Yogesh Jethava

Four genes predict high risk of progression from smoldering to symptomatic multiple myeloma (SWOG S0120)

Multiple myeloma is preceded by an asymptomatic phase, comprising monoclonal gammopathy of uncertain significance and smoldering myeloma. Compared to the former, smoldering myeloma has a higher and non-uniform rate of progression to clinical myeloma, reflecting a subset of patients with higher risk. We evaluated the gene expression profile of smoldering myeloma plasma cells among 105 patients enrolled in a prospective observational trial at our institution, with a view to identifying a high-risk signature. Baseline clinical, bone marrow, cytogenetic and radiologic data were evaluated for their potential to predict time to therapy for symptomatic myeloma. A gene signature derived from four genes, at an optimal binary cut-point of 9.28, identified 14 patients (13%) with a 2-year therapy risk of 85.7%. Conversely, a low four-gene score (<9.28) combined with baseline monoclonal protein <3 g/dL and albumin ≥3.5 g/dL identified 61 patients with low-risk smoldering myeloma with a 5.0% chance of progression at 2 years. The top 40 probe sets showed concordance with indices of chromosome instability. These data demonstrate high discriminatory power of a gene-based assay and suggest a role for dysregulation of mitotic checkpoints in the context of genomic instability as a hallmark of high-risk smoldering myeloma.

Autologous Transplantation in Follicular Lymphoma with Early Therapy Failure: A National LymphoCare Study and Center for International Blood and Marrow Transplant Research Analysis

Patients with follicular lymphoma (FL) experiencing early therapy failure (ETF) within 2 years of frontline chemoimmunotherapy have poor overall survival (OS). We analyzed data from the Center for International Blood and Marrow Transplant Research (CIBMTR) and the National LymphoCare Study (NLCS) to determine whether autologous hematopoietic cell transplant (autoHCT) can improve outcomes in this high-risk FL subgroup. ETF was defined as failure to achieve at least partial response after frontline chemoimmunotherapy or lymphoma progression within 2 years of frontline chemoimmunotherapy. We identified 2 groups: the non-autoHCT cohort (patients from the NLCS with ETF not undergoing autoHCT) and the autoHCT cohort (CIBMTR patients with ETF undergoing autoHCT). All patients received rituximab-based chemotherapy as frontline treatment; 174 non-autoHCT patients and 175 autoHCT patients were identified and analyzed. There was no difference in 5-year OS between the 2 groups (60% versus 67%, respectively; P = .16). A planned subgroup analysis showed that patients with ETF receiving autoHCT soon after treatment failure (≤1 year of ETF; n = 123) had higher 5-year OS than those without autoHCT (73% versus 60%, P = .05). On multivariate analysis, early use of autoHCT was associated with significantly reduced mortality (hazard ratio, .63; 95% confidence interval, .42 to .94; P = .02). Patients with FL experiencing ETF after frontline chemoimmunotherapy lack optimal therapy. We demonstrate improved OS when receiving autoHCT within 1 year of treatment failure. Results from this unique collaboration between the NLCS and CIBMTR support consideration of early consolidation with autoHCT in select FL patients experiencing ETF.

Dose-dense and less dose-intense Total Therapy 5 for gene expression profiling-defined high-risk multiple myeloma

Multiple myeloma (MM) is a heterogeneous disease with high-risk patients progressing rapidly despite treatment. Various definitions of high-risk MM are used and we reported that gene expression profile (GEP)-defined high risk was a major predictor of relapse. In spite of our best efforts, the majority of GEP70 high-risk patients relapse and we have noted higher relapse rates during drug-free intervals. This prompted us to explore the concept of less intense drug dosing with shorter intervals between courses with the aim of preventing inter-course relapse. Here we report the outcome of the Total Therapy 5 trial, where this concept was tested. This regimen effectively reduced early mortality and relapse but failed to improve progression-free survival and overall survival due to relapse early during maintenance.

