients with MM whose PCs expressed K-RAS61
and inhibitors of EGF family members induce MM
were analyzed for the presence of the K-RAS61
cell apoptosis (cell death). Of clinical relevance,
mutation. K-RAS is thought to be a contributor to
these inhibitors appeared to synergize with
the malignant process in some MM. Although MM
dexamethasone to induce cell death, suggesting the
PCs from the same patients expressed K-RAS61, Dr.
potential use of novel combination therapies using
Rasmussen was unable to detect K-RAS61 in the set
inhibitors of the EGF family member ErbB and
of B cells he analyzed. He speculated that the subset
dexamethasone. Further gene-expression profiling
of clonotypic memory B cells analyzed in his studies
analyzed the expression levels of a second B-cell
may represent premalignant remnants of the clone
activation system (known as BAFF-APRIL) and
that gave rise to MM.
found that patients whose PCs had an attenuated
dependence on the microenvironmentally controlled
Dr. Bernard Klein (University Hospital, France)
BAFF-APRIL system had worse outcomes than
discussed the communication signals that may
those whose PCs remained dependent on the bone
mediate interactions between the MM PCs and
marrow microenvironment. Dr. Klein speculated
their microenvironment within the bone marrow.3
that gene-expression profiling may be able to
Syndecan-1 (CD138, a cell-surface proteoglycan)
identify patients with MM who might benefit from
is a strongly expressed growth factor receptor on
treatments that include inhibitors of the BAFF-
MM PCs. Syndecan-1 is the main proteoglycan
APRIL system.
on PCs with heparin sulfate chains. It appears
to concentrate epidermal growth factor (EGF)
Two presentations addressed the impact of a protein
to MM cells through cooperative binding to the
known as CD45 on MM. CD45 is a cell-surface
heparin sulfate chains on syndecan-1. Dr. Klein
receptor/enzyme that contributes to cell-signaling
reported that EGF, along with other cofactors,
pathways in white blood cells and that also appears
appears to regulate MM cell growth in synergy
to have multiple other functional activities. For
with IL-6. He found that heparin sulfate binding
CD45, important functions are carried out by
of EGF is required to induce MM cell growth in
portions of the molecule on the cell surface that
model systems. This MM cell growth appears to be
contact the external microenvironment and by
controlled by a cooperative cascade of interlinked
CD45 domains inside the cell that contribute to
events that are focused by syndecan-1. Dr. Klein
intracellular signaling. It is a complex molecule
used gene-expression profiling to compare MM
with multiple isoforms (different proteins that
PCs and MM microenvironmental cells with
are encoded by the same gene) that are created
their counterparts in normal bone marrow. Gene-
by regulated gene splicing as well as by addition
expression profiling involves analysis of tens of
or removal of carbohydrate modifications. In
thousands of genes to determine which are expressed
B lineage cells, the CD45 isoform expressed by
21
early B cells differs from that expressed by late B
bright MM cell lines appear to be stimulated by
cells or PCs, and in MM some PCs lose CD45
IL-6, whereas CD45-low/no MM cell lines were
entirely. This may reflect a loss of dependence on
stimulated by IL-6 and by insulin growth factor
CD45-mediated interactions and signaling for
receptor 1 (IGF-1). Dr. Bataille speculated that MM
terminally differentiated MM PCs. Analysis of
PCs may represent a self-renewing compartment of
CD45 levels and the interactions between CD45
the MM clone.
and other receptors on PCs may provide important
information on the ways PC growth is regulated.
Dr. Michio Kawano (Yamaguchi University, Japan)
analyzed heterogeneity within the PCs of patients
Dr. Regis Bataille (University Hospital and Cancer
with MM, showing at least 5 distinct subsets of
Center, France) discussed the proliferative capacity
MM PCs.5 These subsets were defined based on
of MM PC subsets having different surface densities
their expression of CD45, an adhesion receptor
of CD45, as measured by flow cytometry.4 Overall,
(the fibronectin receptor VLA5), and the MPC-1
the growth rate for MM is determined by the
antigen, and appear to represent increasingly mature
balance between cell proliferation and cell death
subsets of PCs. For those subsets that express CD45,
(apoptosis). In MM, only a small proportion of
the isoforms detected were different from those
cells appear to be proliferating. In total, MM PC
expressed by normal PCs. Immature PCs appear to
populations include a mix of PCs having a high
proliferate or have proliferative capacity, whereas
expression density and those having a low or no
intermediate or mature PCs have low proliferation
expression of CD45. Dr. Bataille reported that in
and long survival. Immature CD45+ PCs respond
MM, PC populations having a component with the
to IL-6, the CD45 isoform expressed translocates
highest density of CD45 on their surface (termed
to lipid rafts (signaling regions of the cell surface),
CD45-bright) were the most proliferative and may
and are sensitive to stress stimuli. CD45- PCs of
represent the growth fraction. MM populations
intermediate maturity appear to be more stable in
that include only PCs having low or no CD45
stressful conditions. Using a model system in low
are poorly proliferative. In 51 patients with MM
levels of IL-6, a CD45+ MM cell line differentiates
whose PCs were taken at the time of diagnosis,
to CD45-, perhaps reflecting inadequate growth
12% had CD45-bright PCs and a high labeling
support and implementation of mechanisms that
index (7%), whereas 88% had low or no CD45
confer resistance to stress stimuli, hence facilitating
and a low proliferative index (1.3%). Thus, the
malignant cell survival. Immature CD45+ PCs
decline of CD45 from bright to low CD45 versus
occur at higher frequency as MM progresses.
CD45-bright to no CD45 appears to discriminate
Dr. Kawano speculated that IL-6 stimulation of
between 2 types of MM. For 98 patients with MM,
MM may be attenuated or blocked by inhibiting
MM with CD45-negative PCs appeared to have
translocation of a CD45 isoform to lipid rafts,
worse survival than those patients with CD45-
suggesting a potential therapeutic strategy.
low MM PCs. The presence of a CD45-bright
fraction of PCs appeared to influence the associated
References
PCs with low or no CD45 in that these remained
more proliferative. Furthermore, the presence of
1.
Sahota SS, Zojer N, Babbage G, Orchard
populations having both CD45-bright and CD45-
K, Klein B, Stevenson FK. Normal plasma
negative PCs increased as disease progressed,
cell development and pathogenesis of
suggesting that the coexistence of these 2 subsets--
monoclonal gammopathy of undetermined
defined by high and no CD45, respectively--may
significance/multiple myeloma [abstract].
Haematologica. 2005;90(suppl 1):14.
have clinical implications. Based on work with
Abstract F3.01.
MM cell lines, Dr. Bataille reported that CD45-
22
2.
Rasmussen T, Johnsen HE, Lodahl M,
Kuehl M. In multiple myeloma 14q32
translocations are present in memory B
cells but RAS mutations are restricted to
the plasma cell compartment [abstract].
Haematologica. 2005;90(suppl 1):16.
Abstract F3.05.
3.
Klein B, Hose D, Mahtouk K, et al.
Identification of intercellular communication
signals involved in multiple myeloma with
microarrays [abstract]. Haematologica.
2005;90(suppl 1):15. Abstract F3.03.
4.
Bataille R, Robillard N, Pellat-Deceunynck
C, Moreau P, Amiot M. A cellular model for
myeloma cell growth and maturation based
on an intraclonal CD45 hierarchy [abstract].
Haematologica. 2005;90(suppl 1):14-15.
Abstract F3.02.
5.
Kawano MM, Ishikawa H. The function
and movement of CD45 molecule in
interleukin-6­induced myeloma cell
proliferation [abstract]. Haematologica.
2005;90(suppl 1):15-16. Abstract F3.04.
Post-test Questions
14.
MM plasma cells have undergone
immunoglobulin gene-class switching
rearrangement.
True
False
15.
MM plasma cells expressing CD45 have
a lower proliferation rate than those with
absent expression of CD45.
True
False
16.
Clonotypic immunoglobulin gene
rearrangements are not found in B cells in
MM.
True
False
23
Plenary Sessions 4 and 8: published, a superior EFS has been shown in 3, thus
supporting the conclusions of IFM94. The IFM
Autologous
observed that the double HDT was superior only in
patients failing to achieve at least a very good partial
Transplantation
remission (VGPR) within 3 months of the first
transplant. Thus, patients with complete remission
John Gibson
(CR) or VGPR do not need to be offered second
HDT.
Institute of Haematology,
Royal Prince Alfred Hospital
To extend these observations and to build on the
Camperdown, Australia
efficacy of HDT, the IFM99 trial was designed to
evaluate a number of specific patient subgroups.
High-dose therapy (HDT) supported by autologous
IFM99-04, for patients with a predicted poor prog-
stem-cell transplantation is an integral part of
nosis (high beta-2-microglobulin and del-13 by
therapy for all suitable patients with multiple
fluorescence in situ hybridization [FISH]) incorpo-
myeloma (MM). As a measure of the widespread
rates a tandem approach using melphalan dose esca-
acceptance of this therapy, data from the Center
lation in the second procedure, 200 mg/m2 followed
for International Blood and Marrow Transplant
by 220 mg/m2. An encouraging CR and VGPR
Research (CIBMTR) reveal that MM is the single
rate of 59% and a median EFS of 30 months were
largest disease-specific indication for autografting.
seen. IFM99-02 for standard-risk patients evaluates
Thus, it was not surprising that 2 plenary sessions
the impact of thalidomide maintenance and was
were devoted to this topic. Plenary 4 provided
reviewed by Michel Attal in a subsequent presenta-
a forum to review recent developments with
tion. Finally, the IFM99-06 component for patients
the aim of defining the current state of the art.
aged 65 to 75 years compares standard melphalan
Subsequently, in Plenary 8 the leading international
and prednisone (MP) with MP+thalidomide (MPT)
cooperative groups provided updates from their
and a double low-dose autograft using melphalan at
current randomized trials.
100 mg/m2. Preliminary results have so far shown
no difference in response rates for the MPT and
State of the Art
double autograft arms for CR (14% vs 18%,
Dr. Jean-Luc Harousseau1 (Intergroupe
respectively) or VGPR (65% vs 57%, respectively).
Francophone du Myelome [IFM], France) was
asked to address the question, "Is double autografting
Dr. Michel Attal2 (Hôpital Purpan, France) sum-
the new standard of care for suitable newly diagnosed
marized the detailed results of IFM99-02. Between
patients?" He started from the premise that a single
April 2000 and October 2004, 780 patients with
autograft is standard of care, at least for those
no adverse factors or only 1 adverse factor (beta-2-
younger than 65. Limitations of this therapy were
microglobulin >3 mg/dL or del-13) were uniformly
an event-free survival (EFS) of only 25 to 30 months
treated with vincristine, doxorubicin, dexametha-
with a median overall survival (OS) of only 55 to
sone (VAD) induction and 2 autologous transplants.
58 months. The IFM94 study was the first to test
Patients without progressive disease were random-
the concept of double autografts in a randomized
ized to receive no maintenance (group A), monthly
fashion. An intention-to-treat analysis of the
pamidronate (B), or the combination of thalido-
394 patients enrolled in this study demonstrated
mide and pamidronate (C). Seventy-five percent of
that those who received a double autograft had a
eligible patients had been randomized at the time
superior 7-year EFS of 20% compared with 10%
of evaluation (October 2004); A=197, B=194, and
for the single autograft arm (P=0.03). The 7-year
C=197. Progression-free survival (PFS) was signifi-
OS was 42% and 21%, respectively. Preliminary
cantly superior in the thalidomide-treated patients:
results from 4 other less mature studies have also
56% vs 34% (A) and 37% (B), P<0.001. With a
addressed this issue, and, although not yet formally
median follow-up of 3 years, OS is, however, similar
24
in the 3 groups: 83% (A), 78% (B), and 78% (C),
Other benefits of the registry data include the
presumably reflecting short follow-up and effective
following:
salvage therapy, including thalidomide, following
progression. In multivariate analysis, 4 factors were
1. Continuous monitoring of transplant
shown to be associated with a longer PFS: low beta-
activity, identification of trends, and
2-microglobulin at diagnosis (P<0.001), response
confirmation of randomized trials. Examples
at randomization (P<0.001), absence of del-13
include the virtual complete replacement
(P<0.02), and randomization arm (P<0.02). The
of bone marrow by mobilized peripheral
second variable addressed in this study, the impact
blood as the source of autologous grafts,
of pamidronate on subsequent progress, confirmed
retrospective registry analyses confirming
the efficacy of bisphosphonates following transplan-
the adverse effect of total body irradiation
tation with a greater than 50% reduction in skeletal
(TBI)-containing conditioning regimens,
the lack of benefit of CD34-selection of
events observed in arms B (26%) and C (24%)
grafts, and support for the efficacy of double
compared with the control arm A (65%), P<0.04.
autologous grafts compared with single
grafts.
Transplant registries represent a significant data
resource from which a variety of transplant-related
2. Retrospective studies using case matching
questions can be addressed. Dr. Bo Björkstrand3
and other statistical methods to obtain
(Karolinska Institute and University Hospital
comparable groups. For example, 473
Huddinge, Sweden), representing the European
patients who had received interferon
Group for Blood and Marrow Transplantation
maintenance post-transplant were compared
(EBMT), reviewed this data repository and
with 417 untreated controls. After statistical
the contribution of transplantation registries to
correction for difference in the distribution
current knowledge. The EBMT database contains
of prognostic factors, the EBMT comparison
information on more than 15,000 autologous and
found that OS and PFS were significantly
1500 allogeneic patients collected consecutively
superior in the interferon-treated patients.
from more than 500 centers since 1983. One
advantage of this database is the long follow-up
3. Studies of rare events. Another EBMT
time of more than 17 years. For patients who
analysis has evaluated transplant outcomes
underwent autologous grafts in the early years, there
in rare Ig isotypes: 149 with IgD and 415
is no evidence of a plateau in survival curves with
with nonsecretory MM. Compared with
10-year PFS of 10% falling, as does OS, to 5% at
patients with "common" MM, they found
15 years. Clearly, however, many of these patients
that patients in both subgroups contained
would have been transplanted "late" in their disease
a higher proportion with stage III MM
after a number of courses of therapy. It could thus
at diagnosis and that the OS for the IgD
be expected that long-term follow-up of patients
patients was poorer. OS for the nonsecretory
transplanted as part of first-line therapy may be
patients was, however, comparable.
superior. Favorable prognostic factors include lower
Similarly, 135 patients with plasma-cell
leukemia (PCL) were compared with 9887
age, response to therapy, 1 line of primary induction
patients with standard MM who were
therapy, stage I­II at diagnosis, and a low beta-2-
matched for demographic and prognostic
microglobulin. By comparison, for patients who
factors. Survival was significantly inferior in
underwent allogeneic grafts, the 17-year OS and
the PCL group: 22 vs 55 months.
PFS are 15% and 10%, respectively, raising the
possibility that a small cohort may be cured.
25
A focus of studies from the Italian Multiple
TT 1, 2, and 3 studies. Long-term follow-up for
Myeloma Study Group has been an evaluation of
the TT1 (n=231) cohort indicates a 40% OS and
whether the older patient with MM may benefit
a 30% EFS (10 years). One third of the 40% of
from HDT. Dr. Mario Boccadoro4 (Universitá di
treated patients entering CR remain in continuous
Torino, Italy) discussed the issue that many consider
CR. A matched-pair analysis, comparing this cohort
standard conditioning (such as melphalan 200
with patients treated with standard chemotherapy
mg/m2) to be too toxic for this group. The majority
on a Southwest Oncology Group (SWOG)
of randomized autograft trials restrict enrollment
protocol, demonstrates superiority for the TT1-
to those younger than age 60. Thus, the potential
treated patients: EFS 24% vs 5% P<0.001) and OS
benefits of HDT have been hitherto unvalidated
35% vs 13% (P<0.001).
in a significant proportion of the MM population.
In their multicenter study, 194 newly diagnosed
Subsequently, TT2 contained an initial
patients aged 50 to 70 were randomized to receive
randomization to thalidomide (or not) throughout
either conventional chemotherapy (6 courses of MP,
the course of treatment. Although the thalidomide
99 patients, median age 63) or intermediate-dose
randomization remains blinded, overall 5-year EFS
therapy with 2 courses of melphalan at 100 mg/
and OS appear superior to the TT1 cohort: 50%
m2 with stem-cell support (MEL100, 95 patients,
vs 25% (P<0.001) and 70% vs 60% (P<0.06),
median age 65). Their conclusion, using a variety
respectively. The benefits of TT2 were most
of evaluations, was that MEL100 constitutes a
apparent in the two thirds of patients lacking
more effective first-line therapy in this group than
identifiable cytogenetic abnormalities. Achieving
standard therapy. Specifically, the MEL100 group
CR at the completion of induction and eradication
had a higher frequency of near complete remission
of a pretherapy cytogenetic abnormality prior
to autografting were associated with extended
(nCR) (25% vs 6%, P<0.0002), a lower proportion
post-transplant survival. Baseline gene-expression
of patients with nonresponsive or progressive
profiling was carried out on 351 TT2 patients.
disease (26% vs 55%, P<0.05), and a superior 3-
High-risk patients (n=35), characterized by
year EFS (37% vs 16%) and OS (77% vs 62%,
altered expression of chromosome 1 genes, in
P<0.001). Stratification of clinical outcome for
particular overexpression of CKS1B, had a
age demonstrated that the superiority of MEL100
significantly higher rate of MM-related deaths
was maintained in the 65 to 70 cohort for both
(63% vs 12%) and an inferior 3-year OS (20%
EFS (31% vs 18%, P=0.01) and OS (73% vs
vs 85%, P<0.00001) compared with 316 good-
58%, P=0.01). Median survivals were 58 months
risk patients. Evolution to the final cohort (TT3,
(MEL100) and 37.2 months (MP). Hematologic
n=108 to date) incorporates bortezomib, building
toxicity was, however, significantly lower in the MP
on experience with dexamethasone, thalidomide,
group, although in all patients older than age 65,
and cisplatin, doxorubicin, cyclophosphamide,
the incidence of hematologic and nonhematologic
etoposide (PACE) (VDT-PACE) induction prior to
toxicity was similar to that of the whole group.
tandem transplantation and post-transplant VDT
maintenance. Although follow-up is still relatively
Another major series of contributions to the
short, superiority over TT2 was reported. Median
knowledge base in autologous transplantation comes
time to M-protein reduction and the proportion
from the Arkansas group, developers of the concept
of patients entering nCR (only immunofixation-
of total therapy (TT) and double autografts. Dr.
positive), 80% vs 60% (P<0.02) were superior.
Bart Barlogie5 (Myeloma Institute for Research
CD34+ yields (usually >20x106/kg) appeared
and Therapy, University of Arkansas for Medical
to be unaffected by induction of bortezomib.
Sciences, United States) reviewed their experience of
Included within this study are a variety of ancillary
more than 1000 patients enrolled in the sequential
investigations, including imaging with magnetic
26
resonance imaging (MRI) and positron-emission
thrombosis (DVT) the prominent complication in
tomography/computed tomography (PET/CT)
patients on TD (15%). The parameters of stem-cell
and gene-expression profiling, aimed at predicting
mobilization and yields were equivalent with 91% of
clinical outcome and delineating molecular
patients in both groups proceeding to HDT. Thus,
pathways in patients receiving TT3.
preliminary analysis of Bologna 2000 indicates that
the orally administered TD protocol may be an
Reports From These Randomized Studies
attractive alternative to VAD in patients who are
Contributions to Plenary 8 came from the Dutch-
candidates for HDT.
