Advances in Biology and Pathophysiology of Multiple Myeloma

1
Advances in Biology and Pathophysiology of
Multiple Myeloma

• Amer G. Rassam, MD

2
History of Multiple Myeloma

• First case, a London grocer Thomas Alexander
  McBean
• Jumped from a cave in 1844
• According to Drs. Thomas Watson and William
  MacIntyre, Mr. McBean had Mollities et
  Fragilitas Ossium
• Mr. McBean died on New Years day in 1846

3
History of Multiple Myeloma

• Urine sample presented to Henry Bence Jones
• Large amount of protein was found in the sample
• The protein has became known as Bence Jones
  Protein

4
History of Multiple Myeloma
In 1890s, Paul Unna and Ramon Cajal identified
the plasma cell as a cell type and the cause of
Multiple Myeloma
Santiago Ramon Y. Cajal 1852-1934
Paul Gerson Unna 1850-1929
5
History of Multiple Myeloma

• In 1873, Rustizky introduced the name Multiple
  Myeloma
• In 1922, Bayne-Jones and Wilson identified 2
  distinct groups of Bence Jones protein
• In 1956, Korngold and Lipari identified the
  relationship between Bence Jones protein and
  serum proteins

6
Epidemiology of Multiple Myeloma

• Prevalence (at any one time) 40000
• Incidence 14000 diagnosed each year
• Median age 65
• Median survival 33 months
• MF 5347
• 1.1 of all cancer diagnosis
• 2 of all cancer deaths

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Age Distribution in Multiple Myeloma
35
30
25
20

15
10
5
0
lt40
40-49
50-59
60-69
70-79
gt80
Age
8
Monoclonal Gammopathies Mayo clinic
Macro 3 (30)
Extramedullary 1 (8)
Other 3 (33)
SMM 4 (39)
LP 3 (37)
AL 8 (90)
MGUS 62 (659)
MM 16 (172)
9
Immunophenotype of Multiple Myeloma
Marker
Features
CD10 Subset
CD19 CD20 Rarely expressed
CD28 CD86 Occurs with progressive disease
CD34 Not expressed by malignant clone
CD38 High expression of most but not all malignant cells
CD56 (N-CAM) Absent in MGUS and PCL
CD138 Syndecan-1 is over expressed
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Normal B-cell Development
Lymph Node
Short-lived plasma cell

...
Lymphoplasmacyte (memory B Cell)
IgM
IgM
Follicle center
Lymphoblast
Somatic Hypermutation of Ig Sequences

Stimulation with Antigen
Plasmablast
Naïve B Cell
Isotype Switching
Bone Marrow
...
G, A, D, E
Long-lived plasma cell
Pre-B cell
11
Mechanisms of Disease Progression in Monoclonal
Gammopathies
Kyle RA et al. N Engl J Med. 2004 Oct
28351(18)1860-73
12
Chromosomal Abnormalities in MM
Translocations (listed in order of frequency)
14q32 with 11q13 (cyclin D, other new fibroblastic growth factors) 4p16 (FGFR3) 6p25 (Interferon regulatory factor 4) 16q23 (C-MAF transcription factor) 8q24 (C-MYC) 18q21 (BCL-2)
1q with 5, 8, 12, 14, 15, 16, 17, 19q, 21, 22
Losses 6q, 13q
Gains 3, 5, 7, 9q, 11q, 12q, 15q, 17q, 18, 19, 21, 22q
13
Chromosome 13 Deletions in MM
11
12
13
14
21
22
31
32
33
34
Shaughnessy J et al, Blood, 2000 961505
14
Pathogenesis of Multiple Myeloma
Two pathways involved in the early pathogenesis
of MGUS and MM
50 non-hyperdiploid
50 Hyperdiploid
IgH Translocations
Infrequent IgH Translocations
4p16 FGFR3 MMSET
11q13 (cyclin D1)
6p21 (cyclin D3)
Multiple trisomies of chromosomes 3, 5, 7, 9, 11,
15, 19 and 21
20q11 (mafB)
16q23 (c-maf)
Hideshima et al, Blood, August 2004, 607-618
15
Pathogenesis of Multiple Myeloma
100
90
80
70
60
Prevelance of IgH Translocations
50
40
30
20
10
0
MGUS
MM
PPCL
HMCLs
Hideshima et al, Blood, August 2004, 607-618
16
Prevalence of IgH Translocations
4p16 or 16q23

