Comparison of progression risk of monoclonal gammopathy of undetermined significance by method of detection.

Monoclonal gammopathy of undetermined significance (MGUS) is an asymptomatic pre-malignant disorder. The current standard of care is not to screen for MGUS, so it is often incidentally diagnosed in the clinic. It is unknown whether the outcomes of screened versus clinically detected MGUS differ. We compared the progression risk between screened versus clinical MGUS cohorts and assessed whether the MGUS detection method impacted risk prediction of established clinical factors (score). We included 379 screened MGUS from the Olmsted County population based study and 1384 MGUS patients diagnosed during routine clinical evaluation at Mayo Clinic. Median follow-up time for the screened versus clinical cohort was 26.6 and 40.1 years, respectively. Accounting for death as a competing risk, the cumulative incidence of progression at 25 years was similar in the screened (11.1% [95% CI 8.3-14.8]) versus clinical (10.1% [95% CI 8.6-11.8%]) MGUS cohorts, even when stratified by sex, age, or the baseline MGUS risk score. Overall, 0.9 (95% CI 0.6-1.2) screened versus 1.0 (95% CI 0.9-1.2) clinically detected MGUS patients experienced disease progression for every 100 person years of follow-up. MGUS detection method did not modify the association between MGUS risk score and progression risk (pinteraction=0.217) and did not add to known risk factors for progression (likelihood ratio test, p=0.839). Here we show that progression risk among patients with screened versus clinically detected heavy-chain MGUS was similar. Future studies are needed to assess if tailored follow-up of screened MGUS patients affects clinical outcomes.

Functional variant rs9344 at 11q13.3 regulates CCND1 expression in multiple myeloma with t(11;14).

Multiple myeloma (MM) is a plasma cell (PC) malignancy characterized by cytogenetic abnormalities, such as t(11;14)(q13;q32), resulting in CCND1 overexpression. The rs9344 G allele within CCND1 is the most significant susceptibility allele for t(11;14). Sequencing data from 2 independent cohorts, CoMMpass (n = 698) and Mayo Clinic (n = 661), confirm the positive association between the G allele and t(11;14). Among 80% of individuals heterozygous for rs9344 with t(11;14), the t(11;14) event occurs on the G allele, demonstrating a biological preference for the G allele in t(11;14). Within t(11;14), the G allele is associated with higher CCND1 expression and elevated H3K27ac and H3K4me3. CRISPR/Cas9 mediated A to G conversion resulted in increased H3K27ac over CCND1 and elevated CCND1 expression. ENCODE ChIP-seq data supported a PAX5 binding site within the enhancer region covering rs9344, showing preferential binding to the G allele. Overexpression of PAX5 resulted in increased CCND1 expression. These results support the importance of rs9344 G enhancer in increasing CCND1 expression in MM.

Dexamethasone dose intensity does not impact outcomes in newly diagnosed multiple myeloma: a secondary SWOG analysis.

Dexamethasone is a key component of induction for newly diagnosed multiple myeloma (NDMM) despite common toxicities including hyperglycemia and insomnia. In the randomized ECOG E4A03 trial, dexamethasone 40 milligrams (mg) once weekly was associated with lower mortality than higher doses of dexamethasone. However, the performance of dexamethasone dose reductions below this threshold with regard to progression-free survival (PFS) and overall survival (OS) in NDMM have not been fully characterized. We conducted a secondary pooled analysis of the S0777 and S1211 SWOG studies of NDMM, which employed lenalidomide-dexamethasone (Rd) alone with or without bortezomib (VRd) and with or without elotuzumab (Elo-VRd). Planned dexamethasone intensity was 40-60 mg weekly in all arms. Patients were categorized into FD-DEX (full-dose dexamethasone maintained throughout induction) or LD-DEX (lowered-dose dexamethasone or discontinuation; only permitted for Grade 3+ toxicities per both study protocols). Of 541 evaluated patients, the LD-DEX group comprised 373 patients (69%). There was no difference in PFS or OS between the FD-DEX or LD-DEX groups, which were balanced in terms of age, stage, and performance status. Predictors of PFS and OS in multivariate models were treatment arm, age ≥70, and thrombocytopenia; FD-DEX did not significantly improve either outcome. Our study suggests that dexamethasone dose reductions are common in multiple myeloma, even within clinical trials. Given dexamethasone's many toxicities and unclear benefit in the era of modern treatment regimens, dexamethasone dose reduction during NDMM induction warrants further prospective study. NCT00644228, NCT01668719.

Toxic effects of dibutyl phthalate on testes of adult zebrafish: evaluation of oxidative stress parameters and histopathology.