Belgian (HOVON) group,6 the German Multiple
Myeloma Group (GMMG),7 the Spanish Myeloma
The GMMG-2 trial, presented by Dr. Hartmut
Group (PETHEMA/GEM),8 the "Bologna Group"
Goldschmidt7 (University of Heidelberg, Germany),
from Italy,9 the French Myélome-Autogreffe Group
compared single vs HDT. An initial randomization
(MAG),10 and the Medical Research Council
compared induction with VAD or VID (idarubicin)
(MRC) from the United Kingdom.11
followed by a second randomization (n=261) to
a single or 2 sequential cycles of melphalan 200
Direct single vs double transplant studies have
mg/m2. The EFS was significantly longer in those
been conducted in Italy, France, and Germany.
patients who received 2 courses of HDT (P=0.03,
Dr. Michele Cavo9 (Institute of Hematology
28 months vs not reached). An inferior EFS was
and Medical Oncology, University of Bologna,
associated with an elevated beta-2-microglobulin
Italy) reviewed the Bologna 96 study for patients
(>3 mg/dL) but not a low albumin (<35 mg/mL)
younger than 60. An intention-to-treat analysis
nor the presence of 13q deletions by FISH.
demonstrated that the double autograft group (Tx-
2) had a prolonged median EFS (P<0.002) and time
Dr. Jean Paul Fermand10 (Myélome-Autogreffe
to progression (TTP) (P<0.0001). Median OS was
[MAG group], France) then reviewed the experience
59 months in Tx-1 and 79 months in Tx-2 (P<0.3).
of the MAG group's randomized single vs double
In the Tx-1 group, attainment of nCR (negative
transplant in patients younger than 56 (n=227). In
immunofixation) or nCR (negative electrophoresis
contrast to the trials already reviewed, no difference
but positive immunofixation) was associated with a
in EFS (31 vs 33 months) or OS (49 vs 73 months,
significantly longer OS, EFS, and TTP. In a similar
P<0.14) was found.
observation to the IFM94 study, the benefit of the
second transplant was greatest in those in the Tx-2
The approach in the current PETHEMA/GEM
group who had failed to attain at least nCR after
2000 study, presented by Dr. Joan Bladé8 (Institute
their first HDT.
of Hematology and Oncology, Postgraduate School
of Hematology, Spain) on behalf of the Spanish
As an extension, the Bologna 2000 trial is
Myeloma Group, builds on the IFM94 and Bologna
evaluating the efficacy and toxicity of 4 months
96 experiences, assigning patients to a second HDT
of a combined thalidomide-dexamethasone (TD)
or not on the basis of their responses to an initial
induction in patients who are candidates for double
course of the HDT. Patients younger than 70
autograft. This group was compared with an equal
responding to induction received an initial HDT
number of matched pairs from the "96" trial. TD
intensification (busulfan12/MEL140 or MEL200).
patients had a significantly higher rate of attainment
Those achieving CR (by immunofixation) or nCR
of at least a PR (76% vs 52%, P<0.0004) and had
received maintenance therapy with interferon and
a more profound reduction in tumor-cell mass. As
prednisone, whereas those with a residual M-spike
would be expected, the side-effect profile of TD
underwent second HDT with cyclophosphamide,
differed from VAD with nonfatal deep venous
etoposide, and carmustine BCNU (CVB) or a
27
reduced-intensity allograft (fludarabine-melphalan)
24 trial, in which the efficacy of intensified
depending on the availability of a suitable donor.
treatment with intermediate-dose melphalan (IDM,
A preliminary analysis of 528 cases addressed the
doses of 70 mg/m2 without stem-cell support, arm
impact of CR after the first autograft. In univariate
A) was compared with the same therapy followed
analysis, with a median follow-up of 27 months,
by a myeloablative regimen (cyclophosphamide
OS (not reached) and EFS (4-year 56%, median
and TBI) with stem-cell support (arm B). Of 331
49 months) are significantly better in CR or nCR
randomized patients, 81% received both courses
groups than in those with partial response (PR),
of IDM (A=81%, B=79%), whereas 79% of arm
minimum response (MR), stable disease (SD),
B patients underwent HDT. Although OS was
and progressive disease (PD) with P values ranging
equivalent (55 vs 50 months, respectively) arm
from 0.00009 to 0.03. EFS and OS for those
B patients demonstrated superior outcomes as
with residual M components by immunofixation
measured by CR rate (28% vs 13%, P<0.002), EFS
alone (nCR) are not significant at the present
(22 vs 20 months, P<0.016), PFS (33 vs 24 months,
time compared with those with PR, MR, or SD.
P<0.036), and TTP (33 vs 25 months, P<0.001).
Median EFS times are 35, 37, 35, and 28 months,
These differences only became apparent after at
respectively (P<0.03). As expected, patients with
least 4 years of follow-up. By multivariate analysis,
PD had a vastly inferior survival compared with
treatment arm A, higher age, hemoglobin, stage
the other groups, OS and EFS, P<0.00000. A
III, 1p/q cytogenetic abnormalities, and elevated
multivariate analysis confirms the statistical
LDH were adverse factors for poorer EFS. Using the
significance of CR with the odds ratio for survival
combination of beta-2-microglobulin >3 mg/dL,
3.7 and 2.2 for EFS (P<0.001).
del-13/13q- and 1p/q prognostic groups could be
defined with significant impact on OS, EFS, PFS,
The PETHEMA/GEM study also prospectively
and TTP.
evaluated the fate of patients with primary
refractory disease to investigate the efficacy of
The final presentation in this session came from
early HDT in this subgroup. Forty-nine patients
the MRC (United Kingdom). Dr. Tony Child11
(median age 57) with refractory disease following
(University of Leeds, United Kingdom) reviewed
VBMCP/VBAD induction were slated to receive
an intention-to-treat analysis with long-term fol-
HDT. Twenty-two patients' disease had progressed
low-up (median 68 months) of the Myeloma VII
while on therapy, whereas 29 had nonresponding,
trial, which compared standard therapy with a
nonprogressive, or stable disease. Eighty percent
single (mostly melphalan 200 mg/m2) autograft.
achieved some form of response after the first HDT,
In the intensive-therapy group, 150 of 201 patients
although only 24 went on to a second procedure (17
actually received the HDT, whereas 196 of 200
auto and 7 allo) with an upgrading of their response
patients completed the standard protocol. Of the
in a little less than half. The median survival of the
latter group, 20% subsequently went on to receive
an autograft (18%) or allograft (2%). Patients
whole series was 32 months, with patients who had
in the intensive-therapy group had superior rates
PD after initial therapy faring significantly worse
of CR (44% vs 8%, P<0.001), OS (56.3 vs 42.2
than the nonresponding, nonprogressive group.
months, P<0.004), and PFS (31.2 vs 19.5 months,
The latter group, in fact, had a similar survival to
P<0.0001). A significant interaction between treat-
chemosensitive patients.
ment effect and pre-treatment beta-2-microglobulin
level was observed, most marked in the high beta-
A somewhat different approach has been followed
2-microglobulin stratum (>8 mg/L), 41.5 vs 13.1
by the HOVON group. Dr. Pieter Sonneveld6
months. The MRC group had also calculated odds
(Erasmus Medical Center, The Netherlands)
ratios and 95% confidence intervals (CIs) for their
presented the long-term follow-up of the HOVON
study and 2 comparable (IFM90 and MAG) single
28
autograft trials. The estimated combined treatment
4.
Boccadoro M, Bringhen S, Petrucci MT,
effect was found to be consistent with a significant
et al. High dose therapy options for elderly
survival benefit for treatment incorporating HDT
myeloma patients: results of a randomized
compared with standard therapy (odds ratio 0.70
controlled trial [abstract]. Haematologica.
with 95% CI 0.53­0.93, P<0.001).
2005;90(suppl 1):18-19. Abstract PL4.03.
5.
Barlogie B, Rasmussen E, Shaughnessy J,
In the current MRC IX trial, a single HD
et al. Total therapy for newly diagnosed
melphalan (200 mg/m2) autograft is considered
multiple myeloma: the Arkansas experience
standard for all suitable patients. A theme of this
with 1000 patients treated with total therapy
and many of the current randomized trials is that
1, 2, and 3 [abstract]. Haematologica.
HDT is the "central plank" around which other
2005;90(suppl 1):19. Abstract PL4.04.
strategies, to optimize response and enhance
6.
Sonneveld P, van der Holt B, Segeren CM,
outcomes, can be built. Randomization questions
et al. Intensive versus double intensive
being addressed by the MRC include the intensity
therapy in untreated multiple myeloma:
of induction with infusional CVAD compared
update analysis of the randomized
with oral cyclophosphamide, thalidomide, and
phase III HOVON 24 study [abstract].
dexamethasone (CTD). Additional randomizations
Haematologica. 2005;90(suppl 1):37-38.
include the type of bisphosphonate (oral vs
Abstract PL8.01.
intravenous) as well as a post-HDT randomization
7.
Goldschmidt H. Single vs. double high-
to thalidomide. A preliminary analysis of the
dose therapy in multiple myeloma:
second analysis of the GMMG-HD2 trial
induction question has focused on the risk of
[abstract]. Haematologica. 2005;90(suppl
venous thromboembolism (VTE). In those patients
1):38. Abstract PL8.02.
undergoing the more intensive induction arms, 13
8.
Bladé J, Lahuerta JJ, Sureda A, et al.
DVT, 9 pulmonary embolisms, and 5 line-related
High-dose therapy/stem cell support in
thromboses have been observed corresponding to an
multiple myeloma: update of the Spanish
incidence of 10.6% in the CVAD arm and 9.0% in
studies (PETHEMA/GEM) [abstract].
those patients receiving CTD.
Haematologica. 2005;90(suppl 1):38-39.
Abstract PL8.03.
References
9.
Cavo M, Cellini C, Zamagni E, et al.
Update on high-dose therapy ­ Italian
1.
Harousseau JL, Attal M, Facon T, Moreau
studies [abstract]. Haematologica.
P. Is double autograft the standard of care?
2005;90(suppl 1):39-40. Abstract PL8.04.
[abstract] Haematologica. 2005;90(suppl
10.
Fermand JP. High dose therapy
1):19-20. Abstract PL4.05.
2.
Attal M, Harousseau JL, Leyvraz S, et al.
supported with autologous blood stem cell
Maintenance treatment with thalidomide
transplantation in multiple myeloma: long
and pamidronate after autologous
term follow-up of the prospective studies of
transplantation for myeloma: second
the MAG group [abstract]. Haematologica.
analysis of a prospective randomized
2005;90(suppl 1):40. Abstract PL8.05.
study of the Intergroupe Francophone
11.
Child JA. Update on high dose therapy
du Myelome [abstract]. Haematologica.
­ MRC studies [abstract]. Haematologica.
2005;90(suppl 1):17. Abstract PL4.01.
2005;90(suppl 1):40-41. Abstract PL8.06.
3.
Björkstrand B, Morris C, Drake M, Crawley
C, Niederwieser D, Gahrton G. What have
the transplant registries taught us? [abstract]
Haematologica. 2005;90(suppl1):17-18.
Abstract PL4.02.
29
Post-test Questions
17.
Double autografts benefit all patients who
receive them, irrespective of the response to
the first autograft.
True
False
18.
Thalidomide maintenance in the IFM 99
trial significantly prolonged progression-free
survival.
True
False
19.
In elderly patients, there was no difference
in event-free survival or overall survival
between patients treated with standard-dose
melphalan and prednisone or with 2 cycles
of high-dose melphalan 100 mg/m2.
True
False
20.
The TT2 as reported by the Arkansas group
shows 5-year overall survival and event-free
survival of 50% and 25%, respectively.
True
False
30
Focus Sessions 4 and 8:
mechanisms of MM bone disease, and there were a
number of innovative posters and presentations in
Bone Disease of Multiple other sessions.
Myeloma
Bone is of particular interest to the MM
research community because it forms part of the
Gregory R. Mundy
microenvironment that provides a critical influence
The University of Texas
on the behavior and growth of MM cells in the
Health Science Center at San Antonio
bone-marrow cavity. Bone is also important as a
target tissue for factors produced as a consequence
San Antonio, Texas, USA
of MM: factors that cause either localized or
generalized bone loss. There were several reviews
Based on findings at this symposium, multiple
of factors, both local and systemic, that are
myeloma (MM) bone disease is likely even more
overproduced in MM and significantly affect bone-
common than previously thought and may, in
cell function. In vivo preclinical models of MM
fact, be universal in patients with MM. Moreover,
bone disease are now widely used and accepted. A
although some manifestations are local, the disease
number of these were discussed, including variants
may be more generalized in all patients; that is,
of the 5T Radl model and the human SCID
although the manifestations appear in limited local
models. Studies using the latter model, as reviewed
sites, there is increasing evidence that the disease is
by Dr. Joshua Epstein1 (University of Arkansas
almost always systemic. A multitude of factors that
for Medical Sciences, United States), show that
affect osteoblasts and osteoclasts are overexpressed in
MM cells in the marrow microenvironment are
MM for reasons that are still unclear. Bortezomib
dependent on this microenvironment for growth
therapy improves not only tumor burden but may
and their behavior.
also act directly on the skeleton to stimulate repair
of the lytic lesions through a host response.
The traditional concept of MM bone disease is that
the disease is characterized either by (1) discrete
MM is unique in its propensity to cause osteolysis
osteolytic lesions in the axial skeleton at sites of
in 80% of patients who suffer from devastating and
MM cell collections; (2) generalized osteoporosis,
progressive bone destruction, resulting in severe
in which the tumor cells are spread more diffusely
and unremitting bone pain, pathologic fractures,
throughout the skeleton; or (3) very rarely,
hypercalcemia, and spinal-cord compression. These
osteosclerosis. In the 5T Radl model, Dr. Mundy2
complications are significant clinical problems
described a generalized decrease in bone mass and
for which there is no effective cure. Although
bone formation in skeletal sites away from the
newer treatment modalities, such as stem-cell
osteolytic lesions and collections of tumor cells.
transplantation, have the potential to increase life
This finding was also suggested by imaging studies
span modestly, these modalities do not reverse the
in patients described by Dr. Brian Durie3 (Cedars-
bone disease.
Sinai Comprehensive Cancer Center, United States).
The latter found by positron-emission tomography
Although this is a pessimistic view of the current
(PET) and magnetic-resonance imaging (MRI) that
status of treatment, new ideas proposed at the
the disease is more widespread through the bone
10th International Myeloma Workshop suggest
marrow cavity than had been previously recognized,
that traditional concepts of the bone disease
using simple observations by skeletal radiography.
of MM should be modified. Two exciting oral
These data suggest that MM bone disease may
sessions focused on advances in understanding the
be even more frequent than current skeletal
survey data based on radiographs would suggest.
31
The osteosclerosis associated with the POEMS
Nonetheless, there are some overriding issues with
(polyneuropathy, organomegaly, endocrinopathy, M
respect to MIP1 that require attention. For
protein, and skin changes) syndrome was discussed
example, why is MIP1 overproduced in MM;
by Dr. Morie Gertz4 (Mayo Clinic College of
are the MM cells the source of this upregulation;
Medicine, United States).
and can MIP1 be measured in the circulation of
patients? Dr. Oyajobi6 presented a hypothesis that
The pathogenetic factors accompanying MM
there is a direct relationship between MIP1 and
bone disease were discussed in a number of
RANKL, each one enhancing the production of
presentations, including those of Dr. Roodman,5
the other. Such a cycle could explain the beneficial
Dr. Mundy,2 Dr. Oyajobi,6 Dr. Shipman,7 Dr.
effects of either MIP1 antibodies or inhibitors of
Tian,8 Dr. Vanderkerken,9 Dr. Van Reit,10 and
RANKL on bone resorption in preclinical models of
Dr. Hashimoto.11 MM bone disease is associated
MM bone disease.
with a multitude of cytokines that are capable of
influencing bone resorption and bone formation.
The role of RANKL in MM bone disease was also
These include macrophage inflammatory protein
discussed. Studies show that specific inhibitors of
1 alpha (MIP1 ), RANK ligand (RANKL),
RANKL, such as RANK.Fc6 and OPG,12 clearly
osteoprotegerin (OPG), Dkk1, interleukin-6 (IL-6),
block the bone lesions as well as decrease tumor
lymphotoxin, hepatocyte growth factor, PTH-rP,
burden in MM. However, there are still some
and a number of others. The most prominently
unclear issues, such as the cell source of these factors
studied factors at present are MIP1 , RANKL,
and the relative contributions to the bone disease
OPG, and Dkk1. Mechanisms to explain how these
from MM cells and host cells. In addition, the
factors interact with each other and what initiates
relationship of RANKL to other factors, such as
their expression in MM, as well as the relative
MIP1 , has not yet been determined. As noted,
importance of each factor, are still unclear.
Dr. Oyajobi presented the concept of a cycle that
suggested interactions between these 2 factors.
MIP1 is clearly an important bone-resorbing
cytokine. Its role was discussed in a number of
The relationship between OPG and RANKL was
presentations. Dr. Babatunde Oyajobi6 (University
also a topic of interest. OPG is the natural decoy
of Texas Health Science Center at San Antonio,
receptor for RANKL, and current data from human
United States) described its effects both on normal
studies suggest that its circulating concentrations
bone resorption and in MM bone disease. This
are decreased in patients with MM. This finding
chemokine, which is known to be increased in MM
has the theoretical potential of enhancing the bone
bone marrow plasma, increases bone resorption in
loss when accompanied by increased production
vivo, and the bone destruction associated with MM
of RANKL,13 as bone destruction is probably
in a preclinical model was abrogated by neutralizing
dependent on the ratio of these 2 factors. It
antibodies to this factor. Using the 5T Radl model,
is impossible to know, at present, what is the
Dr. Oyajobi described how the bone lesions, as well
significance of decreased OPG to the localized bone
as the tumor burden, are completely inhibited by
lesions of MM bone disease, but this relationship
antibodies to MIP1 . Dr. Toshihiro Hashimoto
may be an important factor in the generalized bone
and associates11 (University of Tokushima Graduate
loss described at this meeting (see above).
School of Medicine, Japan) described the inhibitory
effects of MIP1 on dendritic cells, although the
significance of these findings to the bone disease
OPG is a member of the tumor necrosis factor
remains unclear. MIP1 appears to increase
(TNF) receptor superfamily group of molecules.
formation of osteoclasts and concomitantly decrease
Another member of this family is TNF receptor
dendritic cell number.
apoptosis-inducing ligand (TRAIL), and Dr. Claire
32
Shipman7 (University of Texas Health Science
presentation did not relate directly to bone disease
Center at San Antonio, United States) described
but clearly has important implications. Other
the effects of TRAIL in opposing the effects of
factors that were described in detail in poster
OPG in MM. Her presentation focused on their
presentations were endothelin-1, BMP-2, s-FRP,
interactions with respect to MM cell apoptosis, but
osteopontin, and SDF-1.
interactions between OPG and TRAIL also could
be important in the bone loss associated with MM
One important but still unsolved issue in the
bone disease. These data also suggest a potential
treatment of MM bone disease is the relationship
problem with using OPG as a form of therapy. If
between bone lesions and tumor burden. With
OPG antagonizes the effects of endogenous TRAIL
few exceptions, when bone destruction is inhibited
to promote MM cell apoptosis, this inhibition could
in the preclinical models, tumor burden decreases
clearly be harmful to the beneficial effects of TRAIL
concomitantly. This finding is seen with RANK.
in limiting the life span of MM cells.
Fc, MIP1 antibodies, in most situations with
bisphosphonates, and with OPG. Dr. Peter
Dkk1 also received much attention at this meeting.8
Croucher12 (University of Sheffield Medical
This naturally occurring inhibitor of the Wnt
School, United Kingdom) made the case that
pathway is increased in MM, and could account
bisphosphonates could be having a direct effect
for systemic effects on bone formation, as Dkk1
on MM cells to enhance cytotoxicity. Although
has been shown to be a product of MM cells by
there are in vitro data showing that large doses of
microarray studies. This factor inhibits osteoblast
bisphosphonates do, in fact, have a cytotoxic effect
differentiation and also has the potential to
on tumor cells in vitro, there is still no proof that
impair the self-renewal capacity of hematopoietic
this effect occurs in vivo independent of the effects
stem cells, thus leading to anemia and immune
of bisphosphonates in decreasing bone resorption.
suppression in patients with MM.
There have not been any significant new findings
Dkk1 may be regulated by proteasome
with respect to the efficacy of bisphosphonates in
inhibitors when these agents are used as therapeutic
treating MM bone disease. This area was reviewed
agents in patients with MM. Dr. Mundy
by Dr. James Berenson14 (Institute for Myeloma and
described experiments in which Dkk1 expression
Bone Cancer Research, United States) and was also
was decreased by proteasome inhibitors, which
addressed in 1 of the industry-sponsored satellite
independently have been shown by this group to
symposia. Bisphosphonates are now the standard
be powerful stimulators of normal bone formation.
of care in the treatment of MM bone disease,
Dr. Erming Tian8 (Myeloma Institute for Research
and they are used in the majority of patients. Dr.
and Therapy, University of Arkansas for Medical
Berenson suggested that zoledronic acid is more
Sciences, United States) suggested that bortezomib
effective than pamidronate in reducing skeletal
therapy is associated with increased markers of
events over 24 months of treatment and stressed the
bone formation. Other factors were also described
need for slower 15-minute infusions to reduce the
that could be playing a role. For example, Dr.
risk of increasing serum creatinine concentrations.
Karin Vanderkerken9 (Vrije Universiteit Brussel,
There were several posters addressing the issue
Belgium) presented a convincing case that insulin-
of osteonecrosis of the jaw associated with
like growth factor-1 (IGF-1) and the IGF-1 receptor
bisphosphonates that described separate series of
complex play an important role in the progression
cases and a proposed association with dental disease.
of MM and that blocking the signal transduction
The onset of this adverse effect seems to occur
pathway by a specific receptor kinase inhibitor
more rapidly after exposure to zoledronic acid than
(PPP) can significantly reduce tumor burden. This
pamidronate, although the overall relative frequency
33
appears to be the same following treatment with
References
zoledronic acid or pamidronate. This issue clearly
requires more scientific study to determine the
1.
Epstein J, Yaccoby S. Mouse models of
precise frequency of this effect, related mechanisms,
tumor microenvironment and bone disease
and appropriate management guidelines. Until
[abstract]. Haematologica. 2005;90(suppl
these areas are clarified, it would be wise to
1):22-23. Abstract F4.04.
delay bisphosphonate treatment in patients with
2.
Mundy GR, Oyajobi K, Garrett IR.
active dental disease. It is anticipated that this
Osteoblast function in myeloma (endothelin
modification in treatment management will reduce
1, osteoblast proteasome) [abstract].