Relapse of Hodgkin lymphoma after autologous transplantation: Time to rethink treatment?

Relapse of Hodgkin lymphoma after autologous hematopoietic cell transplantation (autologous HCT) is a major therapeutic challenge. Its management, at least in younger patients, traditionally involves salvage chemotherapy aiming to achieve disease remission followed by consolidation with allogeneic hematopoietic cell transplantation (allogeneic HCT) in eligible patients. The efficacy of salvage therapy is variable and newer combination chemotherapy regimens have improved the outcomes. Factors such as shorter time to relapse after autologous HCT and poor performance status have been identified as predictors of poor outcome. Newer agents such as immunoconjugate brentuximab vedotin, checkpoint inhibitors (e.g., pembrolizumab, nivolumab), lenalidomide, and everolimus are available for the treatment of patients relapsing after autologous HCT. With the availability of reduced intensity conditioning allogeneic HCT, more patients are eligible for this therapy with lesser toxicity and better efficacy due to graft versus lymphoma effects. Alternative donor sources such as haploidentical stem cell transplantation and umbilical cord blood transplantation are expanding this procedure to patients without HLA-matched donors. However, strategies aimed at reduction of disease relapse after reduced intensity conditioning allogeneic HCT are needed to improve the outcomes of this treatment. This review summarizes the current data on salvage chemotherapy and HCT strategies used to treat patients with relapsed Hodgkin lymphoma after prior autologous HCT.

Adverse metaphase cytogenetics can be overcome by adding bortezomib and thalidomide to fractionated melphalan transplants

Purpose: To determine whether a reduction in the intensity of Total Therapy (TT) reduces toxicity and maintains efficacy. Experimental Design: A total of 289 patients with gene expression profiling (GEP70)-defined low-risk multiple myeloma were randomized between a standard arm (TT4-S) and a light arm (TT4-L). TT4-L employed one instead of two inductions and consolidations. To compensate for potential loss of efficacy of TT4-L, bortezomib and thalidomide were added to fractionated melphalan 50 mg/m2/d for 4 days. Results: Grade ≥3 toxicities and treatment-related mortalities were not reduced in TT4-L. Complete response (CR) rates were virtually identical (P = 0.2; TT4-S, 59%; TT4-L, 61% at 2 years), although CR duration was superior with TT4-S (P = 0.05; TT4-S, 87%; TT4-L, 81% at 2 years). With a median follow-up of 4.5 years, there was no difference in overall survival (OS) and progression-free survival (PFS). Whereas metaphase cytogenetic abnormalities (CAs) tended to be an adverse feature in TT4-S, as with predecessor TT trials, the reverse applied to TT4-L. Employing historical TT3a as training and TT3b as test set, 51 gene probes (GEP51) significantly differentiated the presence and absence of CA (q < 0.0001), seven of which function in DNA replication, recombination, and repair. Applying the GEP51 model to clinical outcomes, OS and PFS were significantly inferior with GEP51/CA in TT4-S; such a difference was not observed in TT4-L. Conclusions: We identified a prognostic CA-linked GEP51 signature, the adversity of which could be overcome by potentially synergizing anti–multiple myeloma effects of melphalan and bortezomib. These exploratory findings require confirmation in a prospective randomized trial. Clin Cancer Res; 23(11); 2665–72. ©2016 AACR.

Flow cytometry defined cytoplasmic immunoglobulin index is a major prognostic factor for progression of asymptomatic monoclonal gammopathies to multiple myeloma (subset analysis of SWOG S0120).