Dibutyl phthalate (DBP) is a phthalic compound and is most commonly used as a plasticizer in the polymer industry. It affects the hypothalamus-pituitary-gonadal axis and produces infertility in exposed animals. A total of 366 adult male zebrafish were used to evaluate the toxicological effects of DBP in testes following continuous exposure for 28 days. To evaluate histological changes during phase I of the study, 30 zebrafish were equally divided into five groups viz., control (RO water), vehicle control (0.01% DMSO), T0 (250 µg/L of water), T1 (500 µg/L of water), and T2 group (1000 µg/L of water). The protocol for phase II of the study was decided based on the results of phase I of the study. During phase II, for evaluation of oxidative stress parameters and gene expression profile, a total of 336 fish were equally divided into four groups viz., control, vehicle control, T1 (500 µg/L of water), and T2 (1000 µg/L of water). The activity of SOD, CAT, and TAC was significantly lower in zebrafish from the T2 group; however, a significantly increased level of MDA in the T2 group was recorded as compared to control groups. mRNA expression profile of sod, cat, and nrf2 genes was significantly downregulated in the T2 group as compared to the control group. Histopathology and proliferating cell nuclear antigen immunostaining revealed a reduction in spermatozoa with increased spermatocytes and spermatogonia in testes from T1 and T2 groups. The result indicated that DBP can induce oxidative stress and affect spermatogenesis in zebrafish testes.

Mucoid Degeneration of Anterior Cruciate Ligament-A Systematic Approach for Debulking.

Anterior cruciate ligament (ACL) mucoid degeneration is an underdiagnosed condition that occurs when mucinous material develops in the ACL in the absence of synovial lining. Several authors have diagnosed this condition, discussed their own personal observations, and put forward their own suggestions for management. When diagnosed, one important strategy for management entails "debulking" the ACL using an arthroscopic debridement. No protocol has been described on the sequence of steps for ACL debridement during arthroscopy. We present our own in this Technical Note, with the addition of video footage that describes our arthroscopic technique for ACL mucoid degeneration debridement using radiofrequency ablation and the sequence of steps. This Technical Note aims to demonstrate the procedure needed for arthroscopic debulking of a mucoid ACL, which will lessen ACL impingement while maintaining a stable knee.

Temporal Genomic Dynamics Shape Clinical Trajectory in Multiple Myeloma.

To comprehensively unravel the temporal relationship between initiating and driver events and its impact on clinical outcomes, we analyzed 421 whole-genome sequencing profiles from 382 patients. Using clock-like mutational signatures, we estimated a time lag of 2-4 decades between initiating events and diagnosis. In patients with hyperdiploidy, we demonstrate that trisomies of odd-numbered chromosomes can be acquired simultaneously with other chromosomal gains, such as 1q gain. We provide evidence that hyperdiploidy is acquired after canonical IGH translocation when both events are present. Finally, patients with early 1q gain had adverse outcomes similar to those with 1q amplification (>1 extra-copies), but faring worse than those with late 1q gain. This underscores that the prognostic impact of 1q gain/amp depends more on the timing of acquisition than on the number of extra copies gained. Overall, this study contributes to a better understanding of the life history of MM and may have prognostic implications.

Progression-free survival as a surrogate endpoint in myeloma clinical trials: an evolving paradigm.

Measurement of overall survival (OS) remains the gold standard for interpreting the impact of new therapies for multiple myeloma in phase 3 trials. However, as outcomes have improved, it is increasingly challenging to use OS as the primary endpoint if timely approval of novel agents is to be ensured to enable maximum benefit for patients. Surrogate endpoints of OS, such as progression-free survival (PFS) and response to treatment, have contributed to approval decisions by the Food and Drug Administration (FDA) and European Medicines Agency as endpoints demonstrating clinical benefit, and the FDA has recently supported the use of minimal residual disease (MRD) as an accelerated approval endpoint in multiple myeloma. This review aims to address situations in which the use of PFS as a surrogate endpoint warrants careful interpretation especially for specific subgroups of patients and considers ways to ensure that studies can be designed to account for possible discordance between PFS and OS. The utility of subgroup analyses, including the potential for those not pre-specified, to identify target populations for new agents is also discussed.

Influence of solution pH dependency on structure, optical with photoelectrochemical characteristics of SILAR deposited copper oxide thin films.