• Lower incidence with MGUS/SMM
• de novo MM
• Rapid progression of MGUS to MM
• Extremely poor prognosis

17
Translocations in MM
Primary
Secondary
c-myc
6p21
11q13
20q11
90 HMCLs
40 adv MM
15 MM
4p16
16q23
Hideshima et al, Blood, August 2004, 607-618
18
Translocation and Cyclin D (TC) Molecular
Classification of MM
Group Primary translocation Gene(s) at breakpoint D-Cyclin Ploidy Freq of TC in newly diag MM,
TC1 11q13 6p21 CCND1 CCND3 D1 D3 NH NH 15 3
TC2 None None D1 H 37
TC3 None None D2 HNH 22
TC4 4p16 FGFR3/MMSET D2 NHgtH 16
TC5 16q23 20q11 c-maf mafB D2 D2 NH NH 5 2
Bergsagel and Kuehl, Immunol Rev, 2003, 19496-104
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Cyclin D Expression in Normal and Malignant
Plasma Cells
D1Green, D2Red, D3Blue
PPC
BMPC
6p
D1
11q13
D1D2
other
maf
4p16
TC1
TC2
TC5
TC3
TC4
Tarte k. et al, Blood. 20021001113-1122.
Zhan F. et al, Blood. 2002 991745-1757
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Dysregulation of cyclin D1, D2, D3 a unifying
oncogenic event in MM

• MGUS and MM appear closer to normal PCs than to
  normal PBs
• gt30 of cells can be in S phase
• Expression level of cyclin D1, D2, D3 mRNA in MM
  and MGUS is distinctly higher than normal PCs
• Expression level of cyclin D2 mRNA is comparable
  with that expressed in normal proliferating PBs

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Dysregulation of cyclin D1, D2, D3 a unifying
oncogenic event in MM

• Cyclin D1 is not expressed in normal hemopoitic
  cells
• Cyclin D1 expressed in 40 of MM lacking a
  t(1114) translocation
• Ig translocations that dysregulate cyclin D1 or
  D3 occur in about 20 of MM tumors
• Therefore, almost all MM tumors dysregulate at
  least one of the cyclin D genes

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Progression to Plasma Cell Neoplasia
Germinal center B cell
Intramedullary Myeloma
Extramedullary Myeloma
MGUS
HMCL
11q13
6p21
NON-HYPER DIPLOID
16q23
20q11
Primary IgH tx
4p16
Other
TRISOMY
HYPER DIPLOID
3, 5, 7, 9, 11, 15, 19, 21
Hideshima et al, Blood, August 2004, 607-618
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Progression to Plasma Cell Neoplasia
Normal Plasma Cell
Intra- medulary myeloma
Extra- medullary myeloma
MGUS
IgH translocations
Deletion of 13q
Chromosomal instability
RAS mutations
Dysregulation of c-MYC
p53 mutations
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The TC Molecular Classification Predicts
Prognosis and Response to Therapies
Increased PC Labeling Index
Lack of Cyclin D1 Expression
Deletion of p53
Monosomy of chro 13/13q
Hypodiploidy
Bad prognosis
Activating Mutations of K-Ras
Monosomy of chro 17
Tumor Cells with Abnormal Karyotype
t(414) TC4
t(1416) TC5
25
The TC Molecular Classification Predicts
Prognosis and Response to Therapies
t(414) translocation (TC 4)
Shortened Survival
Standard Therapy (42)
High-dose Therapy (22)
Median OS 26 months
Median OS 33 months
Fonseca R et al, Blood. 2003 1014569-4575
Moreau et al, Blood. 2002 1001579-1583
26
The TC Molecular Classification Predicts
Prognosis and Response to Therapies
t(1416) translocation (TC 5)
Shortened Survival (worse Prognosis)
Standard Therapy (15)
Median OS 16 months
Fonseca R et al, Blood. 2003 1014569-4575
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The TC Molecular Classification Predicts
Prognosis and Response to Therapies
t(1114) translocation (TC 1)
Better Survival
Standard Therapy (53)
High-dose Therapy (26)
Median OS 50 months
Median OS 80 months
Fonseca R et al, Blood. 2003 1014569-4575
Moreau et al, Blood. 2002 1001579-1583
28
The TC Molecular Classification Predicts
Prognosis and Response to Therapies