Multiple myeloma (MM) is a clonal plasma cell (PC) disorder characterized by end organ damage that is in turn characterized by CRAB criteria (calcium and creatinine elevation, anemia and bone lesions).1 It is commonly accepted that nearly all cases of MM are preceded by a clinically benign phase of monoclonal gammopathy of undetermined significance (MGUS) that evolves through a stage of smoldering multiple myeloma (SMM) without end organ damage,2 collectively referred to as asymptomatic monoclonal gammopathies (AMG).3 Although traditionally SMM is considered more prone to MM progression than MGUS, additional variables, such as involved-to-uninvolved free light-chain ratio4 and magnetic resonance imaging-defined focal lesion number and size,5 have been linked to progression to MM and form the basis for the newest International Myeloma Working Group criteria for MM.6 As the treatment of MM has been greatly advanced, emphasis has been placed on identifying patients with AMG at high risk of progression to MM so that, with earlier treatment, end organ damage can be minimized.7 Many new high-risk variables have indeed been identified such as level of circulating plasma cells8 and gene expression profiling (GEP).9, 10 We have previously reported that two-parameter flow cytometry of DNA and cytoplasmic light-chain immunoglobulin (DNA/CIG) is highly predictive of progression-free and overall survival in newly diagnosed MM treated with Total Therapy.11 In the current subset analysis of S0120, we have investigated whether the DNA/CIG assay can also identify patients with AMG at high risk for progression to MM requiring therapy (time to therapy, TTT).12 Of 254 patients enrolled at the University of Arkansas in the observational SWOG S0120 protocol with AMG, 110 had evaluable DNA/CIG information and retained AMG status according to the revised International Myeloma Working Group criteria for MM.6 All patients underwent detailed clinical staging as previously reported.9, 10 DNA/CIG assay was performed on whole bone marrow aspirates along with metaphase cytogenetics and GEP of CD138+ purified PC.13 Imaging studies involved metastatic bone surveys and, in the majority of the cases, magnetic resonance imaging examination of the axial and appendicular skeleton. Details of the DNA/CIG method have been published elsewhere.14, 15 A technical modification of the assay was applied uniformly since August 2006. The assay is based on the two-parameter flow cytometry of cytoplasmic immunoglobulin and DNA of whole bone marrow aspirates. Single-cell suspensions were exposed to anti-light-chain reagents (Dako Kappa and Lambda light chain F(AB)2/FITC conjugated) and then counterstained for DNA with propidium iodide with the addition of RNase. To quantitate the cellular DNA content, DNA index (DI)16 was determined and calculated as the ratio of the mean for each light-chain-positive G0/1 DNA peak divided by the mean of the light-chain-negative diploid G0/1 peak on the X axis. A DI between 0.99 and 1.01 was referred to as diploid, while hyperdiploid implied DI>1.01 and hypodiploid DI<0.99. The excess of kappa- or lambda-positive cells identified the involved or light-chain-restricted (LCR) cell population, the percentage of which was calculated in relation to the total number of gated events. Among the LCR cell population, discrete populations of cells with different DI were identified, which we refer to from here on as DNA stem lines. The involved DNA stem line with the highest percentage was considered dominant. To quantitate the cytoplasmic immunoglobulin content of a light-chain-positive population, the cytoplasmic immunoglobulin index (CIg) was used and calculated from the ratio of the geometric mean of the Y axis (cytoplasmic immunoglobulin fluorescence intensity) for the light-chain-positive G0/1 peak divided by the Y axis geometric mean of the light-chain-negative diploid G0/1 population. The CIg of each distinct DNA stem line was calculated as explained above. Kaplan–Meier methods were used to generate survival distribution graphs, and comparisons were made employing the log-rank test. For continuous variables, the running log-rank method was applied for the calculation of optimal cutoff points. The R2 statistic was used to