Haematologica. 2005;90(suppl 1):21.
the risk considerably.
Abstract F4.02.
3.
Durie B. Advances in diagnosis and
One other treatment that deserves attention is the
imaging in multiple myeloma [abstract].
use of bortezomib and other proteasome inhibitors
Hematologica. 2005;90(suppl 1):13. Abstract
for bone formation. Bortezomib and other
PL3.05.
proteasome inhibitors are powerful stimulators of
4.
Gertz MA, Lacy MQ, Dispenzieri A,
bone formation and osteoblast differentiation. It
Hayman SR. Cryoglobulinemia, POEMS
is conceivable, as was presented by Dr. Mundy,
and gammopathy-associated neuropathy
that proteasome inhibitors have multiple effects in
[abstract]. Haematologica. 2005;90(suppl
MM in that they (1) cause MM cell apoptosis by
1):33. Abstract F6.05.
their inhibitory effects of NF- B; (2) inhibit bone
5.
Roodman GD. Pathogenesis of myeloma
resorption, again by their inhibitory effects on NF-
bone disease [abstract]. Haematologica.
B; and (3) enhance bone formation by reversing
2005;90(suppl 1):20-21. Abstract F4.01.
6.
Oyajobi BO, Mundy GR. Macrophage
the effects of MM cells to enhance Dkk expression.
inflammatory protein-1 : osteolytic and
Evidence for these multiple roles was presented
tumour promoting effects in myeloma
in a poster by Dr. Maurizio Zangari15 (Myeloma
bone disease [abstract]. Haematologica.
Institute for Research and Therapy, United States),
2005;90(suppl 1):42-43. Abstract F8.02.
which showed that in several patients with MM
7.
Shipman CM, Croucher PI, Russell RGG.
treated with bortezomib, there was enhanced
New therapeutic approaches in myeloma
expression of bone-active proteins such as alkaline
bone disease [abstract]. Haematologica.
phosphatase and BMP-2.
2005;90 (suppl 1):42. Abstract F8.01.
8.
Tian E, Iang Y, Zhan F, et al. Toward
It was striking how little attention was given to
the elucidation of the role of altered Wnt
the bone disease of MM by the clinical trialists
signaling myeloma and development
in the many clinically oriented sessions of this
of therapeutic interventions based on
conference, either as a factor in response to
these findings [abstract]. Haematologica.
2005;90(suppl 1):44-45. Abstract F8.04.
cytotoxic therapy or as a response parameter. For
9.
Vanderkerken K, Menu E, Wiklund-
example, the preclinical data with bortezomib
Jernberg H, et al. Role of insulin-like
strongly suggest that bone should be examined
growth factor and its receptor in the 5TMM
closely in any clinical study in which this drug is
experimental mouse model [abstract].
used. During the question-and-answer sessions, the
Haematologica. 2005;90(suppl 1):51-52.
speakers acknowledged that this will be an area of
Abstract F9.02.
focus in future clinical studies now being designed.
10.
Van Camp B, Vanderkerken K, Van Reit
I. Bone marrow homing of multiple
myeloma cells [abstract]. Haematologica.
2005;90(suppl 1):51. Abstract F9.01.
34
11.
Hashimoto T, Abe M, Tanaka Y, et
al. Macrophage inflammatory protein-
1 may cause reciprocal regulation of
osteoclast and dendritic cell differentiation
from monocytes in myeloma [abstract].
Haematologica. 2005;90(suppl 1):46.
Abstract F8.05.
12.
Croucher P. Bisphosphonates and the
bone marrow microenvironment [abstract].
Haematologica. 2005;90(suppl 1):21-22.
Abstract F4.03.
13.
Terpos E, Rahemtulla A. RANKL and
macrophage inflammatory protein-1a in
multiple myeloma: clinical implications
[abstract]. Haematologica. 2005;90(suppl
1):43-44. Abstract F8.03.
14.
Berenson J. New advances in the
management of myeloma bone disease
[abstract]. Haematologica. 2005;90(suppl
1):9. Abstract F2.03.
15.
Zangari M, Lee CK, Barlogie B, et al.
Responses to Velcade and bone metabolism
in multiple myeloma patients [abstract].
Haematologica. 2005;90(suppl 1):189-190.
Abstract PO.1208.
Post-test Questions
21.
MIP1 is an important osteoclast-activating
factor.
True
False
22.
Bone disease is localized to the immediate
site of plasma-cell infiltration.
True
False
23.
OPG is a decoy receptor for RANK-L.
True
False
24.
Therapy with pamidronate has been shown
to decrease skeletal events in MM.
True
False
35
Plenary Session 5:
cytochrome C from mitochondria and downstream
caspases. Specifically, bortezomib induces caspase-
New Therapeutic Agents 8­and caspase-9­mediated apoptosis and can
augment apoptosis by agents that trigger either
Kenneth C. Anderson
caspase-8 or caspase-9. In vitro studies show that
Dana-Farber Cancer Institute
overexpression of heat shock protein 27 (hsp27)
Boston, Massachusetts, USA
confers bortezomib resistance, whereas blocking
hsp27 function confers bortezomib sensitivity.
One of the highlights of the 10th International
In mice, bortezomib triggers dose-dependent
Workshop in Multiple Myeloma is the rapidly
inhibition of human MM cell growth and related
evolving bench-to-bedside research in novel targeted
angiogenesis and prolongs host survival. These in
therapies. These therapies target not only the
vitro studies, coupled with a phase 1 study that
multiple myeloma (MM) cell directly but also the
defined the maximal tolerated dose and showed
interaction of the MM cell with the bone marrow
anti-MM clinical activity, provided the framework
(BM) and the BM microenvironment. These agents
for a multicenter phase 2 trial in 202 patients
have rapidly evolved from validation in laboratory
with relapsed, refractory MM. There were 35%
and animal models to clinical phase 1, 2, and 3
responses including 4% immunofixation-negative
trials and have demonstrated remarkable ability to
complete responses. Time to progression was 7
overcome clinical drug resistance.
months, and median duration of response was 12
months. Responses were clinically meaningful,
Dr. Paul Richardson (Dana-Farber Cancer Institute,
as they were associated with improvements in
United States) updated the bench-to-bedside
quality of life, increased hemoglobin, decreased
translation of proteasome inhibitor bortezomib.
need for transfusion, improved renal function, and
Bortezomib was initially used to inhibit activation
increased normal immunoglobulin levels.1 These
of NF- B, which confers resistance in MM cells,
studies led to accelerated FDA approval for use in
regulates expression of adhesion molecules and
MM. Dr. Richardson reported on the results of a
binding of MM cells to BM stromal cells (SCs),
phase 3 multicenter international trial comparing
and regulates both constitutive and MM-cell
bortezomib with dexamethasone (dex) treatment of
adhesion-induced transcription and secretion of
669 patients with relapsed MM who had undergone
cytokines in BMSCs. Bortezomib does block NF-
1 to 3 previous therapies.2,3 Patients treated with
B and these sequelae, but comparative studies
bortezomib had higher response rates (38% vs 18%
with a specific I B kinase inhibitor show that
complete and partial response rates), longer time to
bortezomib acts against MM through mechanisms
progression (6.2 vs 3.5 months), and longer survival
other than NF- B blockade as well. We have
(80% vs 66% at 1 year) than patients receiving dex.
delineated its actions at the MM cell surface, at the
Rates of serious adverse events occurred in similar
level of mitochondria, and downstream apoptotic
proportions in both groups. Therefore, bortezomib
signaling. The selectivity of bortezomib for MM
is superior to high-dose dex for the treatment of
cells can, in part, be explained by bortezomib-
patients with MM who have had relapses after 1 to
induced cleavage of gp-130, the common subunit
3 previous therapies, and FDA approval has been
of the receptor for cytokines (ie, IL-6) that
extended to include this population. Ongoing
augment MM cell growth, survival, drug resistance,
studies are evaluating bortezomib therapy earlier in
and migration. It triggers activation of JNK
the disease course as treatment for newly diagnosed
kinase and generation of reactive oxygen species,
MM; gene microarray and proteomic studies are
which induces release of proapoptotic Smac and
both defining novel mechanisms of action and
suggesting therapeutic strategies. For example,
36
gene microarray studies show that bortezomib
Two studies combined lenalidomide with other
induces apoptotic signaling, downregulates survival
agents with promising results. Dr. Mohamad
signaling, and transiently upregulates ubiquitin
Hussein (Cleveland Clinic Taussig Cancer Center,
proteasome cascade and stress responses. Induction
United States) showed that combining lenalidomide
of hsp90 in bortezomib-treated MM cells suggests
with doxorubicin, vincristine, and reduced-
coupling this agent with hsp90 inhibitor 17AAG
schedule dex treatment of patients with refractory
to augment anti-MM activity, and clinical trials are
MM achieved 66% responses, including 33%
now ongoing. These bench-to-bedside studies show
near complete and complete responses, and was
that a new treatment paradigm targeting not only
well tolerated.8 Dr. Richardson reported on the
the tumor cell but also the tumor host interaction
results of a phase 1 trial combining bortezomib
and BM milieu can achieve improved patient
and lenalidomide.9 This study is predicated upon
outcomes in MM.
preclinical studies showing that combining these
drugs induces dual apoptotic signaling. Remarkably,
Lenalidomide is an immunomodulatory drug
responses have occurred in 10 of 11 patients, all of
(iMiD) that, in 2000, was shown to induce
whom were refractory to either agent or both when
cytotoxicity of human MM cells resistant to
given alone. This supports the concept of "cocktails"
conventional therapies bound to the BM both in
of novel agents to enhance cytotoxicity, avoid drug
laboratory and animal models of human MM.4 A
resistance, and allow for use of lower doses and
phase 1 trial of the iMiD lenalidomide in 2001
fewer side effects.
demonstrated benefit in 20 of 24 patients with
refractory MM,5 and 2 phase 2 trials confirmed
responses, including some complete responses
Finally, Dr. Anderson further demonstrated the
and a favorable side-effect profile.6 Two phase 3
ability of preclinical models of the MM cell in
trials comparing lenalidomide/dex vs dex/placebo
the BM microenvironment to identify potential
were recently unblinded because lenalidomide/dex
novel therapies that can overcome drug resistance
significantly prolonged time to progression, setting
and improve patient outcomes in MM. Clinical
the stage for FDA approval of this drug later this
phase 1/2 protocols are ongoing to evaluate
year. A major highlight of the workshop was the
hsp90 inhibitors (17AAG), VEGF tyrosine kinase
presentation by Dr. Donna Weber (M.D. Anderson
inhibitors (PTK 787), histone deacetylase inhibitors
Cancer Center, United States) of the results of
(SAHA), arsenic trioxide, TRAIL, atiprimod, anti-
phase 3 trials comparing lenalidomide/dex vs dex in
CD40, and anti-CD56 based upon preclinical
patients with relapsed and refractory MM, including
leads.10 Importantly, gene array, proteomic, and
354 patients in the United States and 351 patients
cell-signaling studies have helped to identify in vivo
in Europe.7 There were 60% vs 20% complete
mechanisms of action and drug resistance, as well
and partial responses in the combined drug vs dex
as aid in the clinical application of combination
cohorts, respectively. One quarter of patients in the
therapies. For example, gene-microarray profiling
US trial achieved complete responses to combined
of bortezomib-treated MM cells reveals induction
therapy vs only 4% in the dex-alone arm. Most
of hsp90 stress response,11,12 providing the rationale
remarkably, time to progression in the US and
for the combined clinical use of bortezomib and
European trials was 3-fold longer (15 and 13.3
17AAG to enhance anti-MM activity; clinical trials
months) in the combined therapy arms vs dex (5.1
of 17AAG alone and combined with bortezomib
and 5.1 months). These studies provide the basis
are ongoing. Proteomics also forms the basis for
for the new drug application for its FDA approval.
clinical application of novel agents. For example,
Moreover, ongoing phase 2 trials evaluating
protein profiling of bortezomib-treated MM cells
lenalidomide/dex as initial therapy demonstrate
demonstrated cleavage of DNA repair enzymes,13
responses in the overwhelming majority of patients.
37
providing the rationale for combining bortezomib
References
with DNA-damaging agents to enhance sensitivity
1.
Richardson PG, Barlogie B, Berenson J,
or overcome resistance to these conventional
et al. A phase 2 study of bortezomib in
therapies. Cell-signaling studies suggested
relapsed, refractory myeloma. N Engl J
that combining lenalidomide with bortezomib
Med. 2003;348(26):2609-2617.
would trigger dual apoptotic signaling,14 and
2.
Richardson PG. Bortezomib--first in
an ongoing clinical trial has shown responses to
the class of proteasome inhibitors and
the combination in 10 of 11 patients who were
animportant advance in the treatment
refractory to either agent alone. Finally, correlative
of multiple myeloma [abstract].
science studies on blood and BM samples from
Haematologica. 2005;90(suppl 1):23-24.
patients on clinical protocols can both define targets
Abstract PL5.01.
of drug sensitivity and resistance as well as inform
3.
Richardson PG, Sonneveld P, Schuster
design of protocols. For example, gene array studies
MW, et al. Bortezomib or high-
showed that hsp27 was overexpressed in patients
dosedexamethasone for relapsed
multiple myeloma. N Engl J Med.
with intrinsic or acquired resistance to bortezomib;
2005;352(24):2487-2498.
our studies then demonstrated that overexpressing
4.
Hideshima T, Chauhan D, Shima Y, et al.
hsp27 in sensitive MM cells conferred bortezomib
Thalidomide and its analogs overcomedrug
resistance and, conversely, that knockdown of hsp27
resistance of human multiple myeloma
in resistant MM cells via antisense oligonucleotide
cells to conventional therapy. Blood.
or siRNA restored sensitivity.15,16 Subsequently, it
2000;96(9):2943-2950.
was shown that p38MAPK inhibitor downregulates
5.
Richardson PG, Schlossman RL, Weller
hsp27 in bortezomib-resistant MM cell lines
E, et al. Immunomodulatory drug CC-
and patient cells, thereby restoring sensitivity
5013 overcomes drug resistance and is well
to bortezomib17 and providing the rationale for
tolerated in patients with relapsed multiple
an ongoing clinical trial combining p38MAPK
myeloma. Blood. 2002;100(9):3063-3067.
inhibitor and bortezomib. Ultimately, it might be
6.
Richardson PG, Jagannath S, Schlossman R,
possible to carry out gene and protein profiling,
et al. A multi-center, randomized, phase 2
study to evaluate the efficacy and safety of 2
both to select cocktails of targeted therapies for
CC-5013 dose regimens when used alone or
specific patients18 and to define targets of sensitivity
in combination with dexamethasone (dex)
vs resistance to develop more potent and less toxic
for the treatment of relapsed or refractory
next-generation therapeutics.
multiple myeloma (MM) [abstract]. Blood.
2003;102(11):235a. Abstract 825.
7.
Weber D. Lenalidomide (CC-5013,
These studies have therefore demonstrated the
RevlimidTM) and other iMiDs [abstract].
critical role of host BM­tumor cell interactions
Haematologica. 2005;90(suppl 1):24-25.
both in MM pathogenesis and as targets for novel
Abstract PL5.02.
therapies. They have provided the framework for a
8.
Hussein MA, Karam MA, Reed J, et al.
new treatment paradigm targeting MM cell­host
Pegylated doxorubicin in combination
BMSC interactions in the BM milieu, as well as
withimmune-modulators and arsenic-
their sequelae, including induction of cytokines,
containing regimens for the management
to overcome drug resistance and improve patient
of multiple myeloma [abstract].
outcomes in MM.
Haematologica. 2005;90(suppl 1):25-26.
Abstract PL5.03.
38
9.
Richardson PG, Schlossman R, Munshi N,
18.
Munshi NC, Hideshima T, Carrasco D,
et al. Phase I study of the safety and efficacy
et al. Identification of genes modulated in
of bortezomib (Velcade) in combination
multiple myeloma using genetically identical
with CC-5013 (Revlimid) in relapsed and
twin samples. Blood. 2004;103(5):1799-
refractory multiple myeloma (MM): the
1806.
REVVEL study [abstract]. Haematologica.
2005;90(suppl 1):26-27. Abstract PL5.04.
Post-test Questions
10.
Anderson K. Overview of new therapies and
future directions [abstract].Haematologica.
25.
The mechanism of action of bortezomib is
2005;90(suppl 1):27-28. Abstract PL5.05.
only due to its effect on I B.
11.
Mitsiades N, Mitsiades CS, Poulaki V, et al.
True
False
Molecular sequelae of proteasome inhibition
in human multiple myeloma cells. Proc Natl
26.
In the pivotal phase 3 studies of bortezomib
Acad Sci U S A. 2002;99(22):14374-14379.
and lenalidomide versus dexamethasone,
12.
Hideshima T, Mitsiades C, Akiyama
both agents showed higher response
M, et al. Molecular mechanisms
rates and increased duration of response
mediating antimyeloma activity of
compared with dexamethasone alone.
proteasome inhibitor PS-341. Blood.
True
False
2003;101(4):1530-1534.
13.
Mitsiades N, Mitsiades CS, Richardson
27.
Drugs with possible activity in MM include
PG, et al. The proteasome inhibitor
hsp90 inhibitors (17AAG), VEGF tyrosine
PS-341potentiates sensitivity of
kinase inhibitors (PTK 787), histone
multiple myeloma cells to conventional
deacetylase inhibitors (SAHA), arsenic
chemotherapeutic agents: therapeutic
trioxide, TRAIL, atiprimod, anti-CD40,
applications. Blood. 2003;101(6):2377-
and anti-CD56.
2380.
True
False
14.
Mitsiades N, Mitsiades CS, Poulaki V,
et al. Apoptotic signaling induced by
immunomodulatory thalidomide analogs in
human multiple myeloma cells: therapeutic
implications. Blood. 2002;99(12):4525-
4530.
15.
Chauhan D, Li G, Shringarpure R,
et al. Blockade of Hsp27 overcomes
bortezomib/proteasome inhibitor PS-341
resistance in lymphoma cells. Cancer Res.
2003;63(19):6174-6177.
16.
Chauhan D, Li G, Auclair D, et al.
2-Methoxyestradiol and bortezomib/
proteasome-inhibitor overcome
dexamethasone-resistance in multiple
myeloma cells by modulating Heat Shock
Protein-27. Apoptosis. 2004;9(2):149-155.
17.
Hideshima T, Podar K, Chauhan D, et
al. p38 MAPK inhibition enhances PS-
341 (bortezomib)-induced cytotoxicity
against multiple myeloma cells. Oncogene.
2004;23(54):8766-8776.
39
Plenary Session 6:
The MM Microenvironment and Its Relationship
to How Patients Respond to Drug Therapy
Tumor
The first topic in this session on tumor
microenvironment and angiogenesis was discussed
Microenvironment
by Dr. Melissa Alsina2 (Moffitt Cancer Center and
Research Institute, United States). The relationship
and Angiogenesis
between the MM cells and the surrounding bone
marrow microenvironment can be seen as analogous
S. Vincent Rajkumar
to the relationship between seed and the soil. In
Mayo Clinic
fact, although it is relatively easy to kill MM cells
Rochester, Minnesota, USA
in a test tube, Dr. William Dalton (Moffitt Cancer
Center and Research Institute, United States) and
colleagues have shown that it is much harder to
Over the last several years, we have learned that
eliminate MM cells when they are in their optimal
multiple myeloma (MM) cells depend greatly
microenvironment.3,4 Therefore, there has been
on various factors in the bone marrow to grow.1
significant research looking at the most important
The bone marrow is the home for the MM cells
factors that play a role in the growth of MM cells in
and is referred to as the microenvironment. The
the bone marrow.
microenvironment in MM is different from
normal and allows the MM cells to grow and
The resistance of MM cells to chemotherapy
flourish. The various pieces (components) of the
drugs may be these cells' innate, natural ability,
microenvironment include proteins known as
but this resistance could also be something with
cytokines and chemokines that almost function like
which the cells interact in the various supporting
fertilizer for the MM cells to grow and new blood
(stromal) cells of the bone marrow. The resistance
vessels (formed by a process called angiogenesis)
to chemotherapy that MM cells show when they
that provide oxygen and nutrition to the cancer
are in close contact with other supporting cells in
cells. In addition, the normal immune cells in the
the bone marrow is known as cell adhesion-mediated
bone marrow microenvironment that are supposed
drug resistance (CAM-DR). Studies by Dr. Dalton
to kill cancer cells stop functioning normally and
and colleagues have shown that the binding of MM
instead allow the cancer cells to grow unchecked.
cells to the supporting cells in the bone marrow
MM cells also acquire special skills at surviving
prevents melphalan and other chemotherapy drugs
even chemotherapy once they bind to supporting
from working effectively on the cell.2 Essentially,
cells in the bone marrow called stromal cells. Clearly,
this binding triggers various proteins that interfere
the bone marrow microenvironment is a culprit in
with the action of chemotherapy on the MM cells.