• The TC classification may be clinically useful
  way to classify patients into groups that have
  distinct subtypes of MM (and MGUS) tumors.
• The TC classification identifies clinically
  important molecular subtypes of MM with
  different prognosis and with unique responses to
  different treatments.

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The TC Molecular Classification Predicts
Prognosis and Response to Therapies

• High dose therapy and TC1
• Microenvironment-directed
  therapy and TC2
• FGFR3 inhibitor and TC4
• maf dominant-negative and TC5

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Critical role for Cyclin D/Rb pathway in MM
TC1
TC3
TC4
TC5
TC2
11q13 CCND1
Hyperdiploid
Other
4p16
16q23 c-maf
6p21 CCND3
Cyclin D1
FGFR3
20q11 mafB
MMSET
p16
INK4a
p15
INK4b
Cyclin D1
Cyclin D2
Cyclin D3
p18
INK4c
CDK 4, 6
CDK 4, 6
CDK 4, 6
p19
INK4d
G1 Phase
S Phase
Rb
E2F
E2F
Rb
OFF
ON
31
Novel Therapeutic Strategies targeting Genetic
Abnormalities
Silencing of CDK inhibitor mRMA expression
might be reversed
Targeting Cyclin D
Targeting the genes Directly dysregulated By
translocation
HDAC Inhibitors
Desferroxamine
Targeting FGFR3 by monoclonal antibodies
DNA methyl Transferase inhibitor
Selective CDK inhibitors
Targeting FGFR3 by selective tyrosine kinase
inhibitor
32
Interaction of MM cells and their BM milieu
GSK-3ß FKHR Caspase-9 NF-KB mTOR Bad
migration
Survival Anti-apoptosis Cell cycle
PKC
Akt
TNFa TGFß VEGF IL-6
PI3-K
Bcl-xL MCL-1
Survival Anti-apoptosis
JAK/STAT3
Proliferation
MEK/ERK
Survival Anti-apoptosis Cell cycle
Bcl-xL IAP Cyclin-D
NF-KB
IL-6 VEGF IGF-1 SDF-1a
MEK/ERK
Proliferation Anti-apoptosis
p27Kip1
MM
ERK
Smad2
NF-KB
Adhesion molecules
LFA-1
ICAM-1
NF-KB
BMSC
MUC-1
VCAM-1 Fibronectin
VLA-4
33
Myeloma Cells and BM Microenvironment
Bruno et al, The Lancet Oncology, July 2004,
430-442
34
Apoptotic Signaling Pathways
Velcade ZME-2
TNFa FasL TRAIL
ImiDs, Velcade HDAC-I, 2ME-2
Dex
JNK
Mitochondria
FADD
Bid
Smac
Cytochrome-c
IL-6 IGF-1
Caspase-9
Caspase-8
Caspase-3
PARP
Apoptosis
Hideshima et al, Blood, August 2004, 607-618
35
Novel biologically based therapies targeting MM
cells and the BM microenvironment
A
Apoptosis Growth Arrest
Novel Agents
Adhesion Molecule
B
Inhibition of Adhesion
Proliferation
C
bFGF VEGF
Inhibition of Cytokines
IL-6 IGF-1 VEGF SDF-1a
D
Angiogenesis
Drug Resistance
36
Novel Agents for Myeloma

