Therapy of multiple myeloma. Italian Multiple Myeloma Study Group.
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Antineoplastic Combined Chemotherapy Protocols↗
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Biology and treatment of multiple myeloma.
Multiple myeloma remains a fatal disease. However, in the last few months new biologic and clinical information has been provided about this disease. In particular, the immunophenotype of myeloma cells seems to indicate, at least in some patients, the possibility of a stem cell involvement in the pathogenesis of myeloma. Moreover, the recent progress in understanding the complex cytokine network has revealed the possibility that myelomatous proliferation is highly influenced by some cytokines such as interleukin-6, interleukin-3, interleukin-2, and granulocyte-macrophage colony-stimulating factor. Furthermore, it has been shown that the mechanism responsible for the resistance of myeloma cells to chemotherapy may be partially overcome by the use of calcium antagonists associated with quinine. Finally, new insights into the pathogenesis and biology of the disease have been provided by studies of molecular biology and flow cytometry undertaken in multiple myeloma patients. The best conventional induction treatment remains to be defined. However, the increased use, as new therapeutic modalities, of interferon-alpha and transplantation procedures in multiple myeloma opens new hopes of a cure. In the future, a better comprehension of the multiple myeloma biology associated with a wider use of new and more effective therapeutic approaches will certainly improve the natural course of the disease.
Bone Marrow Transplantation↗
[Recent biological and therapeutic advances in multiple myeloma].
Multiple myeloma still remains a fatal disease. However, in the last months new biological and clinical informations have been provided about this disease. In particular, the immunophenotype of myeloma cells seems indicate, in some patients, a clonal involvement of a stem cell in the pathogenesis of mieloma. Moreover, new biological insights concerning the cytokine network, have revealed a probable effect of some cytokines, such as IL6, IL3, IL4. Finally, new insights in the biology of multiple myeloma have been provided by studies of molecular biology and flow cytometry. As for therapy, the best conventional induction treatment still remains to be defined. In the last years, the increased use of alpha Interferon and new therapeutic modalities, such as transplantation procedures in multiple myeloma, open new hopes toward a cure of this disease. Therefore, in the future a better knowledge of the multiple myeloma biology, associated with a wider use of new effective therapeutic approaches will certainly improve the natural course of this disease.
Antineoplastic Combined Chemotherapy Protocols↗
The effect of ranitidine on cellular immunity in patients with multiple myeloma.
Multiple myeloma is characterized by an increased susceptibility to infections and to other malignancies. In a double-blind, placebo-controlled study the potential impact of immunomodulation by ranitidine was studied in 20 patients with multiple myeloma. Three patients were untreated, while 17 after previous cytotoxic therapy were in a stable phase of their disease. All were without clinical signs of infections and at that time had not been treated with other immunomodulating agents. The patients were randomized to oral ranitidine 300 mg twice a day for 21 days or placebo, and several immunological parameters related to multiple myeloma were studied. The blood monocyte chemotactic response was improved in patients treated with ranitidine, and superoxide anion production increased from 2.02 nmol/min to 3.86 nmol/min (median values), while it was unchanged in patients given placebo (2.19-2.25 nmol/min) (P less than 0.005 between groups). Among ranitidine-treated patients spontaneous NK cell activity was unchanged, while in vitro interleukin-2- and interferon-alpha-stimulated NK cell activity decreased (P less than 0.03, respectively). As production of oxygen radicals constitutes an important mechanism of monocyte killing activity against microorganisms and probably against malignant cells, it is suggested that ranitidine may be of beneficial impact in the treatment of multiple myeloma.
Adjuvants, Immunologic↗
[New aspects in the clinical course determination and therapy in multiple myeloma].
Multiple myeloma can be regarded as model disease for quantification of tumor mass, investigation of tumor cell kinetics and of tumor response to therapy. The quantification of the tumor cell number allows evaluation of prognosis and monitoring of disease as well as of therapy induced responses. Treatment of multiple myeloma is primarily based on the alkylating drugs cyclophosphamide and melphalan. In recent years other cytostatic substances, also effective in the treatment of this disorder have been introduced. However, the sensitivity determination of the individual myeloma stem cells seems to be the only possible method which possibly increases the response rate significantly. In accordance with these considerations we have, in preliminary clinical investigations, observed a good correlation between the in vitro determined cytostatic drug sensitivity and the in vivo response to therapy. Further progress in the treatment of multiple myeloma is to be expected with the introduction of interferon into the therapeutic regimen. Administration of this glycoprotein has resulted in significant reduction of tumor mass in more than half of all patients treated up to this time.
Antineoplastic Agents↗
Markers of multiple hematopoietic-cell lineages in multiple myeloma.