MM, and much research is ongoing to target the
They also found that a certain protein, Bim, which
microenvironment with new drugs to make the
is a member of a larger family of proteins, Bcl/Bcl-
living conditions difficult for MM cells. Researchers
2, is important in the development of this drug
believe that this approach can help control MM to
resistance. Essentially, the levels of this protein were
a large extent, provided the right drugs are available.
decreased when MM cells bound to supporting
Many exciting developments continue in this field,
cells. Current research is focused on finding ways to
and this article summarizes the various presentations
inhibit the binding of MM cells to the stromal cells
given at the "Tumor Microenvironment and
and also finding drugs that overcome the resistance
Angiogenesis" session.
that arises as the result of this binding.
40
Angiogenesis in MM
of blood vessels in the bone marrow and cause these
Several researchers have shown that cancer cells
blood vessels to shrink.12
require a blood supply to grow beyond the size of 1
The cause of increased blood vessels in the MM
to 2 mm.5,6 They have shown that in the absence
bone marrow has been studied, and several
of new blood supply, cancer cells will not be able
proteins--such as vascular endothelial growth factor
to grow. Therefore, interrupting or interfering with
(VEGF), basic fibroblast growth factor (bFGF),
the blood supply to cancer cells is an attractive
and their receptors--have been found to be released
treatment option. Dr. Rajkumar presented an
by MM cells.13 However, in studies so far, there
overview of the important discoveries made by
does not appear to be a marked difference in the
several researchers worldwide in determining the
level of these proteins in each cell between MM
role of new blood-vessel formation in the growth
and more slow-growing forms of the condition
and spread of MM.7
such as monoclonal gammopathy of undetermined
significance (MGUS). In fact, one theory that is
Several researchers have shown that when one
supported by new discoveries is that patients with
compares bone marrow samples between patients
MM may lack a protein that normally prevents
with MM and healthy subjects, there is a marked
blood-vessel formation.14 The low level of this
difference in their number of blood vessels.8,9
protein in MM therefore allows blood vessels
Patients with MM have marked increase in blood
to grow and proliferate. Studies are ongoing to
supply in the bone marrow, which is clearly
determine the nature of such a protein.
important for the growth of cancer cells. In
In summary, blood-vessel formation (angiogenesis)
contrast, normal bone marrow does not show this
is critical for MM cell growth and may prove to be
type of new vessel formation. Furthermore, it has
a good target for treatment trials. Several new drugs
also been shown that as the patient progresses from
are being developed to interfere with new blood-
more slow-growing, indolent phases of MM to more
vessel formation.
aggressive tumor growth, the level of blood supply
in the bone marrow increases progressively.
New Antiangiogenic Agents
As discussed, given the importance of new blood-
These observations suggest that the tumor blood
vessel formation and MM growth, there have
supply (angiogenesis) is an important factor for
been several attempts made to develop agents that
MM cell growth. The increase in blood supply
will prevent blood-vessel formation and therefore
allows the tumor cell to receive more oxygen. The
be helpful in controlling MM. Several agents in
cells that make up the tumor blood vessels also
clinical trials include thalidomide, lenalidomide,
release substances that are helpful in allowing the
cancer cells to grow. For example, these blood vessel
and bortezomib, all of which have properties against
cells release proteins, such as interleukin-6 (IL-6),
blood vessels.15 In addition, antibodies and proteins
which are known to stimulate MM cell growth.10,11
that interfere and block VEGF--which, as previously
described, is an important protein that stimulates
Studies now show that treatment with conventional
angiogenesis--are being studied. Several other
chemotherapy or transplantation is unable to reduce
drugs--such as 2-methoxy-estradiol, which blocks
the number of blood vessels in the bone marrow.
new blood-vessel formation--are also being tested.
Therefore, these blood vessels may serve as a fertile
soil in which a few remaining MM cells are able
Dr. Guido Tricot16 (University of Arkansas for
to grow back and may represent the reason why
Medical Sciences, United States) presented advances
it is so hard to cure MM. There is, however, new
recently made in new agents for MM. Dr. Tricot
evidence that drugs that attack blood vessels, such
showed that in the very first trial that looked
as thalidomide, are able to decrease the formation
at thalidomide therapy, one third of patients
41
responded to treatment even though most had
in the earlier stages, MM cells are very small and
already failed almost all other treatment options.17
have limited growth. At this stage there is no blood-
Thalidomide was used in the first study because
vessel formation that can be identified. However,
of its known ability to block blood-vessel growth.
following new blood-vessel formation, the cells
In fact, now 4 years from the start of thalidomide
were able to grow rapidly and spread. This change
therapy, 1 in 5 patients are still responding and have
from a quiet form, without blood-vessel formation,
not shown evidence of progression.
to an aggressive tumor following new blood-
vessel formation was associated with change in the
Given the activity of thalidomide, lenalidomide,
nature of the MM cells as well as an increase in the
a safer and more effective analogue (cousin) of
production of VEGF. Several other proteins that
thalidomide, has been developed. In initial studies,
stimulate blood-vessel formation were also found
lenalidomide has been found to be effective in
to be increased such as bFGF, angiopoietin-1, and
patients with advanced MM who have failed other
platelet-derived growth factor (PDGF).
treatment options as well as patients with newly
diagnosed MM.18
Dr. Van Riet20 and colleagues then showed that
using specific proteins to prevent the action of
Another active agent for MM is bortezomib,
VEGF, PDGF, and bFGF on their receptors led to
which also has properties against blood vessels.19
significant decrease in blood-vessel formation in the
Bortezomib has been combined with thalidomide
bone marrow. In fact, the treatment of these mice
and dexamethasone and other active agents in
with such agents led to bone marrow appearing
patients with advanced MM. In one study, Dr.
almost similar to that in normal mice without any
Tricot reported that most patients had failed
increase in bone blood-vessel formation. This
all previous therapies, but despite this, 40% of
suggests that using such proteins that target blood-
patients achieved a good response to therapy with
vessel formation may be an attractive treatment
the combination of bortezomib, thalidomide, and
strategy for MM in the future.
dexamethasone.16 In fact, 20% of patients had more
than 90% reduction in their protein levels. The
Role of Chemokines in MM
most fascinating finding was that when one looked
Dr. Irene Ghobrial21 (University of Pittsburgh,
at all of the genes in patient cells before and after
United States) presented results from several studies
therapy, using a new technique--gene-expression
looking at a small protein known as CXCR4.
profiling--there was a complete normalization
She described that stimulation of CXCR4 led to
of the bone marrow microenvironment following
activation of several pathways in MM cells. Dr.
treatment with this 3-drug cocktail.
Ghobrial found that the expression of CXCR4 was
much higher in the peripheral blood than in the
Targeting of Key Proteins That Induce Tumor
bone marrow. The expression of CXCR4 was much
Blood-Vessel Formation
higher in the bone marrow of normal patients and
Dr. Ivan Van Riet20 (Vrije Universiteit Brussel,
patients with MGUS compared with patients who
Belgium) presented the results of several studies
have MM. She suggested that CXCR4 expression
that have attempted to identify proteins that are
was required for MM cells to circulate and that
important for new blood-vessel formation in MM.
when this expression is lowered, it leads to the cells'
They used a novel mouse model: the 5T2MM
localizing to the bone marrow. She also suggested
model. They demonstrated that MM cells respond
that trials that use inhibitors of this pathway may be
to a variety of proteins that are produced by cells
helpful for the treatment of MM.
lining blood vessels known as endothelial cells.
Using the 5T2MM mouse model, they showed that
42
Summary
8.
Vacca A, Ribatti D, Roncali L, et al. Bone
There are numerous advances being made in
marrow angiogenesis and progression
understanding the role played by the bone marrow
in multiple myeloma. Br J Haematol.
microenvironment (the home) of the MM cells in
1994;87:503-508.
encouraging and supporting their growth. Several
9.
Rajkumar SV, Mesa RA, Fonseca R, et
researchers worldwide are trying to find ways to
al. Bone marrow angiogenesis in 400
make the bone marrow return to its normal state
patients with monoclonal gammopathy
and not allow MM cells to grow. Given the amount
of undetermined significance, multiple
of research going on in this field, it is likely going
myeloma, and primary amyloidosis. Clin
to be only a matter of time before we find ways to
Cancer Res. 2002;8:2210-2216.
expel MM cells from their nesting place and make
10.
Dankbar B, Padro T, Leo R, et al. Vascular
the microenvironment completely unsuitable for
endothelial growth factor and interleukin-6
in paracrine tumor-stromal cell interactions
their survival.
in multiple myeloma. Blood. 2000;95:2630-
2636.
References
11.
Vacca A, Ria R, Ribatti D, et al. A paracrine
loop in the vascular endothelial growth
1.
Hideshima T, Bergsagel PL, Kuehl WM,
factor pathway triggers tumor angiogenesis
Anderson KC. Advances in biology of
and growth in multiple myeloma.
multiple myeloma: clinical applications.
Haematologica. 2003;88(2):176-185.
Blood. 2004;104:607-618.
12.
Kumar S, Witzig TE, Wellik L, Greipp PR,
2.
Dalton W, Lee H. Influence of the tumor
Rajkumar SV. Effect of thalidomide therapy
microenvironment on drug response
on bone marrow angiogenesis in multiple
and drug resistance in multiple myeloma
myeloma. Leukemia.
[abstract]. Haematologica. 2005;90(suppl
2004;18:624-627.
1):28. Abstract PL6.01.
13.
Giuliani N, Colla S, Lazzaretti M, et al.
3.
Dalton WS, Bergsagel PL, Kuehl WM,
Pro-angiogenetic properties of human
Anderson KC, Harousseau JL. Multiple
myeloma cells: production of angiopoietin-
myeloma. In: Schechter GP, Broudy VB,
1 and its potential relationship with
Williams ME, eds. Hematology 2001.
myeloma-induced angiogenesis. Blood.
Washington, DC: American Society of
2003;102(2):638-645.
Hematology; 2001:157-177.
14.
Kumar S, Witzig TE, Timm M, et al. Bone
4.
Hazlehurst LA, Dalton WS. Mechanisms
marrow angiogenic ability and expression of
associated with cell adhesion mediated drug
angiogenic cytokines in myeloma: evidence
resistance (CAM-DR) in hematopoietic
favoring loss of marrow angiogenesis
malignancies. Cancer Metastasis Rev.
inhibitory activity with disease progression.
2001;20(1-2):43-50.
Blood. 2004;104:1159-1165.
5.
Folkman J. Seminars in Medicine of the
15.
Kyle RA, Rajkumar SV. Multiple myeloma.
Beth Israel Hospital, Boston. Clinical
N Engl J Med. 2004;351:1860-1873.
applications of research on angiogenesis
16.
Tricot G. New anti-angiogenic agents
[review]. N Engl J Med. 1995;333:1757-
[abstract]. Haematologica. 2005;90:29.
1763.
Abstract PL6.03.
6.
Folkman J. Angiogenesis-dependent
17.
Singhal S, Mehta J, Desikan R, et al.
diseases. Semin Oncol. 2001;28:536-542.
Antitumor activity of thalidomide in
7.
Rajkumar SV. Angiogenesis in myeloma:
refractory multiple myeloma. N Engl J Med.
an overview [abstract]. Haematologica.
1999;341:1565-1571.
2005;90(suppl 1):28-29. Abstract PL6.02.
43
18.
Richardson P, Jagannath S, Schlossman R,
et al. A multi-center, randomized, phase 2
study to evaluate the efficacy and safety of 2
CDC-5013 dose regimens when used alone
or in combination with dexamethasone
(Dex) for the treatment of relapsed or
refractory multiple myeloma (MM). Blood.
2003;102:235a.
19.
Richardson PG, Barlogie B, Berenson J,
et al. A phase 2 study of bortezomib in
relapsed, refractory myeloma. N Engl J Med.
2003;348:2609-2617.
20.
Van Riet I, Asosingh K, Vande Broek I, et
al. Targeting of vascular endothelial and
platelet derived growth factor signaling by
receptor tyrosine kinase inhibitors impairs
myeloma cell-induced neovascularization
in the 5TMM mouse model [abstract].
Haematologica. 2005;90(suppl 1):29-31.
Abstract PL6.04.
21.
Ghobrial IM, Ghobrial JM, Lu G, et al.
Molecular mechanisms involved in homing
and migration of plasma cells in response
to CXCR4 stimulation and downstream
activation of the PI3K pathway [abstract].
Haematologica. 2005;90(suppl 1):30.
Abstract PL6.05.
Post-test Questions
28.
MM plasma cells are more sensitive to
melphalan when attached to the bone-
marrow stroma.
True
False
29.
Thalidomide, bortezomib, and lenalidomide
have antiangiogenic properties.
True
False
30.
VEGF and bFGF play important roles in
formation of new blood vessels in MM.
True
False
44
Focus Session 6:
the probability of survival, but hemoglobin less than
100 gm/L was associated with inferior survival.1
Waldenström's
Dr. C. Fraga (Saint António's General Hospital,
Portugal) and colleagues performed a retrospective
Symposium and
analysis of 20 patients with WM diagnosed from
1993 to 2004 at Saint António's General Hospital in
Myeloma Variants
Oporto, Portugal. Their mean age at diagnosis was
70 years, and their 5-year rate of survival was 60%.
Meletios A. Dimopoulos
They observed that age and
-microglobulin serum
2
University of Athens School of Medicine
levels were significant prognostic variables associated
Athens, Greece
with patient survival.2
The majority of patients with WM have well-
Focus Session 6 included oral presentations
differentiated, mature B lymphocytes. In some
and posters that referred to unusual forms of
patients, the malignant cells resemble plasma
plasma-cell dyscrasias including Waldenström's
cells, the typical cells found in multiple myeloma
macroglobulinemia (WM); amyloidosis;
(MM)-related cancer. Although we know that
cryoglobulinemia; and polyneuropathy,
WM originates from B lymphocytes that reside in
organomegaly, endocrinopathy, monoclonal
the lymph nodes, the cause of this disease remains
gammopathy, and skin changes (POEMS)
unknown. We also know that the malignant cells
syndrome. Advances in the biology and treatment of
travel to the bone marrow, where they thrive.
these disorders were presented.
Furthermore, at diagnosis, and in relapse, WM
cells are abundant not only in the bone marrow but
WM is an uncommon lymphoproliferative disorder
in blood as well. Dr. Linda Pilarski (University of
defined by the Second International Workshop on
Alberta, Canada) and her colleagues reported data
WM as a lymphoplasmacytoid lymphoma with
from their research that focuses on the mechanisms
a serum IgM monoclonal protein. There are few
of migration and spread of WM. Hyaluronan (HA)
reliable incidence data, as clear diagnostic criteria
is a substance known to be important in cancer
have only recently been defined, and this disease
because it is involved in the migration and spread
is often grouped with other plasma-cell dyscrasias
of cancer cells. The synthesis of HA is regulated
in epidemiologic studies. Ms. Karen Phekoo
by another substance called hyaluronan synthase
and coworkers reported the results of a UK study
1 (HAS1). Increased production of HAS1 results
conducted in the South Thames area, covering a
in high synthesis of HA. As a result, the spread of
population of 7.0 million people. A registration
WM is increased, and the death of WM cells is
form was designed to define cases of WM
decreased. Dr. Pilarski's group found that in patients
prospectively between 1999 and 2000. All patients
with WM there is increased production of HAS1.
diagnosed with WM during that period were
This increased production is regulated by activation
followed until December 2002; 113 new cases of
of the HAS1 gene. They have identified germ-line
WM were identified. The crude incidence rate was
homozygosity in the HAS1 gene that characterizes
1.03 per 100,000 inhabitants. The male-to-female
more than 90% of WM. This HAS1 homozygosity
ratio was 1.26, and the median age was 74 years.
in WM is significantly more frequent than in
The age-specific incidence rates rose steadily with
healthy donors, suggesting that it may confer a
increasing age from 1.41 at age 55 to 64 years to
predisposition to development of this disease. These
5.00 per 100,000 by age 75 to 84 years. Three-year
researchers proposed that the increased synthesis of
survival rate was 61%. Age did not correlate with
HAS1 leads to increased intracellular production
45
of HA. This results in the development of a more
of cytopenias (thrombocytopenia in particular),
aggressive type of WM. Furthermore, as HAS1
need for rapid control of disease, and candidacy
variants are not present in healthy cells, they may
for high-dose therapy with autologous stem-cell
present valuable clinical targets for the development
transplantation (ASCT). The alkylating agent
of new treatments that are highly selective for
most commonly used has been oral chlorambucil.
malignant cells.3
Approximately 50% of patients achieve partial
response; the time to response is slow, and
To delineate mechanisms that permit the growth
several months are needed to determine the
and survival of lymphoplasmatic cells (LPCs)
chemosensitivity of the disease. The optimal
in WM, Dr. Steve Treon (Dana-Farber Cancer
duration of administration of chlorambucil has
Institute, United States) and colleagues performed
not been defined, and most clinicians administer
studies that addressed the genetic basis, molecular
the drug for 1 or 2 years. Prolonged exposure to
pathogenesis, and microenvironment support in
chlorambucil may impair stem-cell collection.
WM. A strong familial predisposition in WM
This agent may be the primary treatment of
was observed; 20% of 257 patients with WM had
choice for elderly patients who do not require
relatives with WM or a related B-cell disorder.
rapid control of disease and who present without
Cytogenetic studies with the BAC-FISH analysis
significant cytopenias. The purine nucleoside
demonstrated losses in 69
as the most common
analogues fludarabine and cladribine are active
21-23
cytogenetic abnormality.4 The same investigators
in WM. Responses occurred in 40% to 80% of
demonstrated loss of expression for BLIMP1,
previously untreated patients, and, in most series,
a master regulatory gene found on 6q21 that
the median time to response was 2 months. Thus,
supports LPC differentiation. Abnormalities in
nucleoside analogues are particularly useful in
other genes involved in LPC differentiation, such
patients requiring rapid control of disease. The
as Bcl-6, PAX5, and XBP1, were also found. Other
administration of these agents should be restricted
experiments from Dr. Treon's group evaluated
to 4 courses or fewer to avoid stem-cell toxicity
the role of bone marrow mast cells (MCs), which
and to reduce the incidence of opportunistic
are usually increased in patients with WM.
infections. Rituximab is active in approximately
They showed that MCs from patients with WM
one third of previously untreated patients. Time
stimulated the expansion of WM LPCs, indicating
to response is slow and exceeds 3 months on the
that MCs may support the growth of WM. If these
average. Treatment with rituximab is well tolerated,
observations are confirmed, MCs could represent a
and myelosuppression is negligible. This agent may
new therapeutic target for the treatment of WM.
represent the treatment of choice for patients who
present with significant cytopenia and patients who
Drs. Dimopoulos and Anagnostopoulos reviewed
are candidates for stem-cell collection. Several phase
current treatment options in WM. Several phase
2 studies indicate that combinations of rituximab
2 studies and consensus panel recommendations
with nucleoside analogues and/or with alkylating
indicate that the 3 main choices for front-line
agents may have a synergistic effect.
treatment of symptomatic patients with WM are
alkylating agents, purine nucleoside analogues
Accumulating data indicate that high-dose therapy
(fludarabine, cladribine), and the anti-CD20
with ASCT is feasible, safe, and associated with
monoclonal antibody rituximab.5 Despite the lack
significant cytoreduction, even in patients with
of prospective randomized trials, a rational selection
chemoresistant disease. Prognostic models need
of primary therapy for patients with WM can be
to be developed that will identify, at diagnosis,
made if certain factors are taken into consideration:
patients with impaired prognoses who will be
age, presence of comorbid conditions, presence
candidates for trials that include high-dose therapy
46
early in the course of the disease. New agents, such
ASCT; 12 patients achieved complete response, and
as thalidomide, lenalidomide, bortezomib, and
3 patients showed very good partial response. In
oblimersen are under investigation in patients with
all cases, remission of plasma-cell proliferation was
advanced WM. There is preliminary evidence of
associated with improvement of the performance
activity, but their precise place in the management
status and of the manifestations associated with
of WM remains to be determined. Advances in the
POEMS including the neuropathy. With a median
understanding of the biology of the disease will help
follow-up of 31 months, only 1 patient experienced
us to develop more rational treatments and targeted
a relapse after 22 months.7 These studies indicate
therapies for WM.
that high-dose therapy is the treatment of choice in
patients with disseminated POEMS syndrome.
Dr. Morie Gertz (Mayo Clinic College of Medicine,
United States) and colleagues reviewed the Mayo
Dr. Philip Hawkins (Royal Free and University
Clinic experience with cryoglobulinemia and
College Medical School, United Kingdom)
POEMS. Over a 6-year period, 66 patients with
presented a comprehensive review on amyloidosis.8
type 2 cryoglobulinemia were seen at the Mayo
Systemic AL (immunocyte-derived) amyloidosis
Clinic. Their median age was 58; the light chain
is a disorder of protein folding in which certain
was kappa in 65 patients; and rheumatoid factor
monoclonal immunoglobulin light chains are
was positive in 97%. Clinical manifestations of
transformed into and deposited as AL amyloid
cryoglobulinemia included palpable purpura,
fibrils. These amyloid deposits progressively disrupt
glomerulonephritis, peripheral neuropathy, and
the normal structure and function of tissues
arthralgias. In 60% of patients, cryoglobulinemia
throughout the body, leading to multiple organ
was associated with hepatitis C. Patients received
failure. The monoclonal plasma-cell infiltrate
a variety of treatments including interferon-alfa,
that underlies AL amyloidosis is usually subtle
steroids, cyclophosphamide, and rituximab. Skin
and not proliferating. Frequent manifestations
involvement was controlled in 85% of patients,
of AL amyloidosis include renal dysfunction,
whereas neuropathy improved in only 35% of
cardiomyopathy, neuropathy, and hepatomegaly.
patients. Overall, only 21% of patients died, and
The diagnosis of amyloidosis requires histologic
the only predictor of survival was age.6
confirmation.