Photoelectrochemical (PEC) technology is a promising approach for converting solar energy into chemical energy, offering significant potential for renewable energy applications. In this work, the CuO thin film was fabricated with different pH value in between 8.5 ± 0.1 and 10.5 ± 0.1 via Successive Ionic Layer Adsorption and Reaction (SILAR) method. The Effect of pH on thickness, structural, morphological, elemental composition and optical properties were investigated by using stylus profilometry, XRD, SEM, TEM, EDX, UV-vis and PL. The XRD results showed that as the pH increased, the crystallite size increased from 19.24 nm to 25.62 nm, with a monoclinic phase along the (111) direction. The CuO film deposited at pH value 10.5 ± 0.1 exhibit well defined identical particle with its size in the range between 200 and 300 nm was confirmed by SEM and TEM analysis. As the pH increased from 8.5 ± 0.1 to 10.5 ± 0.1, the CuO film bandgap (Eg) value reduced from 1.52 eV to 1.42 eV with indirect transition. The CuO photocathode deposited at pH 10.5 ± 0.1 shows maximum photocurrent density of 1.45 mA/cm2 at -0.1 V vs. RHE in 0.5 M Na2SO4 solution. Furthermore, the Electrochemical Impedance Spectroscopy (EIS) analysis shows, the CuO (pH 10.5 ± 0.1) electrode have higher conductivity value of 0.6862 S/cm compared CuO at pH 8.5 ± 0.1 (0.2779 S/cm) and CuO at pH 9.5 ± 0.1 (0.4646 S/cm) electrodes.

Clinical features associated with poor response and early relapse following BCMA-directed therapies in multiple myeloma.

Three classes of BCMA-directed therapy (BDT) exist: antibody drug-conjugates (ADCs), CAR-T, and T-cell engagers (TCEs), each with distinct strengths and weaknesses. To aid clinicians in selecting between BDTs, we reviewed myeloma patients treated at Mayo Clinic with commercial or investigational BDT between 2018-2023. We identified 339 individuals (1-exposure = 297, 2-exposures = 38, 3-exposures = 4) who received 385 BDTs (ADC = 59, TCE = 134, CAR-T = 192), with median follow-up of 21-months. ADC recipients were older, with more lines of therapy (LOT), and penta-refractory disease. Compared to ADCs, CAR-T (aHR = 0.29, 95%CI = 0.20-0.43) and TCEs (aHR = 0.62, 95%CI = 0.43-0.91) had better progression-free survival (PFS) on analysis adjusted for age, the presence of extramedullary (EMD), penta-refractory disease, multi-hit high-risk cytogenetics, prior BDT, and the number of LOT in the preceding 1-year. Likewise, compared to ADCs, CAR-T (aHR = 0.28, 95%CI = 0.18-0.44) and TCEs (aHR = 0.60, 95%CI = 0.39-0.93) had superior overall survival. Prior BDT exposure negatively impacted all classes but was most striking in CAR-T, ORR 86% vs. 50% and median PFS 13-months vs. 3-months. Of relapses, 54% were extramedullary in nature, and a quarter of these cases had no history of EMD. CAR-T demonstrates superior efficacy and where feasible, should be the initial BDT. However, for patients with prior BDT or rapidly progressive disease, an alternative approach may be preferable.

Multiple myeloma: 2024 update on diagnosis, risk-stratification, and management.

DISEASE OVERVIEW: Multiple myeloma accounts for approximately 10% of hematologic malignancies. DIAGNOSIS: The diagnosis requires ≥10% clonal bone marrow plasma cells or a biopsy proven plasmacytoma plus evidence of one or more multiple myeloma defining events (MDE): CRAB (hypercalcemia, renal failure, anemia, or lytic bone lesions) attributable to the plasma cell disorder, bone marrow clonal plasmacytosis ≥60%, serum involved/uninvolved free light chain (FLC) ratio ≥100 (provided involved FLC is ≥100 mg/L and urine monoclonal protein is ≥200 mg/24 h), or >1 focal lesion on magnetic resonance imaging. RISK STRATIFICATION: The presence of del(17p), t(4;14), t(14;16), t(14;20), gain 1q, del 1p, or p53 mutation is considered high-risk multiple myeloma. Presence of any two high risk factors is considered double-hit myeloma; three or more high risk factors is triple-hit myeloma. RISK-ADAPTED INITIAL THERAPY: In patients who are candidates for autologous stem cell transplantation, induction therapy consists of anti-CD38 monoclonal antibody plus bortezomib, lenalidomide, dexamethasone (VRd) followed by autologous stem cell transplantation (ASCT). Selected standard risk patients can delay transplant until first relapse. Frail patients who not candidates for transplant are treated with VRd for approximately 8-12 cycles followed by maintenance or alternatively with daratumumab, lenalidomide, dexamethasone (DRd) until progression. MAINTENANCE THERAPY: Standard risk patients need lenalidomide maintenance, while bortezomib plus lenalidomide maintenance is needed for high-risk myeloma. MANAGEMENT OF RELAPSED DISEASE: A triplet regimen is usually needed at relapse, with the choice of regimen varying with each successive relapse. Chimeric antigen receptor T (CAR-T) cell therapy and bispecific antibodies are additional options.