evaluate the predictive power of different models. Wilcoxon tests were used to compare the medians of continuous measurements between groups. The characteristics of the 110 patients lacking the revised International Myeloma Working Group criteria for MM are portrayed in Supplementary Table 1. The median follow-up time for the 110 patients was 4.8 years. Aneuploidy by DNA/CIG was evident in 64%, all of whom had hyperdiploid stem lines, while additional hypodiploid abnormalities were present in two cases. Low hemoglobin (<10 g/dl) pertained to only 4% (non-plasma cell dyscrasia-related reasons) while creatinine ⩾2 mg/dl was evident in one case due to hypertension-related nephrosclerosis. Metaphase cytogenetic abnormalities (CA) were documented in 16%, a GEP70 score⩾−0.26(ref. 3) pertained to 33% and a recently defined novel GEP4 score⩾9.28(ref. 17) to 12% of patients. We examined the TTT probability of AMG (Table 1). Optimal cutoff points were obtained for all continuous numerical values. We confirm other studies linking older age ⩾65 years, albumin 8.4 The presence of CA, GEP70- and GEP4- high-risk designations was strongly linked to inferior TTT. Among DNA/CIG-derived parameters, CIg 17 were both strongly linked to progression to MM. Other DNA/CIG variables associated with TTT included the presence of aneuploidy and the presence of ⩾2 DNA stem lines (Figure 1). The 26 patients with CIg 17 present in 20 patients conferred a 2-year MM progression rate of 60% versus 9% among the 90 with lower (Figure 1b). Consideration of both DNA/CIG features identified 14 patients displaying two high-risk features with 2-year TTT of 71.4% as opposed to 5.1% in 78 patients with only favorable features, while the presence of one adverse variable present in 18 patients was associated with a 2-year TTT probability of approximately 34% (Figure 1c). Figure 1 Kaplan–Meier plots for the time to progression from AMG to MM requiring therapy according to: CIg, (a) total LCR%, (b) the combination of CIg and total LCR% (c) and the combination of CIg and total LCR% for the SMM population ... Table 1 Cox regression for time to progression to MM In the multivariate model, serum-M⩾3 g/dl, CIg 17% independently conferred adverse outcomes (Table 1). All three parameters combined provided for a high R2 value of 0.861, implying that TTT probability could be accounted for in 86% (Supplementary Table 2). In comparison, the classical criteria of bone marrow plasmacytosis ⩾10% and serum-M⩾3 g/dl had a lower cumulative R2 of 0.632. When only the sub-population of SMM (80 patients; Supplementary Table 3) was considered, DNA/CIG-derived variables retained their statistical significance (Supplementary Table 4). Both LCR>17% and CIg 17% and serum-M⩾3 g/dl; albumin<3.5 g/dl and B2M⩾3.5 mg/l also conferred higher TTT probability for a R2 of 0.862 (Supplementary Tables 4 and 5). The inclusion of GEP variables, available in a subset of 61 patients, identified GEP-4 as a significant variable, dispelling CIg and B2M from the model (R2=0.895; Supplementary Tables 4 and 6). CIg is a measure of plasma cell immunoglobulin production.15 We therefore examined CIg values in patients with MGUS and SMM (both from the S0120 trial), and in newly diagnosed MM patients accrued to Total Therapy 3b.18 Median CIg values declined progressively with the transition from MGUS to SMM and later to MM (10.5 versus 5.6 versus 3.3, P<0.001; Supplementary Figure 1a). To exclude the possibility that the difference in CIg reflects the decreasing percentage of highly secreting normal plasma cells with the evolution of plasma cell dyscrasias,19, 20 the analysis was repeated for strictly aneuploid cases. Again, the evolution from MGUS to SMM to MM was characterized by a progressively lower CIg (16.0 versus 9.1 versus 3.5, P<0.0001; Supplementary Figure 1b). In summary, DNA/CIG offers powerful prognostic information for AMG even in the era of genomic profiling. While LCR% reflects tumor burden, the finding of progressively decreasing CIg with the evolution of plasma cell dyscrasias in this single institution subset analysis of S0120 is novel. It provides evidence that the progression of plasma cell dyscrasias is accompanied by a progressive decline in immunoglobulin production capacity.