The same group presented data on a large number
Immunohistochemistry can usually exclude AA
of patients with POEMS syndrome. Their median
(reactive systemic) amyloidosis, and DNA analysis
age was 51 years, and in almost all patients the
may be required to exclude hereditary forms of
light chain was lambda. For those patients who had
amyloid. In more than 90% of patients with AL
solitary sclerotic lesions, radiation to the side was
amyloidosis, a monoclonal protein is detected
frequently effective. Patients with multifocal lesions
in the serum and/or urine of patients. The
were usually treated with alkylating-agent­based
quantitation of serum free light chains (FLCs) is
chemotherapy, which resulted in a response rate
a useful test in the diagnosis of this disorder and
of 44%. The median overall survival was 165
in the assessment of patients after initiation of
months. They also reported 16 patients who were
treatment. Systemic treatments for AL amyloidosis
treated with high-dose therapy and ASCT. Of 14
have been derived from those used in MM. An
evaluable patients, all had neurologic improvement
important objective in amyloidosis is to suppress
or stabilization. Dr. Arnaud Jaccard (Centre
the production of amyloidogenic light chains as
Hospitalier Universitaire de Limoges, France)
rapidly as possible. Regression of amyloid and
and colleagues reported 15 patients with POEMS
clinical improvement following systemic treatment
syndrome treated with high-dose therapy and
in AL amyloidosis are usually delayed for many
47
months following adequate suppression of the
disease at 3 months received 9 months of adjuvant
underlying clonal disease. Today, most patients
dexamethasone and thalidomide or dexamethasone
with amyloidosis are being initially treated with
alone if there was a history of deep vein thrombosis
high-dose dexamethasone-based regimens such
or neuropathy. Among 42 patients enrolled since
as vincristine, doxorubicin, and dexamethasone
September 2002, 4 patients were rated as high risk.
(VAD) or melphalan-dexamethasone. Goodman
All had symptomatic cardiac involvement and died
and associates reported a large series of 229 patients
at a median of 4 months after treatment. Thirty-
with AL amyloidosis treated with VAD-like
four patients in the low-risk group were treated. The
chemotherapy. Clonal immunoglobulin production
TRM was 6.4%, and at 3 months 63% of patients
was identified at baseline in 95% of patients by an
had hematologic responses; 20 patients with
abnormal serum FLC ratio. Furthermore, serum
persistent clonal disease began adjuvant therapy
monoclonal protein was detected in the serum and
with dexamethasone ± thalidomide. At 12 months,
the urine of 62% and 65% of patients, respectively.
73% of patients had hematologic responses, and
FLC response was a powerful predictor of survival:
67% had organ responses.10
Median survival of patients whose FLCs normalized
(24% of patients) was not reached at 110 months,
Thalidomide is an oral agent with immuno-
was 80 months among patients with >50%
modulatory and antiangiogenic properties that
reduction of FLCs (38% of patients), and was 42
is active in 30% of patients with advanced and
months in patients with 50% reduction (39% of
refractory MM. The administration of high-dose
patients). Treatment-related mortality (TRM) was
thalidomide in amyloid patients is associated with
2%, and function of amyloidotic organs improved
very poor tolerance and significant side effects.
in 21% of patients (kidney 28%, heart 6%, liver
Goodman and coworkers reported the use of
21%, soft tissue 40%), remained stable in 50%, and
thalidomide in 99 patients with AL amyloidosis in
worsened in 29%.9 VAD is the preferred regimen
whom cytotoxic therapy had been deemed either
when the patient is a candidate for blood stem-cell
ineffective or too toxic to pursue. Thalidomide was
collection to support the administration of high-
taken for a median of 5 months at a median dose
dose melphalan. This procedure is associated with a
of 100 mg/day (range 50 to 600 mg). Thalidomide
significant rate of hematologic and organ responses
alone was given in 56 patients, with alkylating
but can cause treatment-related death in 15% to
agents in 13 patients, and with dexamethasone
40% of patients. Thus, careful patient selection and
(with or without alkylating agents) in 30 patients.
experience with the procedure in this specific type
Thalidomide was discontinued because of adverse
of patient are required. Dr. A.D. Cohen (Memorial
effects in 40% of patients; clonal disease responses
Sloan-Kettering Cancer Center, United States) and
were recorded in 36% of patients. Organ function
colleagues reported the interim analysis of a study
improved or remained stable in 23% and 39%
of risk-adapted intravenous melphalan followed
of patients, respectively. Median survival from
by adjuvant dexamethasone and thalidomide for
thalidomide treatment was 26 months. Survival was
newly diagnosed patients with AL amyloidosis.
significantly better when dexamethasone was part of
Low-risk patients (1 or 2 major organs involved, no
the regimen.11
advanced cardiac disease) received melphalan 100,
140, or 200 mg/m2 with autologous blood stem-
Dr. Hugh Goodman (National Amyloidosis Centre,
cell (ABSC) transplantation based on age, cardiac
United Kingdom) and colleagues reported a large
involvement, and renal function. High-risk patients
number of patients (235 cases) with localized AL
(3 organs involved or advanced cardiac disease)
amyloidosis defined by diagnostic Congo-red
received 2 cycles of melphalan 40 mg/m2 without
histology; absence of hepatic, renal, cardiac, and
ABSC. Patients with persistent clonal plasma-cell
nerve involvement; and negative serum amyloid
48
protein scan except from involved sites. Most
6.
Gertz MA, Lacy MQ, Dispenzieri A,
common sites involved included lung and airways
Hayman SR. Cryoglobulinemia, POEMS
(40 cases), urinary tract (37 cases), larynx (28 cases),
and gammopathy-associated neuropathy
nasopharynx (25 cases), skin (25 cases), lymph
[abstract]. Haematologica. 2005;90(suppl
nodes (22 cases), and eye/orbit (20 cases). Evidence
1):33. Abstract F6.05.
of systemic plasma-cell disorder was identified in
7.
Jaccard A, Haroche J, Choquet S, et al.
26% of patients. With a mean follow-up of 39
High dose therapy and autologous blood
months, only 2 patients subsequently developed
stem cell transplantation in 15 patients
systemic AL; 12 patients (5%) have died but in
with POEMS syndrome [abstract].
only 6 patients could death be attributed to the
Haematologica. 2005;90(suppl 1):204.
amyloidosis or to a plasma-cell disorder. This large
Abstract PO.1415.
cohort of patients confirms the excellent prognosis
8.
Hawkins PN. Amyloidosis [abstract].
associated with localized AL amyloidosis.12
Haematologica. 2005;90(suppl 1):32-33.
Abstract F6.04
References
9.
Goodman HJB, Wechalekar A, Lachmann
HJ, Bradwell AR, Hawkins PN. Clonal
1.
Phekoo K, Moller H, Richards M, et al.
disease response and clinical outcome in
Incidence and survival of Waldenström's
229 patients with AL amyloidosis treated
macroglobulinemia: a population study
with VAD-like chemotherapy [abstract].
[abstract]. Haematologica. 2005;90(suppl
Haematologica. 2005;90(suppl 1):201-202.
1):198-199. Abstract PO.1401.
Abstract PO.1408.
2.
Fraga C, Gonçalves C, Coutinho
10.
Cohen AD, Zhou P, Reich L, et al. Interim
J, Pinto-Ribeiro A. Waldenström's
analysis of a phase II study of risk-adapted
macroglobulinemia: a retrospective analysis
intravenous melphalan followed by
of 20 patients from 1993 to 2004 at Saint
adjuvant dexamethasone and thalidomide
Antonio's General Hospital (Oporto,
for newly diagnosed patients with systemic
Portugal) [abstract]. Haematologica.
AL amyloidosis [abstract]. Haematologica.
2005;90(suppl 1):199. Abstract PO.1402.
2005;90(suppl 1):201. Abstract PO.1407.
3.
Pilarski LM, Adamia S, Kriangkum J,
11.
Goodman HJB, Lachmann HJ, Gallimore
Treon S, Reiman T, Belch AR. Mechanisms
R, Bradwell AR, Hawkins PN. Thalidomide
of oncogenesis in Waldenström's
treatment in 99 patients with AL
macroglobulinemia [abstract].
amyloidosis: tolerability, clonal disease
Haematologica. 2005;90(suppl 1):31.
response and clinical outcome [abstract].
Abstract F6.01.
Haematologica. 2005;90(suppl 1):202.
4.
Treon SP. Novel insights into the
Abstract PO.1410.
biology and therapy of Waldenström's
12.
Goodman HJB, Bridoux F, Lachmann
macroglobulinemia [abstract].
HJ, et al. Localized amyloidosis: clinical
Haematologica. 2005;90(suppl 1):31.
features and outcome in 235 cases [abstract].
Abstract F6.02.
Haematologica. 2005;90(suppl 1):203-204.
5.
Dimopoulos MA, Anagnostopoulos
Abstract PO.1413.
A. Treatment of Waldenström's
macroglobulinemia [abstract].
Haematologica. 2005;90(suppl 1):32.
Abstract F6.03.
49
Post-test Questions
31.
Monoclonal anti-CD20 antibody
(rituximab) is an effective therapy for
Waldenström's macroglobulinemia with
a response rate in chemotherapy-naďve
patients of approximately 30%.
True
False
32.
The POEMS syndrome is a combination
of the following: polyneuropathy,
organomegaly, endocrinopathy, monoclonal
gammopathy, and skin changes.
True
False
33.
In more than 90% of patients with primary
amyloidosis, a monoclonal immunoglobulin
can be detected by the free light chain
(FLC) assay.
True
False
50
Plenary Session 7:
Group I:
Uninformative karyotypes in 80%,
normal polyclonal plasma-cell
signature.
How Do We Use
Group II:
The largest group: uninformative
karyotypes in just over one half
Genomics to Tailor
of cases; approximately 40% were
hyperdiploid.
Therapy?
Group III:
Defined by the presence of cyclin
D1 overexpression (characteristic
P. Joy Ho
of t(11;14)); 2 of 3 cases with no
Institute of Haematology,
cyclin D1 spikes overexpress cyclin
Royal Prince Alfred Hospital
D3 instead. Approximately 75% had
uninformative karyotypes.
Camperdown, Australia
Group IV:
Overexpression of proliferation-
associated genes, similar frequencies
Summary
of hyperdiploid and hypodiploid
New developments in genomics have increased
karyotypes.
our understanding of the pathogenesis of
Group V:
Over expression of maf and mafB,
multiple myeloma (MM) and are likely to exert
characteristic of t(14;16) and
an increasing influence on therapy. In this
t(14;20), respectively.
session, Dr. Shaughnessy proposed a molecular
Group VI:
Overexpression of CST6 (a
classification of MM comprising at least 7 distinct
potent endogenous inhibitor
entities and defined the poor prognostic impact
of lysosomal cysteine proteases
of CKS1B. Dr. Stewart discussed the pathogenic,
including cathepsin B, which may
prognostic, and therapeutic significance of
affect sensitivity to TNF-induced
t(4;14) and 1 of the candidate genes, FGFR3.
apoptosis.)
Drs. Morgan and Van Ness analyzed possible
Group VII:
Overexpression of MMSET/
relationships between germline genetic
FGFR3, characteristic of
polymorphisms and tumor predisposition, clinical
t(4;14); approximately 20% had
upregulation of MMSET without
outcome, therapeutic response, and treatment
FGFR3.
toxicities. Finally, Dr. Cremer postulated a
pathogenic role for ribosomal protein genes in
Significant associations were observed among these
del13q-negative/ hyperdiploid MM.
subgroups and clinical characteristics. For instance,
the IgA isotype was predominant in Groups
In the first presentation, Dr. John Shaughnessy1
V, VI, and VII, whereas
microglobulin was
(Myeloma Institute for Research and Therapy,
2
significantly raised in Groups IV and V. Group VI,
University of Arkansas for Medical Sciences, United
with elevated expression of CST6, had significantly
States) outlined a molecular classification of MM
fewer cases with more than 3 MRI lesions. The
comprising 7 subgroups. These 7 molecular entities
apparent polyclonal plasma-cell signature of Group
were defined by the analysis of more than 20,000
I suggested a mixture of normal and malignant
genes in plasma cells from 351 patients with newly
plasma cells in the marrow, possibly indicating a
diagnosed MM who were treated with high-dose
more macro-focal disease. The molecular subgroups
therapy. Correlations with clinical features and
may also have implications for our understanding
cytogenetic abnormalities have been determined.
of pathogenesis. For example, the dysregulation of
Important characteristics of the 7 subgroups are
cyclins is likely to be a crucial pathogenic pathway
summarized as follows:
in Group III.
51
As noted above, correlations with cytogenetic
expression was increased at MM relapse compared
abnormalities were described, with predominance
with baseline and was higher in patients who died
in Groups IV (increased proliferation genes) and
rapidly after relapse as opposed to those who were
VII (MMSET/FGFR3 overexpression). Group II
successfully treated by salvage therapy. Microarray
tended to be hyperdiploid, Group IV had similar
and quantitative polymerase chain reaction (PCR)
numbers of hyperdiploid and hypodiploid clones,
analysis of CKS1B expression demonstrated good
whereas Group VII was mainly hypodiploid.
correlation. In addition, CKS1B expression also
Chromosome 13 deletion was more common in
correlated well with CKS1B copy number. Not
Groups IV, V, and VII.
surprisingly, a strong association between increased
CKS1B ploidy and reduced survival has been
Using multivariate step-wise analysis, 15 genes
observed in 96 primary MM cases.
were identified that could be used to discriminate
among the 7 subgroups. Importantly, clear
How may CKS1B affect survival? This may relate
correlations were found among the above molecular
to the function of CKS1B, as has been examined
subtypes and survival. Significant differences were
in fission yeast. CKS1B promotes the transcription
demonstrated in event-free survival (EFS) and
of CDC20, which, in turn, regulates the anaphase-
overall survival (OS) among the 7 subgroups:
promoting complex/ cyclosome (APC/C). APC/C
Groups IV (proliferation-associated genes), V (maf
controls exit from mitosis by ubiquitinylation of
and mafB overexpression), and VII (MMSET/
mitotic cyclins. There is good correlation between
FGFR3 dysregulation) had relatively poor EFS and
the expression of CKS1B and CDC20 in MM. In
OS. The clinical and prognostic significance of this
addition, the finding that CDC20 expression is
classification may make it an important tool in the
not directly linked to ploidy also suggests that its
use of genomics to tailor therapy, directed at MM
action may be modulated/ controlled by CKS1B
subgroups exhibiting different biologic behavior.
in MM. CKS1B has also been shown to regulate
DNA synthesis directly by the ubiquitinylation
Although high-risk disease is best identified by
and proteasomal degradation of p27 (a cyclin-
karyotype, the characteristics of this group were
dependent kinase inhibitor), as supported by an
examined in greater detail by survival analysis using
inverse correlation between CKS1B and p27Kip1
gene- expression quartiles for 33,000 probe sets.
protein levels.
Upregulation of 93 genes and downregulation of
18 genes were significantly associated with reduced
In the second presentation, Dr. Keith Stewart2
survival. Interestingly, genes from chromosome
(Ontario Cancer Institute, Canada) discussed
1q were overrepresented in the overexpressed
the significance of t(4;14) translocation and
genes, whereas those from chromosome 1p were
dysregulation of FGFR3 in MM, and their
frequent in the underexpressed. These findings
therapeutic implications. The t(4;14) translocation
were supported by observations that cytogenetic
occurs in approximately 15% of MM, with the
abnormalities involving chromosome 1 were more
dysregulation of FGFR3 and MMSET genes
closely correlated with poor survival than those
on chromosome 4p. T(4;14) confers an adverse
involving other chromosomes or clones without
prognosis, as confirmed in 3 large studies of patients
cytogenetic abnormalities.
treated by both standard chemotherapy and high-
dose therapy, with marked reductions in OS. There
CKS1B, situated at chromosome 1q21 and an
is an increased association with the IgA isotype,
important regulator of cell-cycle progression, has
which is known to confer a worse prognosis. In
been found by Dr. Shaughnessy and colleagues
Dr. Stewart's own series, the adverse effect on
to confer a significant adverse prognosis. CKS1B
prognosis is attributed to rapid relapse rather than
52
primary drug resistance, given that the initial
CHIR-258 and dexamethasone when applied
response rate was greater than 80%. In addition, it
to a MM cell line. In an in vivo MM mouse
would also appear that patients with t(4;14) MM
model, CHIR-258 has been shown to induce
in this series may demonstrate a particularly poor
tumor regression and inhibition of tumor growth.
response to alkylating agents and that such patients
Cytotoxicity has also been demonstrated in primary
may not benefit from high-dose therapy with
t(4;14)-carrying MM plasma cells. On the basis of
autotransplantation.
these interesting results, a phase 1 clinical trial of
CHIR-258 has been initiated.
On this background, recent efforts to target the
FGFR3 gene specifically as a therapeutic modality
Although heterogeneity in MM can be attributed to
were presented. FGFR3 expression is lost in
genetic abnormalities of the tumor itself, germline
approximately one third of t(4;14) MM, whereas
genetic polymorphisms in patients with MM may
MMSET dysregulation is retained, raising the
also contribute to differences in response and disease
question of the relative importance of these 2
behavior: the subject of discussion of Dr. Gareth
candidate genes in pathogenesis of MM. FGFR3
Morgan3 (The Royal Marsden Hospital, England)
is a tyrosine kinase receptor. In murine models,
and Dr. Brian Van Ness4 (University of Minnesota,
FGFR3 expression in B cells promotes cell growth,
United States). As Dr. Morgan explained, the most
common form of inherited genetic variation is the
increasing the proliferative response to IL-6 and
single nucleotide polymorphism (SNP) affecting
IL-6 independence. In addition to upregulation by
both coding and noncoding sequences, including
the IgH enhancer in t(4;14), activating mutations
sequences in promoter regions that can alter the
of FGFR3 can also lead to increased expression.
patterns of gene expression. Areas of interest have
However, although such mutations are common in
included variation in immunity and responses
MM cell lines, they are only present in less than 5%
to environmental xenobiotics, which may play
of newly diagnosed MM and are mainly associated
a role in the induction of MM. The analysis of
with progression of disease.
such polymorphisms has been greatly advanced
by high throughput genotyping and the complete
Dr. Stewart's group2 has demonstrated the cytotoxic
sequencing of the human genome. Dr. Morgan's3
action of several FGFR3 receptor tyrosine kinase
emphasis was on pharmacogenomics, the study
inhibitors on t(4;14)-positive MM cell lines. One
of the effect of inherited genetic variations on
specific molecule, CHIR-258, has been shown to
the handling of chemotherapeutic agents, tumor
differentially inhibit FGF-mediated growth of IL-
response, and the side effects of treatment in the
6­dependent B9 cells expressing either wild type
context of the International Myeloma Foundation
or mutant FGFR3. The selectivity of CHIR-258
Bank on a Cure® (BOAC) project. Current efforts
for FGFR3 is supported by the rescue of CHIR-
include (1) the study of families or sibling pairs
258­inhibited B9 cells by the addition of IL-6.
to identify high-risk predisposition genes; (2) case
In FGFR3-expressing MM cell lines, CHIR-258
control studies to elicit etiologic mechanisms,
defining "low-risk" genes, which are relatively
inhibited the viability of these cells even in the
more frequent in the population; and (3) the study
presence of IL-6 and IGF-I, both potent MM
of relationships between genetic variations and
growth factors. The high specificity of CHIR-
disease outcome (response, survival) and treatment
258 was demonstrated by a minimal effect on
toxicities: for example, to elicit the determinants of
non­FGFR3-expressing MM cells. The inhibitory
good/poor responses to specific therapeutic agents
action of CHIR-258 has been shown to involve
or predisposing genetic factors to side effects such
cell-cycle arrest at the G0/G1 phase, inhibition of
as the occurrence of neuropathy in thalidomide or
ERK phosphorylation and apoptosis via caspase
bortezomib treatment.