Multiple myeloma is considered a cancer of mature plasma cells. Recent studies, however, suggest the possible involvement of early B cells and the expression of myelomonocytic antigens by myeloma cells. Using flow cytometry, we searched for evidence of the expression of genes specific for different hematopoietic lineages by tumor cells in bone marrow aspirates from 27 patients with aneuploid multiple myeloma. In addition to features characteristic of myeloma cells, we found evidence of the frequent expression by myeloma tumor cells of the pre-B-cell antigen CALLA (common acute lymphocytic leukemia antigen) (in specimens from 58 percent of patients) and of megakaryocytic (88 percent), myelomonocytic (65 percent), and erythroid (39 percent) surface markers. The proportion of tumor cells expressing the different markers varied among patients, from 2 to 100 percent of recognizable tumor cells. We conclude that cells of multiple lineages are involved in myeloma--a finding that is consistent with the hypothesis that there is a common primary neoplastic lesion for all hematologic cancers.
Aneuploidy↗
Multiple myeloma.
Multiple myeloma (MM) originates from the malignant clonal expansion of transformed B-lymphocytes (in which c-myc and ras oncogenes are probably involved). MM cells have a hybrid phenotype (with coexpression of the markers for both early and late B-differentiation and, sometimes, of T-lymphocyte, myelomonocyte, erythroid and megakaryocyte markers), which accounts for the association between MM and myeloproliferative disorders and for cytokine production. Interleukin-6 and immunologic control mechanisms regulate proliferation and differentiation into plasma cells secreting a monoclonal component (MC). Overt MM is diagnosed 1-2 years following malignant transformation. At this time, several aneuploid clones with resistant phenotype have been selected, and a small pool of actively cycling cells produces the great bulk (over 90%) of non proliferating tumor cells. The clinical and laboratory signs of MM arise from both tumor proliferation and MC damage to organs and organ systems. Tumor proliferation is mainly responsible for bone disease (since MM cells produce cytokines that activate the osteoclasts), inhibition of hemopoiesis and the appearance of plasma cell tumors. The MC causes renal failure, neurological signs, hemorrhagic manifestations. The prognosis for multiple myeloma is probably best estimated by two parameters, serum beta-2-microglobulin and the bone marrow labeling index. Induction therapy is still based on the use of alkylating agents, melphalan and cyclophosphamide, combined with prednisone. Second line treatment consists of VAD polychemotherapy or high-dose pulsed glucocorticoids. Many investigational approaches have been proposed, but their effectiveness awaits confirmation. In the absence of a curative regimen, much effort should be dedicated to the quality of supportive care. In this respect, bisphosphonates represent a new effective tool for the control of myeloma bone disease.
Antineoplastic Agents↗
Comprehensive Analyses of SOX7 Provide Novel Insights on Its Tumor Suppressor Role and Its Target Genes with Therapeutic Implications in Multiple Myeloma.
Multiple myeloma (MM) is an incurable hematological malignancy. SOX7, located within the recurrently deleted 8p23.1 region in MM, is suggested to act as a tumor suppressor. We characterized SOX7 through genetic, epigenetic, and functional analyses in MM cell lines. SOX7 was frequently silenced due to deletion and/or promoter hypermethylation. Ectopic SOX7 expression in KMS-18 and MM.1S cell lines caused a progressive decline in SOX7-transduced cells and induced G1 cell cycle arrest and/or apoptosis. Although SOX7 re-expression did not enhance bortezomib efficacy, treatment with the pan-histone deacetylase inhibitor panobinostat induced G1 arrest, promoted apoptosis, and increased SOX7 expression in MM.1S cells. Whole-transcriptome sequencing identified G1/S progression-related Wnt/β-catenin pathway genes as major SOX7-regulated targets, while ChIP-Seq analysis revealed widespread genomic SOX7 occupancy in MM.1S. Flow cytometric analysis of permeabilized bone marrow tumor cells from newly diagnosed and relapsed MM patients demonstrated generally low SOX7 protein expression. Collectively, these results indicate that SOX7 functions as a tumor suppressor in MM, and its inactivation promotes cell cycle progression. The anti-myeloma effects of panobinostat in MM.1S cells may be partially mediated through SOX7 induction.
Multiple Myeloma↗
The epidemiology of multiple myeloma.
Multiple myeloma is a relatively rare cancer that primarily affects older individuals. In the United States, the highest rates of myeloma are found in black individuals and these rates continue to outpace the rate of myeloma in white individuals. The causes of myeloma are largely unknown. The strongest potential risk factors include radiation and agricultural exposures.
Environmental Exposure↗
Unusual presentations of multiple myeloma.
Multiple myeloma has many unusual manifestations, which may obscure the true cause and delay proper treatment. Physicians in all specialties should be alert to this possibility, since myeloma may be at the root of such diverse disorders as carpal tunnel syndrome, peripheral neuropathy, solitary lytic bone lesions, hypercalcemia, and hyperviscosity syndrome.