Alteration of mitochondrial biogenesis promotes disease progression in multiple myeloma

Many cancers, including multiple myeloma (MM), retain more cytosolic iron to promote tumor cell growth and drug resistance. Higher cytosolic iron promotes oxidative damage due to its interaction with reactive oxygen species generated by mitochondria. The variation of mitochondrial biogenesis in different stages of MM disease was evaluated using gene expression profiles in a large clinical dataset. Sixteen of 18mitochondrial biogenesis related gene sets, including mitochondrial biogenesis signature and oxidative phosphorylation, were increased in myeloma cells compared with normal plasma cells and high expression was associated with an inferior patient outcome. Relapsed and drug resistant myeloma samples had higher expression of mitochondrial biogenesis signatures than newly diagnosed patient samples. The expression of mitochondrial biogenesis genes was regulated by the cellular iron content, which showed a synergistic effect in patient outcome in MM. Pharmacological ascorbic acid induced myeloma cell death by inhibition of mitochondria oxidative phosphorylation in an in vivo model. Here, we identify that dysregulated mitochondrial biogenesis and iron homeostasis play a major role in myeloma progression and patient outcome and that pharmacological ascorbic acid, through cellular iron content and mitochondrial oxidative species, should be considered as a novel treatment in myeloma including drug-resistant and relapsed patients.

Transplantation for Multiple Myeloma

Multiple myeloma is a disorder characterized by accumulation of malignant plasma cells in the bone marrow, hypercalcemia, monoclonal protein, and end organ damage. Recently newer generation proteosome inhibitors, monoclonal antibodies and novel agents have been approved by FDA, which is undoubtedly increasing life expectancy of the patients. However, hematopoietic stem cell transplantation still remains the cornerstone of the treatment. In this chapter, we are discussing the autologous stem cell transplant, allogeneic stem cell transplant and total therapy trials with outcomes.

The flow cytometry-defined light chain cytoplasmic immunoglobulin index and an associated 12-gene expression signature are independent prognostic factors in multiple myeloma

As part of Total Therapy (TT) 3b, baseline marrow aspirates were subjected to two-color flow cytometry of nuclear DNA content and cytoplasmic immunoglobulin (DNA/CIG) as well as plasma cell gene expression profiling (GEP). DNA/CIG-derived parameters, GEP and standard clinical variables were examined for their effects on overall survival (OS) and progression-free survival (PFS). Among DNA/CIG parameters, the percentage of the light chain-restricted (LCR) cells and their cytoplasmic immunoglobulin index (CIg) were linked to poor outcome. In the absence of GEP data, low CIg <2.8, albumin <3.5 g/dl and age ⩾65 years were significantly associated with inferior OS and PFS. When GEP information was included, low CIg survived the model along with GEP70-defined high risk and low albumin. Low CIg was linked to beta-2-microglobulin >5.5 mg/l, a percentage of LCR cells exceeding 50%, C-reactive protein ⩾8 mg/l and GEP-derived high centrosome index. Further analysis revealed an association of low CIg with 12 gene probes implicated in cell cycle regulation, differentiation and drug transportation from which a risk score was developed in TT3b that held prognostic significance also in TT3a, TT2 and HOVON trials, thus validating its general applicability. Low CIg is a powerful new prognostic variable and has identified potentially drug-able targets.

Acute Lymphoblastic Leukemia evolving from atypical Chronic Myelogenous Leukemia: Case Report and Review of the Literature

Atypical chronic myeloid leukemia (aCML) is a rare chronic myeloproliferative disorder characterized by leukocytosis, absence of Philadelphia chromosome or BCR-ABL rearrangement, and marked myeloid dysplasia. The diagnosis of aCML is difficult and challenging, more so if the initial presentation is with blast crisis. In the absence of characteristic mutational profile, blast crisis of aCML can lead to significant diagnostic dilemma. We describe a case of refractory acute lymphoblastic leukemia (ALL), needing critical evaluation of hemopathological and cytogenetic abnormalities. It was hypothesized that patient had undiagnosed aCML and presented with lymphoid blast crisis. To our knowledge, this is the first described case of aCML presenting with lymphoid blast crisis.