• Targeting both MM cells and interaction of MM
  cells with the BM microenvironment
• Targeting circuits mediating MM cell growth and
  survival
• Targeting the BM microenvironment
• Targeting cell surface receptors

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Novel Agents for Myeloma
Targeting both MM cells and their interaction
with BM microenvironment
Targeting circuits mediating MM cell growth and
survival

• Thalidomide and its analogs (Revlimid)
• Proteasome inhibitor (Bortezomib)
• Arsenic trioxide
• 2-Methoxyestradiol (2-ME2)
• Lysophosphatidic acid acyltransferase-ß
  inhibitor
• Triterpinoid 2-cyano-3, 12-dioxoolean-1,
  9-dien-28- oic acid (CDDO)
• N-N-Diethl-8, 8-dipropyl-2-azaspiro 4.5
  decane-2-propanamine (Atiprimod)

• VEGF receptor tyrosine kinase inhibitor
  (PTK787/ZK222584, GW654652)
• Farnesyltransferase inhibitor
• Histone deacetylase inhibitor (SAHA, LAQ824)
• Heat shock protein-90 inhibitor
  (Geldanamycin,17-AAG)
• Telomerase inhibitor (Telomestatin)
• bcl-2 antisense oligonucleotide (Genasense)
• Inosine monophophate dehydrogenase (VX-944)
• Rapamycin

Targeting the bone marrow microenvironment
Targeting cell surface receptors

• I?B kinase (IKK) inhibitor (PS-1145)
• p38 MAPK inhibitor (VX-745, SCIO-469)
• TFG-ß inhibitor (SD-208)

• TNF related apoptosis-inducing ligand (TRAIL) /
  Apo2 ligand
• IGF-1 receptor inhibitor ( ADW)
• HMG-CoA reductase inhibitor (statins)
• Anti-CD20 antibody (Rituximab)

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Proposed Mechanism of Action of Drugs in
Targeting Myeloma Cells and BM Microenvironment
Kyle RA et al. N Engl J Med. 2004 Oct
28351(18)1860-73
39
Homoeostasis of Healthy Bone Tissue and MM Bone
Disease
Bruno et al, The Lancet Oncology, July 2004,
430-442
40
Bone Destruction
Osteoclast Precursor
Osteoclast
Bone Marrow stromal Cells
Interferon ?
MIP1
TNFa IL1ß
IL7
IL6
RANKL
Multiple Myeloma Cells
RANK
41
Effects of Thalidomide on the Myeloma
Microenvironment
Bruno et al, The Lancet Oncology, July 2004,
430-442
42
Proposed Action of Thalidomide in Myeloma
Mutiple Myeloma Cells
Modulation of Cytokines
VEGF IL6 TNFa IL1ß
Bone Marrow Stromal Cells
Direct Action
T Lymphocytes
IL2 ILN?
Modulation of Immune System
Bone Marrow Vessels
VEGF bFGF
Inhibition of Angiogenesis
Cytotoxicity of NK Cells
43
Mechanism of Action of Bortezomib

• Phosphorylation of NFKB inhibitory partner
  protein IKB leads to degradation of IKB by the
  proteosome and release of NFKB
• NFKB migrates into the nucleus to induce arrest
  of apoptosis and expression of adhesion molecule
• Affinity of Bortezomib for the proteosome
  inhibits protein degradation, and prevents
  nuclear translocation of NFKB

Bruno et al, The Lancet Oncology, July 2004,
430-442
44
Mechanism of Action of Arsenic Trioxide

• Mutated P53
• Arsenic trioxide triggers the caspase cascade by
  activation of caspases 8 and 10
• Functional P53
• The cascade is activated through the
  mitochondrial apoptotic pathway and the
  activation of caspase 9

Bruno et al, The Lancet Oncology, July 2004,
430-442
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