Adult↗
SDZ PSC-833--a novel potent in vitro chemosensitizer in multiple myeloma.
Multiple myeloma cell lines and patient tumor samples with and without the expression of the classical multidrug resistance (MDR) phenotype were investigated in vitro for drug induced cytotoxicity and modulation of drug resistance. Overall there was a good correlation in the cell lines between MDR expression, as measured by immunocytochemistry with monoclonal antibodies against P-glycoprotein 170 (Pgp), and in vitro resistance to doxorubicin (dox) and vincristin (vcr). Drug resistance in the cell line RPMI 8226 dox 40, expressing a high level of Pgp, was almost completely reversed by the novel non-immunosuppressive cyclosporin A (CsA) analog SDZ PSC-833 (PSC), while the chemosensitizers verapamil, CsA and quinine, in clinically achievable concentrations, were much less effective. In cell lines with low Pgp expression, PSC and the other chemosensitizers seem equally effective. The patient tumor samples were selected to represent different combinations of Pgp expression, drug resistance and effects of chemosensitizers. PSC and CsA appeared equally potent and resistance modulation was detected not only in Pgp positive, but also in Pgp negative tumor samples. Furthermore, in one case of a Pgp expression myeloma, chemosensitizers were without effect. These findings indicate the need to incorporate in vitro chemosensitivity assays with Pgp determination when the effects of MDR modulating chemosensitizers are to be studied in the clinic.
ATP Binding Cassette Transporter, Subfamily B, Mem↗
[Acute renal insufficiency as presentation form of multiple myeloma].
Multiple Myeloma (MM) causes a wide range of serious clinical, alterations, including acute renal failure (ARF) often present and contributing to the global mortality of this neoplasm. ARF usually occurs well after MM is diagnosed. We describe a case of ARF in a 42 years old male patient requiring urgent hemodialysis that subsequently proved to have MM. The singularity of this case lead us to review cases of ARF admitted to the Nephrology Department between 1978 and 1990. We describe 7 patients (4 male) with ARF as presenting form of MM. Their mean +/- SD age was 60.0 +/- 10.6 (range 42-73). ARF with conserved diuresis was the presenting form in 6, 5 has systemic infection, and none was hypertensive. Replacement therapy with hemodialysis was needed in 6 patients and plasmapheresis was performed in 3. 4 patients died while admitted, 2 were discharged on chronic hemodialysis and there was recovery of renal function in 1 patient.
Acute Kidney Injury↗
Micro-osteoclast resorption as a characteristic feature of B-cell malignancies other than multiple myeloma.
Multiple myeloma (MM) is characterized by the presence of lytic bone lesion and frequent hypercalcaemia. These are due to an excessive osteoclastic resorption in association with a low bone formation, as demonstrated by bone histomorphometry. Conversely, B-cell malignancies other than MM are rarely associated with lytic bone lesion and/or hypercalcaemia. In this study we have analysed quantitative bone histology in 65 patients with B-cell malignancies other than MM at diagnosis: chronic lymphocytic leukaemia (CLL, n = 20), non-Hodgkin's lymphoma (NHL, n = 25), Waldenström's disease (WD, n = 14), hairy cell leukaemia (HCL, n = 6). Fifty patients presented no clinical evidence of increased bone resorption, including no lytic bone lesions radiologically detectable and/or no hypercalcaemia. 80% of these patients (40/50) had increased bone resorption parameter using quantitative bone histology, including 19/29 (65.5%) patients with CLL or WD and 21/21 (100%) patients with NHL or HCL (P less than 0.01). As a control group, seven patients lacking bone marrow involvement on bone sample presented no excessive bone resorption. However, eight patients presented lytic bone lesions and/or hypercalcaemia. All of these patients had increased resorption parameters with high numbers of osteoclasts per surface trabecular bone (mean = 35.3), as opposed to the patients lacking lytic bone lesions and/or hypercalcaemia (mean = 6.6, n = 28) and to normal individuals (mean +/- SD = 3.8 +/- 1.7 and 6.3 +/- 2.6, respectively before and after 60 years). In all the cases, excessive histologic bone resorption was mediated by mononuclear small osteoclasts (mean osteoclast length +/- SD = 27.3 +/- 4.1 as compared to normal range = 35.0 +/- 1.0, P less than 0.001). In different in vitro models, these small mononuclear osteoclasts are considered as progenitors. These data suggest an abnormal osteoclast differentiation in B-cell malignancies other than MM, probably due to differences in the production of local factors acting on bone remodelling.
Adult↗
Multiple myeloma and multiple neoplasms.
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Aged↗
Neutrophil defect in multiple myeloma. Studies on intraneutrophilic lysozyme in multiple myeloma and malignant lymphoma.