3. Synergism has also been demonstrated between
Dr. Van Ness4 further developed this theme by
53
presenting an update on the BOAC initiative of
responses following the application of DNA-
the International Myeloma Foundation, which
damaging chemotherapies. Polymorphisms in
was set up with the aim of collecting more than
the DNA repair genes XRCC1 and ERCC2 were
10,000 DNA patient samples for the analysis of
correlated with toxicity and clinical outcome in the
inherited genetic polymorphisms. The initiative is
ECOG E9486 trial. In patients given interferon
based on the hypothesis that there are associations
as maintenance, there were significant associations
between inherited germline polymorphisms and
between PFS and polymorphisms of the XRCC
MM growth, DNA repair, and drug metabolism,
and ERCC genes. Curiously, these DNA repair
such that correlations can be found with tumor
polymorphisms were also found to correlate
response, disease behavior, and etiologic factors.
with CD8+ T-cell counts, which are affected by
With the cooperation of clinical trial groups,
interferon. Thus, DNA repair polymorphisms may
institutions, and patients, samples collected
affect clinical outcome by their effect on cells of the
include tissue from stored banks and buccal cells
immune system, in keeping with previous reports
for DNA extraction, together with detailed clinical
of a highly significant association between survival
and demographic information.
in MM and immune status. In a separate clinical
trial (Intergroup S9321), preliminary findings also
Approximately 90 SNPs have been selected for
indicated trends in the associations between IL-
examination in the BOAC program, directed at
10, DNA repair genes, and IL-1-RA with clinical
linking these polymorphisms to clinical outcome.
outcome. It is anticipated that completion of the
These can be classified under 5 categories:
full panel of SNPs will provide more detailed
polymorphisms derived from published gene-
analysis on these patients in relation to different
expression profiles, twin studies, bone disease or
treatment modalities.
microenvironment, MM growth and signaling
pathways, and drug toxicity.
In the final presentation, Dr. Friedrich Cremer5
(Medizinische Klinik V, Germany) and colleagues
With more than 2800 samples in the Bank to date,
described their finding of the upregulation of
more than 20,000 genotypes have been completed.
ribosomal protein (RP) genes in MM clones
Dr. Van Ness presented a number of their findings
negative for del13q, as detected by microarray
to date. SNPs that affect the production of
expression profiling. In their study, del13q detected
important regulators of MM growth--IL-6, IL-
by fluorescent in situ hybridization (FISH) was
1 , IL-10, TNF- , and LT- -- were examined
found in approximately 50% of patients, in whom
in relation to progression-free survival (PFS), OS,
the frequency of chromosomal trisomies was lower
tumor response, and the severity of infection,
and that of IgH translocations higher than patients
in patients enrolled in a phase 3 ECOG clinical
without del13q, consistent with previous reports.
trial (E9486). Significant associations between
Conversely, the association between the absence
polymorphisms of TNF- , IL-10, and LT-
of del13q and hyperdiploidy was confirmed.
and disease outcome have been found, specific
By microarray analysis, predictor genes for the
to different treatment regimens. The data were
presence or absence of del13q were found, in
consistent with the hypothesis that patients
which human RP genes were highly represented.
homozygous for the high producer allele of these
RP genes were overexpressed in patients without
MM growth-promoting genes had adverse clinical
del13q compared with normal plasma cells. Specific
outcomes.
RP genes localized to chromosomes 9, 11, and 19
(chromosomes commonly involved in trisomies)
Deficiencies in DNA repair can increase tumor
correlated with copy number. As a result, these
development as well as inhibit DNA repair
investigators have observed an increased expression
54
of RP genes in del13q-negative/hyperdiploid MM.
Post-test Questions
This finding has been associated with cell growth,
progression of disease, and drug resistance in
34.
Molecular classifications of patients with
malignancy. They postulate that upregulation of
MM samples show that there are at least 7
the ribosomal machinery with the overexpression of
distinct molecular entities.
RP genes may play a pathogenetic role in del13q-
True
False
negative/hyperdiploid MM.
35.
The t(4:14) translocation in MM carries a
References
good prognosis.
True
False
1.
Zhan F, Hanamura I, Burington B, et al.
36.
SNPs that affect the production of
The transcriptome of multiple myeloma
regulators of MM growth can influence
defines disease subgroups with distinct
outcome of disease.
genetic and clinical features and also allows
True
False
identification of genes highly correlated
with an aggressive clinical course [abstract].
Haematologica. 2005;90(suppl 1):33-34.
Abstract PL7.01.
2.
Stewart AK, Chang H, Trudel S.
Translocation(4;14), fibroblast growth
factor receptor 3 and myeloma [abstract].
Haematologica. 2005;90(suppl 1):34-35.
Abstract PL7.02.
3.
Morgan GJ. The pharmacogenomics
of myeloma [abstract]. Haematologica.
2005;90(suppl 1):35. Abstract PL7.03.
4.
Van Ness B, Durie B, Crowley J, et al.
Association of genetic polymorphisms
in myeloma: update on Bank on a Cure
[abstract]. Haematologica. 2005;90(suppl
1):35-36. Abstract PL7.04.
5.
Cremer FW, de Vos J, Hose D, et al.
Microarray expression profiling indicates
upregulation of the ribosomal machinery
in del(13)-negative clones [abstract].
Haematologica. 2005;90(suppl 1):36-37.
Abstract PL7.05.
55
Plenary Session 9:
rely more on the graftversus MM effect than on
the highdose treatment. At this conference, both
Allogeneic
kinds of allogeneic transplantation were discussed
and compared.
Transplantation
Myeloablative Allogeneic Transplantation
Gösta Gahrton
Dr. Gahrton reported on the state of the art of
Karolinska Institute
allogeneic transplantation in MM.3 The results
Stockholm, Sweden
were mainly based on reports to the registry of
the European Group for Blood and Marrow
Summary
Transplantation (EBMT). Earlier studies had
Allogeneic hematopoietic stem-cell transplantation
indicated a TRM of about 40% to 60% with high-
in multiple myeloma (MM) may be curative for a
dose treatment. However, in transplants performed
small fraction of patients. Overall survival of about
since 1994, the EBMT results indicated a median
50% at 3 to 5 years for younger patients appears
overall survival that had improved from about 10
similar with standard intensive myeloablative and
months as a median during the period between
reduced-intensity nonmyeloablative conditioning
1983 and 1993 to about 50 months during 1994
(RIC) treatment. The relapse rate is higher with
to 1998.4 The study was based on results in 690
RIC, but the treatment-related mortality is
allogeneic transplants reported to the registry. This
lower. Ongoing prospective studies comparing
improvement in overall survival was mainly due
RIC and allogeneic transplantation may give
to a reduction in TRM--in turn due to better
better information about the place of RIC in the
supportive treatment--but also, to some extent,
treatment of MM.
to earlier transplantation and selection of patients
who had received fewer pretransplant chemotherapy
Introduction
regimens. Unfortunately, there was no obvious
Allogeneic transplantation has been performed in
improvement in the rate of relapse between the 2
MM since the early 1980s.1 The idea is twofold: (1)
periods. Later followup of these studies confirmed
an attempt to eradicate the malignant MM clone by
the improvement that has been approximately the
myeloablative chemotherapy with or without high-
same until recently.
dose total body irradiation (TBI) and thereafter save
the patient with normal donor hematopoietic stem
In earlier studies, bone marrow was the most
cells and (2) to obtain a graft-versus-MM effect by
common source of cells for hematopoietic stemcell
immunocompetent transplanted cells. Unfortunately,
transplantation. However, during the last 10 years,
this approach is hampered by high transplantrelated
there has been an increasing use of peripheral stem
mortality (TRM). Although there may be a potential
cells instead of bone marrow. In the reported EBMT
to cure some patients, the fraction has so far been
study, peripheral blood stem cells were used in
small. Thus, allogeneic transplantation has been used
133 patients from 1994 to 1998. A comparison of
much more rarely than autologous transplantation in
results with bone marrow during this period showed
the treatment of MM.
no significant difference in outcome whether
bone marrow or peripheral blood stem cells were
Recent attempts have been made to lower the
used. However, a later report indicated that using
intensity of the conditioning treatment before
peripheral blood stem cells could have an adverse
allogeneic transplantation to reduce TRM.2
effect on outcome, owing to increased frequency
Although nonmyeloablative, it has been shown
of chronic graftversushost disease (GVHD). Thus,
that engraftment can still occur, and the idea is to
the improvement in overall survival between the
56
2 periods--1983 to 1993 vs 1994 to 1998--was
many attempts have been made to use RIC to reduce
not due to the more frequent use of peripheral
TRM and relying more on the graft-versus-MM
blood stem cells for transplantation during the
effect and on post-transplant donor lymphocyte
later period. Further studies are in progress for
infusions (DLIs) to prevent relapse. Dr. F. Ayuk
comparison of peripheral blood stem cells with bone
(University Hospital of Hamburg, Germany)
marrow in the later EBMT material, taking into
reported on 130 patients with MM who received
consideration other prognostic factors.
RIC.9 Seventythree relapsed following autologous
transplantation, and 57 received RIC as an auto/allo
In a recent study of the impact of donor gender on
tandem approach for newly diagnosed patients. The
outcome, it was shown that the rate of relapse was
conditioning regimen consisted of melphalan 100
significantly lower in male patients who received
to 140 mg/m2 + fludarabine 30 mg/m2 x 5. Some
transplants from female donors, as opposed to male
patients received anti-thymocyte globulin (ATG)
donors.5 However, TRM was higher. Therefore,
or alemtuzumab in addition. The post-transplant
overall survival was poorer with female donors
GVHD prophylaxis consisted of methotrexate and
in earlier studies. With the reduction in TRM in
cyclosporine. The response rate was 49%, and the
transplants performed after 1994, the lower rate of
overall treatment-related mortality at 1 year was 18%.
relapse offsets the higher TRM with female donors,
The 2-year overall survival was 59%. There was a
resulting in similar overall survival, irrespective
significant difference between those who had received
of the donor's gender. One explanation for the
the RIC transplants as a tandem procedure rather
apparent male donor- dependent graftversustumor
than following a relapse. The 2year survival was more
effect may be a chromosome Yencoded minor
than 70% with tandem transplants but only 40%
histocompatibility antigeninduced Tcell response.
in those who had received the transplant following
Such an effect has previously been reported in other
relapse. An interesting observation was that those
hematologic disorders.6
who had deletion of chromosome 13 in the tandem
transplant group had similar progressionfree survival
Overall, female recipients have better prognoses
to those without the deletion, whereas among the
than male recipients, regardless of donor gender.
patients who relapsed, chromosome 13 deletion
However, the best outcome is seen in female-to-
appeared to have the same unfavorable prognostic
female transplants because of a somewhat lower
impact as seen following autologous transplantation.
treatment-related mortality in this combination
In the tandem transplant program, unrelated donor
than in the male-to-female combination.
transplants (n=31) had similar overall survival of
more than 60% at 5 years to those who received
There are numerous other prognostic factors
related donor transplants (n=26). Patients who
identified in allogeneic transplantation. Favorable
received alemtuzumab (n=25) had higher rates of
factors are young age, low beta2microglobulin
relapse than those who received ATG (n=48). This
level, stage I at diagnosis, responsiveness to
corroborates data previously reported by Dr. Crawley
preconditioning treatment, and 1 or few treatment
and associates in a recent EBMT meeting.10 The
regimens before transplantation.7,8
report by Dr. Ayuk is also in accordance with that of
Dr. Bensinger,11 showing TRM rates with RIC (TBI
Reduced Conditioning Nonmyeloablative
2 Gy ± fludarabine) of 15% to 20%, response rates of
Allogeneic Transplantation
25% to 70%, and a 1-year overall survival of 60% to
It has been difficult to document that procedural
80%. However, the estimated relapse rate was 50%
factors, such as alternative conditioning methods or
to 60% at 3 years, even with a tandem autotransplant
graftversushost prevention methods, improve results
+ RIC allograft, which corroborates the report
of allogeneic transplantation. However, recently
presented by Dr. Gahrton.3
57
Other results presented at the poster session
5%--whereas TRM was higher: 17% vs 5%. So far,
corroborate these data12-14: that is, TRM can be
there is no significant difference in overall survival or
reduced by RIC to about 20%, engraftment is no
event-free survival between the 2 groups, but follow-
particular problem, and overall survival at 3 to 4
up time is relatively short, and the study is small.
years is at least in the range of 40% to 45%.
Thus, firm conclusions cannot be drawn concerning
rate of relapse or long-term survival.
In an attempt to compare RIC allogeneic
transplantation with standard conditioning, Dr.
The EBMT has recently closed a study including
Gahrton presented data previously reported by
364 patients with a similar aim3 (Björkstrand
Dr. Crawley and associates at the previous EBMT
et al, unpublished). Patients were treated with
meeting,10 indicating that RIC transplants were not
vincristine, doxorubicin, and dexamethasone
superior to myeloablative standard conditioning
(VAD) and VAD-like regimens, and responsive
transplants. The reason was that although TRM was
patients were allocated to receive either a second
reduced to 23% at 24 months by RIC compared
autologous transplant (or no further treatment) or
with 37% with standard conditioning, the rate of
RIC allotransplant in case the patient had a human
relapse was significantly higher in RIC, amounting
leukocyte antigen (HLA)-identical sibling donor.
to 54% at 3 years compared with 26% with
The safety analysis shows a TRM of 11% in the
standard conditioning. The overall survival was
RIC arm. This was considered feasible to conclude
similar in both groups: that is, about 50% at 3 years
the study, which presumably will be analyzed within
if alemtuzumab-treated patients were excluded.
1 or 2 years. So far, only 55 patients have received
Among RIC transplants, 20% had received
second allotransplants, although 101 patients are
alemtuzumab in the conditioning treatment for T-
eligible for this group. A total of 224 patients are
cell depletion but only 6% of standard conditioning
allocated to the autologous group.
ones. Alemtuzumab was a significant adverse
prognostic factor.
In a separate session, Dr. Phillippe Moreau16
(Intergroupe Francophone du Myélome, France)
Reduced Conditioning Allogeneic Transplantation
reported a similar study based on a different RIC
vs. Autologous Transplantation
regimen, which indicated that the overall survival
RIC allogeneic transplantation is increasingly
was similar in the tandem autologous and RIC
used in tandem with previous autologous
transplant groups. However, longer follow-up is
transplantations. However, it is not known whether
needed to make firm conclusions as to a possible
the second RIC transplant is superior to a second
benefit or no benefit of a second RIC transplant.
autologous transplant. Dr. Laura Rosińol (Spanish
Myeloma Group, Spain) presented a study from
Donor Lymphocyte Infusions
the Spanish PETHEMA Group,15 which compared
It has previously been shown that DLIs may
tandem high-dose treatment with either autologous
induce remission in patients relapsing after an
or RIC allogeneic sibling donor transplants in
allogeneic transplantation. As relapses appear to be
patients who did not enter complete remission
more prevalent after RIC than following standard
following previous autologous transplant. Of 493
conditioning, it may be even more important to use
patients who received the first autologous transplant,
DLI after RIC transplants. It may be advantageous
181 were candidates for second transplant. However,
to use DLI at early signs of recurrence of MM. Dr.
of these, only 59 received second autotransplant
Lokhorst and coworkers have previously shown
and 23 RIC allotransplant. The complete rate of
that responses to DLI can be obtained in about
remission was higher in the allogeneic transplant
30% of patients who relapsed after an allogeneic
group than in the autologous group--26% vs
transplant.17 Now they showed that partial response
58
can be obtained in 35% and complete response
transplants. Bone Marrow Transplant.
in 17%: that is, an overall response rate of 52%
2005;35(6):609-617.
in relapsed or resistant MM following standard
6.
Gratwohl A, Hermans J, Niederwieser
conditioning transplantation.18 Of 63 treated
D, van Biezen A, van Houwelingen HC,
patients, 48 relapsed, and 15 had persistent disease
Apperley J. Female donors influence
after previous allogeneic transplantation. Thirty-
transplant-related mortality and relapse
incidence in male recipients of sibling
three had received ATG or alemtuzumab for T-cell
blood and marrow transplants. Hematol J.
depletion. Overall, 38% of the patients responded
2001;2(6):363-370.
to DLI. Responding patients had an overall survival
7.
Gahrton G, Tura S, Ljungman P, et al.
at 100 days of close to 70%, whereas nonresponding
Prognostic factors in allogeneic bone
patients had a survival of less than 40%. The most
marrow transplantation for multiple
important factor in obtaining a response to DLI
myeloma. J Clin Oncol. 1995;13(6):1312-
was to develop acute or chronic GVHD. Thus,
1322.
although DLI seems important, it should probably
8.
Bensinger WI, Maloney D, Storb
be combined with other maintenance regimens: for
R. Allogeneic hematopoietic cell
example, thalidomide, lenalidomide, or bortezomib.
transplantation for multiple myeloma.
Semin Hematol. 2001;38(3):243-249.
References
9.
Kröger N, Shimoni A, Nagler A, et al.
Current status and perspectives of dose-
1.
Gahrton G, Tura S, Ljungman P, et al.
reduced conditioning followed by related
Allogeneic bone marrow transplantation
and unrelated stem cell transplantation in
in multiple myeloma. European Group for
patients with multiple myeloma [abstract].
Bone Marrow Transplantation. N Engl J
Haematologica. 2005;90(suppl 1):47-48.
Med. 1991;325(18):1267-1273.
Abstract PL9.02.
2.
Storb RF, Sorb CR, Riddell SR, et al. Non-
10.
Crawley C, Iacobelli S, Björkstrand B,
myeloablative transplants for malignant
Apperley J, Niederwieser D, Gahrton G.
disease. In: Schechter GP, Williams ME, eds.
Reduced-intensity conditioning does not
Hematology. Am Soc Hematol Educ Program.
improve survival compared to standard
2001:375-391.
conditioning for patients with myeloma
3.
Gahrton G, Iacobelli S, Apperley J, et al.
[abstract]. Bone Marrow Transplant.
State of the art of allogeneic transplantation
2005;35(suppl 2):S48. Abstract 0260.
in multiple myeloma [abstract].
11.
Bensinger W. High dose or reduced intensity
Haematologica. 2005;90(suppl 1):46-47.
conditioning for multiple myeloma?
Abstract PL9.01.
[abstract] Haematologica. 2005;90(suppl
4.
Gahrton G, Svensson H, Cavo M, et al.
1):48. Abstract PL9.03.
Progress in allogeneic bone marrow and
12.
Mehta J, Gordon L, Tallman M, et al.
peripheral blood stem cell transplantation
Submyeloablative allogeneic transplantation
for multiple myeloma: a comparison
in myeloma: comparison of outcomes with
between transplants performed 1983­93
other hematologic malignacies [abstract].
and 1994­98 at European Group for Blood
Haematologica. 2005;90(suppl 1):135.
and Marrow Transplantation centres. Br J
Abstract PO.628.
Haematol. 2001;113(1):209-216.
13.
Hurst N, Horvath N, Horvath T, Hayes
5.
Gahrton G, Iacobelli S, Apperley J, et al.
D. Mini allograft in multiple myeloma:
The impact of donor gender on outcome
the Royal Adelaide Hospital experience
of allogeneic hematopoietic stem cell
[abstract]. Haematologica. 2005;90(suppl
transplantation for multiple myeloma:
1):135-136. Abstract PO.629.
reduced relapse risk in female to male
59
14.
Mohty M, Benramdane R, Boiron JM, et
Post-test Questions
al. Graft-versus-myeloma effect following
reduced intensity conditioning allogeneic
37.
Data from the European transplant bone
stem cell transplantation [abstract].
marrow registry show that the median
Haematologica. 2005;90(suppl 1):136.
overall survival following myeloablative
Abstract PO.630.
allogeneic transplation has improved from
15.
Rosińol L, Lahuerta JJ, Sureda A, et
10 months to 50 months.
al. Feasibility and efficacy of a planned
True
False
second transplant ("auto" or "mini-
allo") intensification in patients with
38.
Transplant-related mortality after
multiple myeloma not achieving complete
nonmyeloablative transplantation is
remission (CR) or near-CR with a first
approximately 20%.
autologous transplant: results from a
True
False
Spanish PETHEMA/GEM study [abstract].
Haematologica. 2005;90(suppl 1):50.
Abstract PL9.05.
16.
Moreau P, Hulin C, Garban F, et al. Final
results of the IFM9904 protocol: double
transplant ± anti-interleukin-6 monoclonal
antibody in high-risk de novo multiple
myeloma patients less than 65 years old
[abstract]. Haematologica. 2005;90(suppl
1):55-56. Abstract PL10.05.
17.
Lokhorst HM, Schattenberg A, Cornelissen
JJ, et al. Donor lymphocyte infusions for
relapsed multiple myeloma after allogeneic
stem-cell transplantation: predictive factors
for response and long-term outcome. J Clin
Oncol. 2000;18(16):3031-3037.
18.
Lokhorst H, Mutis T, Bloem A, Verdonck
L, Dolstra H, Raymakers R. Strategies to
improve the graft-versus-myeloma effect
of allogeneic stem cell transplantation and
donor lymphocyte infusions in multiple
myeloma [abstract]. Haematologica.
2005;90(suppl 1):49-50. Abstract PL9.04.
