Biological markers and treatment as prognostic factors in multiple myeloma

Multiple myeloma (MM) is an incurable disease with an increasing number of treatment options. The introduction of what are called novel drugs (bortezomib, lenalidomide and thalidomide) was an important step. These treatments have been well studied in clinical trials that involve selected patient groups and that focus on a specific treatment in a specific line of treatment. However, there is scarce information on the survival as a function of the entire treatment sequence. We wanted to clarify the effect of these treatments in a real-life setting. Furthermore, there are several well-known prognostic factors for MM, but the impact of those factors on survival in the era of novel treatment is not fully understood. In this thesis we aimed to: 1) understand in which order the treatments should be given, 2) define factors affecting prognosis, 3) increase the knowledge of cytogenetic abnormalities and their influence on prognosis and choice of treatment. In Paper I, we retrospectively analysed the outcome in high-dose treated (HDT) patients. The patients were divided according to induction therapy. 142 patients had received conventional chemotherapy with either vincristine, doxorubicin, dexamethasone (VAD) or cyclophosphamide, betamethasone (CyBet) and 94 patients had received bortezomib, cyclophosphamide, betamethasone (VCB). We found that the VCB patients had a quicker and better response than the VAD/CyBet group as well as a longer time to progression. In Paper II, we investigated 1 638 consecutive MM patients and compared their survival with that of a sex- and age-matched normal population. The use of novel agents as upfront treatment in non-HDT patients resulted in a significantly longer overall survival (OS) compared to those who received conventional chemotherapy. The OS was further improved by using novel agents in both first and second line of treatment and for these patients the OS approached the survival in the matched normal population. Paper III focused on MM patients with renal impairment at diagnosis. Previous studies have demonstrated the negative impact of renal impairment when conventional chemotherapy is used. We could confirm these findings. However, novel agents significantly improved the OS of non-HDT patients with renal impairment. Moreover, the difference in survival between those with and those without renal impairment vanished with the use of novel agents. Despite high response rates to novel treatment, approximately 20% of the patients do not respond to bortezomib therapy. In Paper IV, we demonstrated that changes associated with del(8)(p21) might be one explanation to bortezomib resistance. We found that MM cells without del(8)(p21) responded to bortezomib treatment by upregulating the pro-apoptotic TRAIL receptors, thus making the cells more sensitive to TRAIL/APO2L-mediated apoptosis. However, in cells with del(8)(p21) no upregulation was seen and the cells were largely resistant to TRAIL/APO2Lmediated apoptosis. These findings were also supported by clinical observations. To summarize, with these studies we could confirm that the survival benefits with bortezomib, lenalidomide and thalidomide that have been demonstrated in clinical trials are also seen in real life. Furthermore, we demonstrate a possible resistance mechanism to bortezomib

Deletion of chromosomal region 8p21 confers resistance to Bortezomib and is associated with upregulated Decoy trail receptor expression in patients with multiple myeloma

Loss of the chromosomal region 8p21 negatively effects survival in patients with multiple myeloma (MM) that undergo autologous stem cell transplantation (ASCT). In this study, we aimed to identify the immunological and molecular consequences of del(8)(p21) with regards to treatment response and bortezomib resistance. In patients receiving bortezomib as a single first line agent without any high-dose therapy, we have observed that patients with del(8)(p21) responded poorly to bortezomib with 50% showing no response while patients without the deletion had a response rate of 90%. In vitro analysis revealed a higher resistance to bortezomib possibly due to an altered gene expression profile caused by del(8)(p21) including genes such as TRAIL-R4, CCDC25, RHOBTB2, PTK2B, SCARA3, MYC, BCL2 and TP53. Furthermore, while bortezomib sensitized MM cells without del(8)(p21) to TRAIL/APO2L mediated apoptosis, in cells with del(8)(p21) bortezomib failed to upregulate the pro-apoptotic death receptors TRAIL-R1 and TRAIL-R2 which are located on the 8p21 region. Also expressing higher levels of the decoy death receptor TRAIL-R4, these cells were largely resistant to TRAIL/APO2L mediated apoptosis. Corroborating the clinical outcome of the patients, our data provides a potential explanation regarding the poor response of MM patients with del(8)(p21) to bortezomib treatment. Furthermore, our clinical analysis suggests that including immunomodulatory agents such as Lenalidomide in the treatment regimen may help to overcome this negative effect, providing an alternative consideration in treatment planning of MM patients with del(8)(p21)

Minimal residual disease status is the prognostic determinant following high-dose treatment for patients with multiple myeloma