Intracellular lysozyme concentration was measured in neutrophilic granulocytes from 25 patients with multiple myeloma. At diagnosis intraneutrophil lysozyme activity was significantly reduced (mean reduction 50%). During clinical remission after 1-4 months of intensive chemotherapy values were normalized. In 18 cases studied at various stages of the disease from 6 to 70 months after diagnosis there was a significant negative correlation between the duration of the disease and neutrophil lysozyme concentration. The decrease in neutrophil lysozyme concentration was significantly correlated to clinical disease activity and the percentage of plasma cells in bone marrow aspirates, whereas there was no correlation between the concentration of M-protein in serum and the neutrophil lysozyme concentration. Plasma lysozyme concentration was normal. In contrast, neutrophil lysozyme concentration was normal in 18 patients with stage III-IV malignant lymphoma. Plasma lysozyme in this group was significantly higher than normal. The difference in neutrophil lysozyme patterns between multiple myeloma and malignant lymphoma supports the hypothesis that the defect in neutrophil maturation seen in malignant blood disorders is directly related to the infiltration of the bone marrow by pathologic cells.
Antineoplastic Agents↗
Integrated Genomic and Epigenomic Analysis Reveals Epigenetic Plasticity in Disease Progression and Multidrug Resistance in Multiple Myeloma.
UNLABELLED: Multiple myeloma is marked by recurrent cytogenetic abnormalities and mutations that accumulate as the disease progresses. In this study, we sought to elucidate the transitions driving tumorigenesis and therapy resistance in multiple myeloma using a unique cohort of nearly 900 patients spanning premalignant to late-stage refractory multiple myeloma, comprehensively characterized at molecular and clinical levels. Waves of epigenetic dysregulation drove these critical transitions. In this paradigm, genomic and cytogenetic events unlocked epigenetic plasticity, reshaping multiple myeloma cell biology to evade tumor microenvironment constraints and therapeutic pressures. Functional perturbation studies in an isogenic proteasome inhibitor-resistant cell line model demonstrated enhanced reliance on transcriptional cofactors, supporting a mechanistic link between chromatin plasticity and therapy adaptation. Collectively, these findings support a unifying framework in which genomic heterogeneity unlocks gene regulatory plasticity, enabling plasma cells (PC) to evade microenvironmental constraints and therapeutic pressure. These results provide a mechanistic explanation for sequential relapse without new genomic alterations and nominate epigenetic plasticity-mediated PC adaptation as a therapeutic vulnerability in the heterogeneous genetic background of multiple myeloma. SIGNIFICANCE: Assembly and analysis of a multiple myeloma cohort spanning the continuum from premalignant to late relapse that integrates bulk transcriptomics with single-cell multiomic data provides insights into disease progression and epigenetic plasticity.
Multiple Myeloma↗
[Current results of chemotherapy in multiple myeloma].
Since multiple myeloma has a heterogenous character in its pathophysiology, it is clinically classified according to various kinds of factors. Therefore, in the treatment of multiple myeloma, it is important to select efficacious regimens considering the different progress or modes of the diseases as defined by both Durie and Salmon's staging systems and tumor distribution classifications. In this review, the correlation between the response to chemotherapy and survival was analyzed and demonstrated to be significant when we used new response criteria, namely the serum albumin and M-protein levels after the treatment. The new criteria should be applied to determine a prognosis and improve survival. Recently, there has been progress in treatments involving high-dose melphalan combined with autologous bone marrow transplantation for refractory or relapsed myeloma patients. This treatment is anticipated to prolong survival.
Adult↗
Evidence for the existence of circulating monoclonal B-lymphocytes in multiple myeloma patients.
Multiple myeloma is characterized by the proliferation of a single clone of plasma cells producing a homogeneous immunoglobulin fraction. In this disease, plasma cells home essentially in the bone marrow. However, controversy exists whether peripheral blood B-lymphocytes in patients with multiple myeloma (MM) are part of the malignant clone. We investigated clonal immunoglobulin gene rearrangement (IgGR) in T-cell-depleted peripheral blood mononuclear cells as well as in bone marrow of these patients. Seven out of 17 MM patients demonstrated an identical IgGR in bone marrow and peripheral mononuclear cells, these patients were in an active stage of the disease. In nine patients in plateau phase, clonal IgGR could not be detected in peripheral blood. Peripheral mononuclear cells from ten patients with monoclonal gammopathies of undetermined significance (MGUS) were also examined and no IgGR was detected. The existence of monoclonal B-lymphocytes in the circulation of patients with MM suggests a mechanism whereby the malignant clone homes in the bone marrow through peripheral blood. These findings may also be used for the evaluation of patients with active myeloma and the determination of plateau phase.
B-Lymphocytes↗