60
Focus Session 9:
degrades collagen-IV, an important component of
the BM endothelium basement membrane, and
Homing Mechanisms
its production is upregulated when MM cells are
exposed to BM-endothelial cells (ECs). Finally, the
and Signal Transduction
Brussels team also demonstrated that MM cells
express different chemokine receptors (CCR1,
Ivan Van Riet
CCR2, and CXCR4) that allow the tumor cells to
Academic Hospital Free University Brussels
migrate to chemokines produced by the BM stromal
Brussels, Belgium
compartment. Dr. Isabelle Vande Broek2 (Vrije
Universiteit Brussel, Belgium), from the same team,
A major feature of multiple myeloma (MM) cells
presented during this workshop a poster describing
is their restricted localization in the bone marrow
that the chemokine receptor expression status
(BM). In this BM microenvironment, the tumor
offers a prognostic value in MM. She found that
cells receive the appropriate signals that stimulate
complete loss of this expression on the tumor cells is
their growth, induce prevention of apoptosis, and
associated with unfavorable disease status. Dr. Van
can lead to drug resistance. This session included
Riet concluded that homing of MM cells to BM is
presentations that focused on the homing of MM
a complex process that involves multiple molecular
cells and signal transduction pathways that might be
pathways. Targeting one or more of these pathways
relevant targets for therapeutic intervention.
might affect disease evolution and can provide new
therapeutic tools.
Dr. Van Riet1 gave an overview of studies performed
by the Brussels MM research group that are related
Dr. Karin Vanderkerken3 (Vrije Universiteit Brussel,
to the BM homing properties of MM cells. The
Belgium) focused her talk on the role of insulin-
team has demonstrated in the 5TMM mouse
like growth factor-1 (IGF-1) in the pathogenesis
model that the restricted localization of MM cells
of MM. IGF-1 has previously been demonstrated
in the BM compartment is the result of a selective
to be an important survival and proliferation
homing to and selective growth in this particular
factor for MM cells in vitro, and patients showing
environment. In analogy to the homing mechanism
expression of the IGF-1 receptor (IGF-1R) on the
of normal leukocytes, it can be assumed that MM
malignant plasma cells seem to have poor prognoses.
homing is also a multistep process, involving
Dr. Vanderkerken investigated the expression and
particular adhesion molecules, chemotactic signals,
role of the IGF-1/IGF-1R pathway in the 5TMM
and proteases. The team in Brussels could identify
experimental mouse model. She demonstrated that
the functional expression of different types of
IGF-1 stimulates the migration of MM cells and
molecules indicating that MM cells home to BM
that this effect is mediated through the PI3K/Akt-
according to this model. Both human MM cells as
signaling pathway. IGF-1 can also induce vascular
well as murine 5TMM cells were found to express
endothelial growth factor (VEGF) secretion by
different adhesion molecules (such as VLA-4,
MM cells through the MEK/ERK pathway. The
CD38, and CD44v10) that allow binding to BM
proliferative effect of IGF-1 on MM cells seems
endothelium, the first step in the homing cascade.
to be mediated by both the PI3K/Akt and MEK/
The next step is the passage through the basement
ERK pathways. By microarray analysis, she could
membrane underneath the BM endothelium,
demonstrate that IGF-1 induces in 5TMM cells
which necessitates that the tumor cells can degrade
increased expression of several gene transcripts
the extracellular matrix. It was demonstrated
that are related to higher metabolic functions,
that both human and murine MM cells express
higher synthesis of DNA and proteins, and altered
metalloproteinase-9 (MMP-9). This MMP
microtubuli. The role of the IGF-1/IGF-1R in the
61
pathogenesis of MM was further explored by a series
rapamycin (RAPA) and CCI-779 (CCI) can inhibit
of in vivo experiments in the 5TMM model. Mice,
proliferation of MM cells by blocking the cells
injected with 5T33MM cells were treated with a
in the G1 phase of the cell cycle. Treatment with
highly selective IGF-1R inhibitor, picropodophyllin
these compounds did also induce in vivo antitumor
(PPP). Treatment with this inhibitor resulted
effects in a xenograft model. Of great interest is
in a significant reduction in tumor growth and
the finding that sensitivity to G1 arrest correlated
blood-vessel formation (angiogenesis). Moreover,
with Akt activity of MM cells. Dr. Lichtenstein
PPP-treated mice showed a significant increase
concluded that the Akt-signaling pathway can be
in survival. Dr. Vanderkerken concluded that the
considered as an attractive therapeutic target in MM
IGF-1/IGF-1R pathway is involved in multiple
and that the degree of Akt activation in MM cells as
aspects of the pathogenesis of MM, and those IGF-
well as the Ras status might be useful parameters to
1R inhibitors, like PPP, might be important in the
predict clinical response.
development of new therapeutic strategies.
Related to this presentation is the work presented
Dr. Alan Lichtenstein4 (University of California Los
as a poster by Dr. Géraldine Descamps5 (University
Angeles, United States) presented data that illustrate
Hospital, France) who confirmed that the Akt/
the potential of the Akt-signaling pathway as a
PI3K pathway is activated in MM and that the
therapeutic target in MM. Akt is a kinase (enzyme)
proliferation of CD45-negative MM cells is
that functions as a critical regulator of cell survival.
nearly completely controlled by this pathway.
Akt can be activated by extracellular signals (such as
Moreover, the team in Nantes also showed that
growth factors) as well as intracellular signals (such
phosphorylation of the IGF-1R is an important
as Ras). Activation of Akt by these signals occurs via
initiating event in the activation of the Akt/PI3K
its pleckstrin homology (PH) domain binding to
pathway in these CD45-negative MM cells. A
products of phosphatidylinositol 3-kinase (PI3K).
poster presented by Dr. Nizar J. Bahlis6 (University
This process is negatively regulated by the PTEN
of Calgary, Canada) described another strategy
tumor suppressor phosphatase. After activation,
to suppress Akt signaling in MM cells. As noted,
Akt can support several processes including cell
PTEN is a negative regulator of Akt activation. In
survival, growth, differentiation, angiogenesis,
MM cells, PTEN function can be lost, owing to
and migration. Proliferation is stimulated by Akt-
gene mutations or phosphorylation. Dr. Bahlis
dependent signaling to the mammalian target of
showed that IGF-1­induced phosphorylation of Akt
rapamycin (mTOR). Recent studies showed that
can be blocked by rottlerin (mallotoxin), which is a
unregulated activation of the PI3K/Akt pathway is
plant-derived 5,7-dihydroxy-2,2-dimethyl-6-(2,4,6-
a prominent feature of many human cancers, and
trihydroxy-3-methyl-5-acetylbenzyl)-8-cinnamoyl-
Dr. Lichtenstein noted that Akt is also frequently
1,2-chromene. Rottlerin suppresses, through
activated in patients' MM cells. Akt activation
inhibition of protein kinase C delta (PKC ),
is not present in monoclonal gammopathy of
the phosphorylation of PTEN, which results in
undetermined significance (MGUS) plasma cells
inhibition of Akt activation.
or in nonmalignant hematopoietic cells. In vitro
experiments provided evidence that this Akt
Dr. Martine Amiot7 (Département de Cancérologie,
activation in MM cells can be induced by Ras
France) focused her talk on the inactivation of a
mutations and IL-6/IGF-1 stimulation, but other
signaling pathway in MM cells that results in the
mechanisms, such as interactions with BM stroma
prevention of programmed cell death (apoptosis).
and extracellular matrix proteins or mutations in
The Nantes team demonstrated previously that
PTEN, might be involved as well. Dr. Lichtenstein's
MM cells show increased expression of myeloid-
team demonstrated that mTOR inhibitors
cell-leukemia 1 (Mcl-1), a protein that inhibits
62
apoptosis. In this presentation, Dr. Amiot showed
involves the transcription factor NF- B and is
that the prevention of apoptosis in MM cells is
also associated with signaling through the c-Jun
also triggered by the inactivation of Bim, (also
NH (2)-terminal kinase (JNK) pathway. Previous
Bcl-3 homology region [BH3]-only molecule),
studies indicated that activation of NF- B and JNK
a molecule that can activate apoptosis in normal
requires TRAF-6. Accordingly, the data of Dr. Chen
cells. In healthy cells, Bim is bound to the
showed that silencing TRAF-6 mRNA with siRNA
microtubuli that are associated with dyneins. These
reduces the expression of NF- B and reduces JNK
dyneins are "molecular motors" that regulate the
signaling. Dr. Chen concluded that TRAF-6 may
position of microtubuli in the cellular skeleton.
be an excellent target to block MM cell signaling
When Bim is bound to the microtubuli-dynein
important for the survival and proliferation of the
complex, it is sequestered from Bcl-2, a factor
tumor cells.
that has antiapoptotic activity. Certain apoptotic
signals release Bim and allow it to translocate to
References
intracellular membranes, where it interacts with
Bcl-2­favoring apoptosis. Dr. Amiot demonstrated
1.
Van Camp B, Vanderkerken K, Van Riet
that in MM cells, the proapoptotic function of
I. Bone marrow homing of multiple
Bim is neutralized through endogenous Mcl-1/Bim
myeloma cells [abstract]. Haematologica.
complex formation on mitochondria rather than
2005;90(suppl 1):51. Abstract F9.01.
by sequestration to the dynein. Under apoptosis
2.
Vande Broek I, Leleu X, Asosingh K, Facon
T. Clinical significance of chemokine
induction, drastic downregulation of Mcl-1 leads to
receptor expression in human multiple
Bim release, which, in turn, exerts its proapoptotic
myeloma cells: a close association with
function through activation of another proapoptotic
disease activity and survival [abstract].
factor, Bax. She concluded that disruption of the
Haematologica. 2005;90(suppl 1):178.
Mcl-1/Bim interaction could be an interesting
Abstract PO.1016.
therapeutic approach.
3.
Vanderkerken K, Menu E, Wiklund-
Dr. Stephen Le Gouill8 (Dana-Farber Cancer
Jernberg H, et al. Role of insulin-like
Institute, United States) from the team of Dr.
growth factor and its receptor in the 5TMM
Kenneth Anderson (Dana-Farber Cancer Institute,
experimental mouse model [abstract].
United States) presented a poster illustrating the
Haematologica. 2005;90(suppl 1):51-52.
important role of Mcl-1 in protection of MM cells
Abstract F9.02.
against apoptosis. The team in Boston also showed
4.
Lichtenstein A, Shi Y, Frost P, et al. AKT
that VEGF upregulates Mcl-1 in MM cells and
in myeloma: therapeutic implications
[abstract]. Haematologica. 2005;90(suppl
that this upregulation could be prevented by a pan-
1):52-53. Abstract F9.03.
VEGF inhibitor (GW654652).
5.
Descamps G, Pellat-Deceunynck C, Bataille
R, Amiot M. Akt signaling is dependent
Dr. Haiming Chen9 (Institute for Myeloma and
on CD45 expression in myeloma cells
Bone Cancer Research, United States) presented
[abstract]. Haematologica. 2005;90(suppl
data that illustrate the potential of tumor necrosis
1):172. Abstract PO.1001.
factor receptor-associated factor 6 (TRAF-6) as
6.
Bahlis N, Miro Y, Koc ON, Gerson SL.
a target molecule to inhibit proliferation and
PKC inhibition suppresses PI3K AKT
to stimulate apoptosis in MM cells. His group
signaling in myeloma cells [abstract].
targeted TRAF-6 by a specific small interfering
Haematologica. 2005;90(suppl 1):172.
RNA (siRNA), which is an RNA molecule that
Poster PO.1002.
interferes with the expression of the TRAF-6 gene.
Cell-cycle progression and proliferation in MM
63
7.
Gomez-Bougie P, Clément M, Bataille
R, Amiot M. In myeloma cells, Bim
pro-apoptotic function is neutralized
through endogenous Mcl-1/Bim complex
formation on mitochondria rather than
by sequestration to the dynein [abstract].
Haematologica. 2005;90(suppl 1):53.
Abstract F9.04.
8.
Le Gouill S, Podar K, Amiot M, et
al. Vascular endothelial growth factor
upregulates Mcl-1 expression and protects
multiple myeloma cells against starvation
induced-apoptosis [abstract]. Haematologica.
2005;90(suppl 1):179-180. Abstract
PO.1020.
9.
Chen H, Campbell RA, Zhu D, et al.
Inhibition of multiple myeloma cell
proliferation and increase of apoptosis
through regulation of the NF-KB and
JNK pathways by silencing TRAF6 C-
domain mRNA [abstract]. Haematologica.
2005;90(suppl 1):53. Abstract F9.05.
Post-test Questions
39.
Adhesion molecules, chemokine receptors,
and metalloproteinases are absent on MM
cells.
True
False
40.
The presence of IGG-1 receptor on plasma
cells is a poor prognostic feature.
True
False
41.
Akt activation is present in MGUS as well as
in active MM.
True
False
64
Plenary Session 11:
The first speaker in the session was Dr. Dhodapkar.
His laboratory has been studying tumor-reactive
Immune Biology
immune effector cells in the blood and tumor bed
of patients with MGUS and MM. One of the
Madhav Dhodapkar
advantages of the MM model is that both tumor
The Rockefeller University
and immune cells can be readily isolated from the
tumor bed, without the need for in vitro culture
New York, New York, USA
or enzyme treatments. Freshly isolated T cells
from blood or tumor bed of patients with newly
Summary
diagnosed progressive MM lack tumor-reactive
Growth and survival of tumor cells in multiple
rapid effector function, as measured using an
myeloma (MM) are affected by the cells in the bone
interferon-g ELISPOT assay.4 Targeting tumor
marrow microenvironment, including the immune
antigens to Fcg receptors of dendritic cells (DCs)
system. Improved understanding of this interaction
leads to enhancement of cross presentation and
is therefore critical to understand the pathogenesis
the generation of tumor-reactive effector T cells.5
of MM. The immunobiology session featured 5
Using this approach, T cells from the tumor bed
speakers who emphasized this theme.
of even patients with progressive tumors can be
activated to yield tumor-reactive killer T cells.4
Antitumor reactivity in these cultures was specific
Clonal expansion of a transformed cell is essential
for autologous tumor and mostly not directed
but not sufficient for the development of clinical
against Ig-derived determinants. In contrast to
cancer.1 This is particularly puzzling in the case
MM, when patients with MGUS were studied,
of monoclonal gammopathies because many of
the presence of tumor-specific interferon-g­
the cytogenetic and genomic changes initially
producing T cells could be demonstrated in the
described in MM have now also been detected
tumor bed in direct assays, without the need for
in premalignant monoclonal gammopathy of
ex vivo expansion.6 This response is enriched in
undetermined significance (MGUS), suggesting
the marrow and is again specific for the antigens
that MGUS is a genetically advanced lesion.2 As
expressed by tumor cells in each patient. Natural
MGUS is observed in up to 1% to 3% of elderly
killer T (NKT) cells are distinct lymphocytes that
persons, why is MM relatively uncommon, with
recognize glycolipid antigens in the context of
only 13,000 new cases per year in the United States?
the CD1 family of antigen-presenting molecules.
The immune system has been postulated to play
Analysis of effector function of these cells also
a role in surveillance of tumors in mice. In recent
indicates that the defects in or loss of NKT
years, several pieces of evidence have emerged
function is frequent in patients with progressive
to provide support to this concept.3 The role of
MM.7 However, this can be reliably restored ex
immune effectors in the control of transformed
vivo using DCs pulsed with an NKT ligand, a-
cells in patients with gammopathies remains to be
galactosyl-ceramide (a-GalCer). Preliminary results
fully defined. Improved understanding of these
from a clinical trial testing the injection of mature
interactions will undoubtedly provide newer
DCs loaded with a-GalCer demonstrate sustained
insights into the development of novel immune-
expansion of NKT cells in vivo, lasting more than
based approaches to prevent or treat MM. Some of
6 months in patients with advanced cancer.8 In
these studies were the focus of presentations at the
summary, these data point to the changes in both
immunobiology session at the 10th International
innate and adaptive arms of the immune system in
Myeloma Workshop.
the progression from MGUS to MM and suggest
that harnessing both arms of the immune system
would be needed for protective immunity.
65
Dr. Bjarne Bogen (University of Oslo, Norway)
antibodies and have identified and characterized
has been studying the development of protective
at least 5 distinct populations. His group has also
immunity to plasmacytomas in mice. The model
developed methods to isolate DCs from the blood
system used is the pristane oil-induced MOPC-
of patients with MM that can be loaded with tumor
315 plasmacytoma in BALB/c mice. His group
antigen of interest, for vaccination. Preclinical data
has previously shown that immunization with
demonstrate the feasibility of obtaining clinical
tumor-derived idiotype can mediate protection
grade DCs, which can be loaded with model
against tumor challenge in these mice.9-10 More
antigens in the laboratory and can be used to
recent studies have focused on understanding the
generate T-cell immunity in culture. These data
mechanism of protection mediated by antitumor
have therefore set the stage for clinical trials, using
CD4+ T cells.11 This has been somewhat puzzling,
this approach in patients with MM. He noted that
as MM tumor cells are major histocompatibility
some of the challenges in this area remain, such as
complex II (MHC II) negative. To study this,
which antigens to target, which patient populations
they injected plasmacytoma cells in matrigel plugs
to study, and what end points to use for monitoring
in these mice. Within 3 days, tumor cells were
efficacy. Dr. Hart has also developed novel mouse
surrounded by macrophages that captured tumor
models to study biology of human DCs in mice,
antigens. By 6 days, naďve tumor-specific CD4+ T
which would be helpful in addressing some of these
cells were activated in the draining lymph nodes
questions. Improved understanding of the biology
that migrated to tumor site. Upon recognition of
of DCs and optimizing their immunogenicity may
the tumor-derived peptides presented on MHC II
be the key to bringing this approach to the clinic.13
of the macrophages, CD4+ T cells were activated
and started to secrete cytokines such as interferon-
Dr. Massimo Massaia (Universitá di Torino, Italy)
g. These locally activated macrophages were then
discussed the recent work from his laboratory
responsible for inhibition of tumor growth. These
on phenotypic and functional properties of gd T
data therefore provide an elegant model to help
cells in MM. A growing body of evidence points
understand the mechanism of CD4+ T-cell­
to the importance of gd T cells in defense against
mediated inhibition of tumor cell growth, even in
pathogens and immune surveillance against
the setting when the tumor cells do not express the
tumors.14 These "innate" lymphocytes recognize
restricting MHC II molecule recognized by these
phosphoantigens such as isopentenyl pyrophosphate
cells. In more recent studies, Dr. Bogen's group has
(IPP) generated during the mevalonate pathway
now begun to modify the model and has developed
of cholesterol biosynthesis15 as well as MHC-like
a subline of the tumor that is capable of growth in
ligands induced by cellular stress on tumor cells (eg,
the marrow, which is closer to the situation in MM.
MIC-A or MIC-B). A subset of gd T cells, Vg9/Vd2
T cells can be activated and expanded in culture
Dr. Derek Hart (Mater Medical Research Institute,
by aminobisphosphonates such as zoledronic acid,
Australia) described the efforts by his group to
owing to the similarities of this molecule to IPP.
develop DC-mediated therapy in MM. DCs are
This particular group is of particular interest in MM
specialized antigen-presenting cells (APCs) that are
because these agents are routinely used to treat bone
central to initiation and regulation of immunity in
disease in MM. Dr. Massaia's group has observed
vivo. Dr. Hart's group has pioneered the study of
skewed distribution of naďve/memory subsets in gd
circulating DCs in human blood and has developed
T cells in about half the patients with MM. They
reliable methods to quantify these cells in blood
have also observed a defect in the ability of gd cells
and tissues of patients.12 They have now begun to
from these patients to expand in vitro in response
dissect the phenotypic and functional heterogeneity
to antigenic stimulation.15 The clinical significance
of the DC population in the blood using specific
of this is under investigation. Immunosensitivity
66
of MM cells to gd T cells is enhanced by
3.
Dunn GP, Bruce AT, Ikeda H, Old LJ,
aminobisphosphonates such as zoledronic acid,
Schreiber RD. Cancer immunoediting: from
which is mediated via the mevalonate pathway. This
immunosurveillance to tumor escape. Nat
distinct set of innate lymphocytes may be attractive
Immunol. 2002;3(11):991-998.
targets for immune-mediated intervention in MM
4.
Dhodapkar MV, Krasovsky J, Olson K. T
and other cancers.
cells from the tumor microenvironment
of patients with progressive myeloma can
Dr. Reiner Raymakers (University Medical Center
generate strong, tumor-specific cytolytic
Radboud, The Netherlands) discussed the role of
responses to autologous, tumor-loaded
DC genotype in the induction of T-cell responses
dendritic cells. Proc Natl Acad Sci U S A.
after allogeneic stem-cell transplantation. Several
2002;99(20):13009-13013.
groups have now shown that, in the setting of
5.
Dhodapkar KM, Krasovsky J, Williamson
allogeneic stem-cell transplantation, infusions
B, Dhodapkar MV. Antitumor monoclonal
of donor lymphocytes can be effective if given
antibodies enhance cross-presentation of
relatively early after transplant.16 This approach can
cellular antigens and the generation of
lead to enhancement of minor histocompatibility
myeloma-specific killer T cells by dendritic
antigen-specific T cells in the blood in vivo in
cells. J Exp Med. 2002;195(1):125-133.
patients with leukemia.17 However, the clinical
6.
Dhodapkar MV, Krasovsky J, Osman K,
efficacy of donor lymphocyte infusion (DLI) in
Geller MD. Vigorous premalignancy-
the setting of disease relapse in MM, relative to
specific effector T cell response in
chronic myelogenous leukemia (CML) is limited.
the bone marrow of patients with
Raymakers and colleagues hypothesized that host
monoclonal gammopathy. J Exp Med.