Background: The presence of minimal residual disease (MRD+) following autologous stem cell transplantation (ASCT) in multiple myeloma represents a poor prognostic factor for progression-free survival (PFS) and overall survival (OS).Methods: At our department, we recommend lenalidomide maintenance for patients who are MRD+ after ASCT, while MRD-negative (MRD-) patients, after information about the national guidelines, were not advised to follow this regimen.Results: Out of the total 228 patients, 175 received ASCT following first-line induction (MRD- 92 (53%), MRD+ 83 (47%), at 2 months post-ASCT), while 53 underwent ASCT after second-line treatment (MRD- 27 (51%), MRD+ 26 (49%), at the same time point). Comparatively, MRD- patients who did not receive maintenance demonstrated better OS than MRD+ patients who received upfront ASCT and maintenance treatment (96% vs. 86%, p = 0.030, at 3 years). However, nonsignificant difference was found in PFS (76% vs. 62%, at 3 years). Furthermore, second-line ASCT, MRD- non-maintained patients exhibited significantly better PFS than MRD+ (71% vs. 27%, p &amp;gt; 0.001, at 3 years). However, OS was better but nonsignificant (96% vs. 76%, at 3 years). Fluorescence in situ hybridization (FISH) analysis was performed on 141 out of the 228 patients. Of these, 85 (60%) patients were deemed standard risk (SR), and 56 (40%) were classified as high risk (HR). In the SR cohort, MRD- patients exhibited better PFS and OS than MRD+ patients (71% vs. 59% and 100% vs. 85%, respectively). In the HR cohort, the MRD- patients showed superior PFS but similar OS compared to MRD+ patients (66% vs. 42% and 81% vs. 80%, respectively).Conclusions: Our results indicate that being MRD- is a more crucial prognostic factor for the 3-year PFS and OS than the presence of high-risk cytogenetic markers or undergoing maintenance treatment. The latter appears insufficient, particularly for MRD+ patients following ASCT in the second-line setting, suggesting that these patients may require a more intensive treatment approach.Funding Agencies|We would like to extend our gratitude to all patients and their families who participated in this study. Their willingness to contribute has been crucial for the continuation of our research. We would also like to acknowledge the invaluable work of our col</p

Population characteristics for all patients comparing those with and without renal impairment.

<p>The HDT patients are those that at some point have received high-dose treatment, irrespective of treatment line and the non-HDT those that have not. Patients classified has having received novel drugs implies that they have received this treatment in one or more treatment lines.</p><p>HDT, high-dose treated; non-HDT, non-high-dose treated; MM, multiple myeloma; novel drugs, bortezomib, lenalidomide or thalidomide; IgG, immunoglobulin G; IgA, immunoglobulin A; BJ, Bence Jones; Hb, hemoglobin; Ca, calcium; β2μ, beta-2-mikroglobulin.</p

Patients with 8p21 deletion respond poorly to bortezomib treatment.

<p>Patients diagnosed with MM and receiving bortezomib based treatment at 1^st line were selected to this study (n = 88). (<b>A)</b> left panel is the non-HDT patients that received bortezomib (Vel: Velcade®, n = 33) as 1^st line treatment and right panel is the non-HDT patients that did not respond to 1^st line bortezomib treatment or relapsed and treated with Lenalidomide based regimen as a 2^nd line treatment (n = 16). B. Left panel displays patients received high dose treatment and bortezomib as 1^st line treatment (n = 55) and right panel is the response to Lenalidomide based treatment as 2^nd line for relapse patients (n = 18). Details of the treatments are shown in materials & methods section. Chi-square test was performed to analyze results.</p

The Use of Novel Drugs Can Effectively Improve Response, Delay Relapse and Enhance Overall Survival in Multiple Myeloma Patients with Renal Impairment

<div><p>Background</p><p>Renal impairment is a common feature in multiple myeloma and is considered a poor prognostic factor.</p><p>Aim</p><p>To determine the impact of novel drugs (i.e. bortezomib, lenalidomide and thalidomide) in the treatment of myeloma patients with renal impairment. The primary endpoint was overall survival and secondary endpoints were time to next treatment and response.</p><p>Methods</p><p>The study population included all patients diagnosed with treatment-demanding multiple myeloma January 2000 to June 2011 at 15 Swedish hospitals. Renal impairment was defined as an estimated glomerular filtration rate under 60 mL/min/1.73 m².</p><p>Result</p><p>The study population consisted of 1538 patients, of which 680 had renal impairment at diagnosis. The median overall survival in patients with renal impairment was 33 months, which was significantly shorter than 52 months in patients with normal renal function (<i>P</i><0.001). Novel agents in first line improved overall survival (median 60 months) in non-high-dose treated patients with renal impairment (n = 143) as compared to those treated with conventional cytotoxic drugs (n = 411) (median 27 months) (<i>P</i><0.001). In the multivariate analysis up front treatment with bortezomib was an independent factor for better overall survival in non-high-dose treated renally impaired patients. High-dose treated renally impaired patients had significantly better median overall survival than non-high-dose ones (74 versus 26 months) and novel drugs did not significantly improve survival further in these patients. Patients with renal impairment had both a shorter median time to next treatment and a lower response rate than those with normal renal function. However, novel drugs and high dose treatment lead to a significantly longer time to next treatment and the use of novel agents significantly improved the response rate of these patients.</p><p>Conclusion</p><p>High dose treatment and novel drugs, especially bortezomib, can effectively overcome the negative impact of renal impairment in patients with multiple myeloma.</p></div

Quantitative RT-PCR analysis of gene expression in MM patients with or without del(8)(p21).

<p>TLDA cards were used to analyze mRNA levels in patients with (n = 19) and without (n = 6) del(8)(p21). For the analysis, GAPDH and ACTB genes were used as endogenous controls while RNA samples from K562 and U266 cell lines were used as calibrators. (*p<0.05, unpaired t test) (A) The mRNA level relative expression of TRAIL receptors in patients with and without the deletion. TRAIL-R1,-R2 and–R3 did not show any change while TRAIL-R4 was expressed at significantly higher levels in patients carrying the deletion. (B) Genes on or near 8p21 <b>(C)</b> other analyzed genes located elsewhere in the chromosome that show at least two-fold differential expression in MM cells with the deletion. Depicted are the gene expression levels in MM cells carrying the deletion, normalized to samples without the deletion.</p