APCs are critical for effective graft-versus-tumor
2003;198(11):1753-1757.
(GVT) effect, analogous to their role in graft-versus-
7.
Dhodapkar MV, Geller MD, Chang DH,
host disease (GVHD).18 Data from mouse models
et al. A reversible defect in natural killer T
suggest that donor APCs help mediate maximal
cell function characterizes the progression
GVHD but are not required for GVT effect.19 To
of premalignant to malignant multiple
test these concepts, they are conducting a clinical
myeloma. J Exp Med. 2003;197(12):1667-
trial of injection of recipient DCs, along with DLI,
1676.
in patients with persistent MM after allogeneic
8.
Chang DH, Osman K, Connolly J, et al.
stem-cell transplantation following reduced-
Sustained expansion of NKT cells and
intensity conditioning. Current data show that
antigen-specific T cells after injection
functional DCs can be successfully generated from
of -galactosyl-ceramide loaded mature
blood mononuclear cells frozen before allogeneic
dendritic cells in cancer patients. J Exp Med.
stem-cell transplantation. Restoration of recipient
2005;201(9):1503-1517.
DC function may be an interesting approach to
9.
Bogen B. A mouse model for
enhance the efficacy of DLI in MM.
immunotherapy of myeloma. Hematol J.
2002;3(5):224-229.
References
10.
Bogen B, Malissen B, Haas W. Idiotope-
specific T cell clones that recognize
1.
Bissell MJ, Radisky D. Putting tumours in
syngeneic immunoglobulin fragments in the
context. Nat Rev Cancer. 2001(1):46-54.
context of class II molecules. Eur J Immunol.
2.
Fonseca R, Bailey RJ, Ahmann GJ, et al.
1986;16(11):1373-1378.
Genomic abnormalities in monoclonal
11.
Corthay A, Skovseth DK, Lundin KU, et
gammopathy of undetermined significance.
al. Primary antitumor immune response
Blood. 2002;100(4):1417-1424.
mediated by CD4+ T cells. Immunity.
2005;22(3):371-383.
67
12.
Vuckovic S, Gardiner D, Field K, et al.
Post-test Questions
Monitoring dendritic cells in clinical
practice using a new whole blood single-
42.
T cells from patients with MM can be
platform TruCOUNT assay. J Immunol
activated to show specific antitumor
Methods. 2004;284(1-2):73-87.
reactivity.
13.
Hart DN. Dendritic cell biology
True
False
evolves into clinical application. Lancet.
2005;365:102-104.
43.
Dendritic cells do not circulate in the
14.
Kunzmann V, Bauer E, Feurle J, Weissinger
peripheral blood of patients with MM.
F, Tony HP, Wilhelm M. Stimulation of
True
False
T cells by aminobisphosphonates and
induction of antiplasma cell activity in
44.
Gamma delta T cells have a normal
multiple myeloma. Blood. 2000;96(2):384-
distribution in MM.
392.
True
False
15.
Mariani S, Muraro M, Pantaleoni F,
et al. Effector
T cells and tumor
cells as immune targets of zoledronic
acid in multiple myeloma. Leukemia.
2005;19(4):664-670.
16.
Lokhorst HM, Schattenberg A, Cornelissen
JJ, et al. Donor lymphocyte infusions for
relapsed multiple myeloma after allogeneic
stem-cell transplantation: predictive factors
for response and long-term outcome. J Clin
Oncol. 2000;18(16):3031-3037.
17.
Marijt WA, Heemskerk MH, Kloosterboer
FM, et al. Hematopoiesis-restricted minor
histocompatibility antigens HA-1- or HA-
2-specific T cells can induce complete
remissions of relapsed leukemia. Proc Natl
Acad Sci U S A. 2003;100(5):2742-2747.
18.
Shlomchik WD, Couzens MS, Tang CB, et
al. Prevention of graft versus host disease by
inactivation of host antigen-presenting cells.
Science. 1999;285:412-415.
19.
Matte CC, Liu J, Cormier J, et al. Donor
APCs are required for maximal GVHD but
not for GVL. Nat Med. 2004;10(9):987-
992.
68
Plenary Session 12:
nodes. Studies showed that T cells did survive the
high-dose therapy portion of the treatment regimen.
Immunotherapy
Clinical outcomes are promising with 1 patient in
complete remission thus far and 5 patients recruited.
Kathleen Boyle
These studies show that it is feasible to combine DC
Institute for Continuing
vaccine with high-dose therapy and that specific T
Healthcare Education
cells survive and expand upon vaccination.
Philadelphia, Pennsylvania, USA
Dr. Michael Bishop3 (National Cancer Institute,
United States) presented preliminary results of a
Dr. Derek Hart1 (Mater Medical Research Institute,
trial looking at tumor antigen immunization of
Australia) gave an overview of cancer vaccines and
human allotransplant donors in MM. Progression
their important implications for multiple myeloma
and relapse are significant problems with reduced-
(MM). The goal of vaccine therapy is to enhance
intensity allogeneic stem-cell transplantation
antitumor immunity so that tumors can be cured
(RIST). The hypothesis for the studies was
by immunotherapy. In MM, the immune system
that vaccination in donors with patient-specific
is failing on multiple fronts (DC T, NK, NKT
idiotype would result in improved remissions.
cells), and so regulatory cells can be considered
The objective of the trial was to induce cellular
as problems or as targets for therapy. Dendritic
and humoral immunity in allogeneic donors and
cell (DC) vaccination is developing as a possible
recipients against the unique idiotype expressed
option for immunotherapy; DCs are harvested
by the recipient MM. Results of the trials showed
from patients, modified, and then administered
that the vaccine was successfully generated from
to patients as the vaccine. Such vaccines may be
10 patients. The study included 7 matched siblings
effective with clinical outcomes correlating with
who completed vaccination. In terms of safety
cytotoxic responses.
findings, there was a single grade 3 toxicity observed
(lymphopenia that was transient after vaccination).
Dr. Qing Yi2 (University of Arkansas for Medical
Other safety findings included grade 1 and 2
Sciences, United States) spoke about tumor
toxicities, including reactions at the injection site
lysate DC vaccination in patients with MM.
and systemic bone pain.
DC-mediated cross priming is a key step in priming
of CD4, CD8, NKT, and NK cells. Previous DC
Dr. Freda Stevenson4 (Southampton University
vaccination studies were initiated in MM 20 years
Hospitals Trust, United Kingdom) presented
ago. Less than 50% of patients mounted responses
data about DNA vaccination against MM
to the antigen in these studies. These data suggested
postautologous or postallogeneic transplantation.
that a better target may be MM tumor cells;
Tumor cells have cell-surface glycoproteins, secreted
these cells could be used to identify antigen to be
and shed antigens, and MHC class I associated
targeted. Studies demonstrated that MM-specific
peptides, all which may be targets for immune
cytotoxic T-lymphocytes (CTLs) were able to kill
therapy. For DNA vaccines, there are 2 options
MM tumor cells but not normal cells, suggesting
to consider: to overcome tolerance issues or to
that the T cells recognized specific antigens on
vaccinate a donor who is immunocompetent. To
the cells. Lysate DC vaccine studies were used in
improve uptake (transfection) of the DNA vaccines,
patients with advanced disease, as those patients
electroporation of the vaccine into muscle tissue
would have sufficient cells to produce the lysate and
was tested in a mouse model. Issues to be resolved
the vaccine. The lysate DC vaccine was injected
include determining the immune status of patients
intranodally and led to an enlargement of liver
with MM, the clinical setting in which DNA
69
vaccines should be used, and whether patients
5.
Munshi NC. Dendritic cell based
with MM can respond to conventional (microbial)
vaccination and beyond [abstract].
vaccines. Preliminary results show that patients
Haematologica. 2005;90(suppl 1):66.
with MM can mount an immune response to
Abstract PL12.05.
conventional vaccines 1 year after transplant, so this
was considered a reasonable time to administer the
DNA vaccine.
Post-test Questions
Dr. Nikhil Munshi5 (Dana-Farber Cancer Institute,
45.
Dendritic cell function is normal in MM.
United States) closed the session with a review
True
False
of various strategies to load antigens onto DCs.
His laboratory has fused DCs and MM cells so
46.
In MM, there is a well-defined tumor
that the resulting cell would present for antigen
antigen in addition to the idiotype.
True
False
development. Notably, the fused DC/MM cells
are highly viable and functional in terms of ability
47.
Dendritic cell­plasma cell hybrids can
to stimulate T-cell proliferation. In a clinical
stimulate a cytotoxic T-cell response.
study, 6 patients were treated with fused DC/MM
True
False
cells, and an immune response was observed.
As no serious adverse events were observed, the
study is continuing with dose escalation. With
only preliminary data available, clinical efficacy
is unknown. Dr. Munshi suggested that novel
antigens should be identified, and studies need
to be conducted to arrive at an understanding of
immune dysregulation in MM. Use of immune-
modulating agents may allow immune responses to
be augmented while avoiding immunosuppression.
References
1.
Mellstedt H. Active specific immunotherapy
in multiple myeloma: an overview [abstract].
Haematologica. 2005;90(suppl 1):63.
Abstract PL12.01.
2.
Yi Q, van Rhee F. Tumor lysate dendritic
cell vaccination in multiple myeloma
[abstract]. Haematologica. 2005;90(suppl
1):63-64. Abstract PL12.02.
3.
Kwak LW. Tumor antigen immunization of
human allotransplant donors in myeloma
[abstract]. Haematologica. 2005;90(suppl
1):64-65. Abstract PL12.03.
4.
Rice J, Buchan SL, Sahota SS, et al.
DNA vaccination against myeloma post
autologous or allogeneic transplantation
[abstract]. Haematologica. 2005;90(suppl
1):65. Abstract PL12.04.
70
Focus Session 12:
cells from the normal bone marrow (BM) stroma
cells for their survival and proliferation. Interleukin-
Drug Resistance:
6 (IL-6) and insulin-like growth factor-1 (IGF-
1)­mediated paracrine growth stimulation of MM
Mechanisms and
cells in the BM microenvironment are a major
mechanism for survival and a major determinant to
Therapeutic Strategies
overcome drug-induced cell kill. Experiments from
several laboratories have indicated that effective cell
Pieter Sonneveld
killing by conventional agents, such as doxorubicin
Erasmus Medical Center
and melphalan, in the absence of normal stroma
Rotterdam, The Netherlands
cells may be completely abolished if such cells are
added to the MM cells. Three intracellular signaling
In multiple myeloma (MM), acquired or de
pathways have been identified that mediate IL-6
novo multidrug resistance (MDR) prohibits the
and possibly IGF-1­induced cell stimulation
ultimate cure of the disease. Acquired MDR
(Fig. 1, pg.74). The PI3-kinase/Akt pathway
(aMDR) is generally conferred by a selection of
involves NF- B, and m-TOR induces cell-
cells that are capable of overcoming the injury
cycle activation and prohibits apoptosis. The
of cytotoxic treatment. In his introduction, Dr.
JAK/STAT pathway involves Bcl-xL and Mcl-1,
Sonneveld1 gave an overview of intercellular
preventing apoptosis and increasing survival. The
and intracellular mechanisms that are involved
Ras/MEK/ERK pathway primarily stimulates
in intrinsic or acquired drug resistance in MM.
cell proliferation and may be activated through
Examples of the mechanisms that are involved
adhesion molecules such as LFA-1 and ICAM.
in classical aMDR are reduced intracellular drug
Activation of these pathways through signaling
accumulation by increased expression of ABC
from the BM microenvironment by IL-6, IGF-1,
transporter proteins such as P-glycoprotein (Pgp),
vascular endothelial growth factor (VEGF), and
breast cancer resistance protein (BCRP), or the
other cytokines may induce cell proliferation and
MDR-associated protein (MRP ); increased drug
inhibit apoptosis and, in this way, protect the
1-7
detoxification by glutathione-S-transferases (GSTs)
MM cell from drug-induced cytotoxicity. Another
that catalyze the conjugation of glutathione (GSH)
important reason why MM cells may be refractory
to many chemotherapeutics; and alterations in drug
to conventional chemotherapy is that they induce
targets such as topo-isomerases II /II or altered
apoptosis through activation of caspase-8, with
expression or point mutations in the hormone
the exception of dexamethasone, which acts
binding domain of the glucocorticoid complex. To
through caspase-9 and can be counteracted by IL-6
some extent, expression of antiapoptotic proteins,
stimulation.
such as Bcl-2 or Mcl-1, has been shown to modify
the drug response in MM cell lines, and these may
Recently, several new anti-MM drugs have become
represent targets for drug therapy and to overcome
available that have unique and complementary
drug resistance. Pharmacologic approaches to
mechanisms of action. Thalidomide is the first-of-
circumvent classical aMDR, for example by
class agent with several characteristics that interfere
blocking Pgp-mediated drug efflux, have not been
with MM growth. It may disrupt the interaction
successful so far.
of MM cells with the BM microenvironment
by inhibiting angiogenesis and downregulating
Recently, increasing evidence has been obtained
adhesion molecules, and it disrupts the IL-
about the important role of de novo MDR, which
6­mediated pathways. Lenalidomide is a second-
has provided insight into the dependence of MM
generation immunomodulatory drug (iMiD), which
71
lacks the teratogenic effects of thalidomide and
In the session on drug resistance, Dr. Laurence
has direct anti-MM activity. Bortezomib is a newly
Catley2 (Dana-Farber Cancer Institute, United
developed proteasome inhibitor that downregulates
States) discussed his data and data from Dr.
NF- B and restores I- B. Bortezomib appears to
Dharminder Chauhan2 (Dana-Farber Cancer
overcome intrinsic drug resistance in patients with
Institute, United States) on the antiapoptotic
deletion of chromosome 13.
signaling pathways in MM and how these may be
targeted for new therapeutic concepts. Again, he
We have investigated arsenic trioxide (As O ),
emphasized the relevance of different intracellular
2
3
which has antitumor activity and induces apoptosis
apoptosis activation pathways through caspase-8
in association with downregulation of Bcl-2. In
and caspase-9, respectively (Fig. 2, pg.75).
addition, multiple other effects have been observed,
including inhibition of NF- B and VEGF. The in
Bortezomib reduces I- B degradation in
vitro effects in MM include inhibition of STAT3
proteasomes by binding to the 26S subunit,
activation and JAK/STAT signaling. As O decreases
and it activates apoptosis through the intrinsic
2
3
MM cell adhesion to the BM microenvironment
and extrinsic death pathways. Next-generation
and sensitizes chemoresistant cells to chemotherapy.
proteasome inhibitors, such as NPI 0052, may be
active in bortezomib-refractory cells. Hence, these
Although these new agents have demonstrated
inhibitors, as well as the Heat Shock Protein 27
significant activity in relapsed/refractory MM, their
inhibition, may overcome resistance to bortezomib.
intracellular targets and the potential mechanisms
He discussed several other approaches to improve
of drug resistance are largely unknown. However,
bortezomib-induced cytotoxicity including the
they clearly interfere with de novo MDR through
use of a p38 MAPK inhibitor, inhibition of a
interaction with the intracellular signaling pathways
mitochondrial benzodiazepine receptor, and use
and/or with DNA methylation and/or acetylation.
of the active irinotecan metabolite SN-38. He
Several research groups have recently started to use
concluded that improved knowledge of cellular
new high throughput analysis techniques to analyze
processes that are involved in cell death may help to
the complex effects of these new agents. In addition
design more effective drug-combination regimens.
to gene-expression profiling in cell lines and fresh
patient samples, an alternative approach focuses on
Dr. Steven Le Gouill3 (Dana-Farber Cancer
the status of intracellular signaling activation by
Institute, United States) discussed the role of
using a peptide phosphorylation array on which the
the antiapoptotic protein Mcl-1. This protein is
major intracellular signaling kinases are spotted. In
involved in post-translational regulation of caspase-
this approach, the downstream effectors of these
3 activation and normally plays an important role
pathways, and how they are expressed following
in cell survival in lymphoma and MM. Bortezomib,
therapeutic intervention, are investigated. The
but not doxorubicin or melphalan, triggers Mcl-
results show that effects of bortezomib and other
1 cleavage before PARP cleavage, indicating that
new agents are complex and affect many different
presence of Mcl-1 is required for proper activation
targets. Although this makes it difficult to fully
of apoptosis by bortezomib.
comprehend their action, it also illustrates the
potential of the MM cell to overcome targeted
Dr. Suzanne Lentzsch4 (University of Pittsburgh,
therapy. By analyzing the different antiapoptotic
United States) has studied the potential mechanisms
and survival pathways with each drug, the potential
of drug resistance toward thalidomide and its iMiDs
targets for rational and effective drug combinations
CC-4047 and CC-5013. She used gene array
can be determined, and this opens the door for
studies to identify genes that regulate the sensitivity
overcoming primary or acquired drug resistance.
or resistance to CC-4047, and she found that the
72
CAAT/enhancer-binding protein
(C/EBP ) is
Post-test Questions
downregulated in cell lines that are sensitive to CC-
4047. Even in the presence of IL-1 , which induces
48.
Pharmacologic methods that block P
C/EBP gene expression, the protein remains down
glycoprotein drug efflux successfully
regulated and still renders the cells sensitive to CC-
overcome drug resistance.
4047. These data can be used to further elucidate
True
False
the role of C/EBP overexpression as a means of
49.
IL-6 and IGF-1 mediated paracrine growth
resistance to iMiDs.
stimulation of MM cells can overcome drug-
induced cell death.
In conclusion, these selected abstracts illustrate
True
False
that MM cells may become resistant to 1 or several
anticancer agents through a variety of mechanisms
50.
The JAK/STAT pathway prevents apoptosis
including cell­cell interactions, stimulation, and
and increases survival.
activation of intracellular survival pathways and
True
False
multiple genetic and molecular transformations.
For a proper understanding of these mechanisms,
studies in MM cell lines and fresh patient samples
are needed. Identification of new cellular targets
will be the basis for the development of new agents
that are capable of overcoming drug resistance to
conventional agents. These studies will lead to more
rationally designed drug- administration programs
that may result in better disease control.
References
1.
Sonneveld P. Drug resistance in multiple
myeloma [abstract]. Haematologica.
2005;90(suppl 1):66-67. Abstract F12.01.
2.
Chauhan D, Anderson KC. Anti-
apoptotic signaling in multiple myeloma
cells: therapeutic implications [abstract].
Haematologica. 2005;90(suppl 1):67.
Abstract F12.02.
3.
Le Gouill S, Podar K, Zorn E, et al. Mcl-1 is
triggered by bortezomib and its lack confers
resistance to bortezomib and melphalan but
not doxorubicin [abstract]. Haematologica.
2005;90(suppl 1):68. Abstract F12.05.
4.
Janz M, Bargou R, Mapara MY, Stirling D,
Roodman D, Lentzsch S. Mechanisms of
drug resistance towards thalidomide and its
immunomodulatory derivatives in multiple
myeloma cells: role of C/EBPb [abstract].
Haematologica. 2005;90(suppl 1):67-68.
Abstract F12.04.
73
Figure 1. Intracellular signaling pathways in MM.
Role of cytokines and potential targets for inhibition
of cell proliferation and survival. (P. Sonneveld)
74
Thal/IMiDs
PS-341
As2O3
FAS/FASL, TRIAL
Dexamethasone
IL - 6
Caspase - 8
Caspase - 9
IGF1
Conventional
Chemotherapy
Caspase - 3
Ionizing
Radiation
PARP Cleavage
Apoptosis
Figure 2. Activation pathways of apoptosis in MM
by conventional agents and novel targeted agents. L.
Catley, from Hideshima T, Anderson KC. Nat Rev
Cancer. 2002;2(12):927-937.
75
A Comprehensive Guide to Sydney 2005: A Review of the 10th International Myeloma Workshop
Release Date: September 2005
Expiration Date: September 30, 2006
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PLENARY SESSION 1
PLENARY SESSION 6
1. True
False
28. True
False
2. True
False
29. True
False
3. True
False
30. True
False
PLENARY SESSION 2
FOCUS SESSION 6
4. True
False
31. True
False
5. True
False
32. True
False
6. True
False
33. True
False
FOCUS SESSION 2
PLENARY SESSION 7
7. True
False
34. True
False
8. True
False
35. True
False
9. True
False
36. True
False
PLENARY SESSION 3
PLENARY SESSION 9
10. True
False
37. True
False
11. True
False
38. True
False
12. True
False
FOCUS SESSION 9
13. True
False
39. True
False
FOCUS SESSION 3
40. True
False
14. True
False
41. True
False
15. True
False
PLENARY SESSION 11
16. True
False
42. True
False
PLENARY SESSIONS 4 AND 8
43. True
False
17. True
False
44. True
False
18. True
False
PLENARY SESSION 12
19. True
False
45. True
False
20. True
False
46. True
False
FOCUS SESSIONS 4 AND 8
47. True
False
21. True
False
FOCUS SESSION 12
22. True
False
48. True
False
23. True
False
49. True
False
24. True
False
50. True
False
PLENARY SESSION 5
25. True
False
26. True
False
27. True
False
77