Bone metabolism parameters and their relation to cytogenetics in multiple myeloma.

OBJECTIVES: Our aim was to correlate serum levels of selected markers of bone metabolism and bone marrow microenvironment to cytogenetic changes in patients with multiple myeloma (MM). METHODS: We assed cytogenetic changes in 308 patients and correlated them with the following levels of bone marrow metabolism: thymidine kinase (TK), ß2-microglobulin (b-2-m), Dickkopf-1 protein (DKK-1), C-terminal telopeptide collagen-I (ICTP), N-terminal propeptide of type I procollagen (PINP), receptor for interleukin 6 (rIL-6), vascular cell adhesive molecule-1 (VCAM), soluble intercellular adhesion molecule-1, osteoprotegerin (OPG), hepatocyte growth factor (HGF), vascular endothelial growth factor (VEGF), syndecan-1 (SYN-1) and Fas antigen. RESULT: Individuals with delRB1 had lower levels of OPG (M = 7.39 vs. 5.46 pmol/L, p = .025) and VEGF (M = 304 vs. 196 pg/ml; p = .036). t(14;16) was associated with higher ß2m levels (M = 7.59 vs. 4.13 mg/L; p = .022) and lower DKK-1 levels (M = 4465 ng/L vs. 12,593). The presence of 1q21 gain was associated with higher levels of TK (M = 100.0 vs. 11.0 IU/L, p = .026) and lower levels of PINP (M = 49.3 vs. 67.4 mg/L, p = .030). CONCLUSIONS: Our analysis has shown, some cytogenetic changes, especially delRB1, t(14;16) and 1q21gain, which affect the components of the cytokine network in multiple myeloma.

Survival benefit of ixazomib, lenalidomide and dexamethasone (IRD) over lenalidomide and dexamethasone (Rd) in relapsed and refractory multiple myeloma patients in routine clinical practice.

BACKGROUND: We have performed a head to head comparison of all-oral triplet combination of ixazomib, lenalidomide and dexamethasone (IRD) versus lenalidomide and dexamethasone (RD) in patients with relapsed and refractory multiple myeloma (RRMM) in the routine clinical practice. METHODS: A total of 344 patients treated with IRD (N = 127) or RD (N = 217) were selected for analysis from the Czech Registry of Monoclonal Gammopathies (RMG). Descriptive statistics were used to assess patient's characteristics associated with the respective therapy. The primary endpoint was progression free survival (PFS), secondary end points included response rates and overall survival (OS). Survival endpoints were plotted using Kaplan-Meier methodology at 95% Greenwood confidence interval. Univariable and multivariable Cox proportional hazards models were used to evaluate the effect of treatment regimens and the significance of uneven variables. Statistical tests were performed at significance level 0.05. RESULTS: In the whole cohort, median PFS for IRD was 17.5 and for RD was 11.5 months favoring the all-oral triplet, p = 0.005; in patients within relapse 1-3, the median PFS was 23.1 vs 11.6 months, p = 0.001. The hazard ratio for PFS was 0.67 (95% confidence interval [CI] 0.51-0.89, p = 0.006). The PFS advantage translated into improved OS for patients treated with IRD, median 36.6 months vs 26.0 months (p = 0.008). The overall response rate (ORR) was 73.0% in the IRD group vs 66.2% in the RD group with a complete response rate (CR) of 11.1% vs 8.8%, and very good partial response (VGPR) 22.2% vs 13.9%, IRD vs RD respectively. The IRD regimen was most beneficial in patients ≤75 years with ISS I, II, and in the first and second relapse. Patients with the presence of extramedullary disease did not benefit from IRD treatment (median PFS 6.5 months). Both regimens were well tolerated, and the incidence of total as well as grade 3/4 toxicities was comparable. CONCLUSIONS: Our analysis confirms the results of the TOURMALINE-MM1 study and shows benefit of all-oral triplet IRD treatment versus RD doublet. It demonstrates that the addition of ixazomib to RD improves key survival endpoints in patients with RRMM in a routine clinical setting.

CD38-negative relapse in multiple myeloma after daratumumab-based chemotherapy.

We present a case report of a patient relapsing after anti-CD38 treatment (daratumumab). The phenotype of the disease changed during this treatment, and the myeloma clone became CD38 negative and daratumumab refractory. We expected clonal shift, however, based on immunophenotyping, cytogenetics and arrayCGH; the clone was identical as before daratumumab-based treatment with the exception of CD38 negativity. We suggest that the downregulation or loss of CD38 might be an epigenetic "escape mechanism" of malignant plasma cells from antibody-based treatment. The aim of our study was to point out the pitfalls of immunophenotyping and cytogenetics in both assessing the minimal residual disease and clone detection after monoclonal antibody-based therapy.

Prospective study of signalling pathways in myeloma bone disease with regard to activity of the disease, extent of skeletal involvement and correlation to bone turnover markers.

AIMS: The aim of our study was to address the utility of serum levels of selected parameters of myeloma bone disease (MBD) signalling with regard to the pathogenesis of multiple myeloma (MM), activity, markers of bone turnover and extent of skeletal changes. PATIENTS AND METHODS: We assessed prospectively 77 individuals with monoclonal gammopathies - 46 patients with active MM (AMM), 12 patients with smouldering MM (SMM) and 19 individuals with monoclonal gammopathy of undetermined significance (MGUS) to determine the role of HGF, MIP-1α, Syndecan-1, osteoprotegerin, Activin A, DKK1, Annexin A2 and NF-κB. RESULTS: We found significant differences of most of the parameters between MGUS and AMM, and with respect to the activity of MM assessed by International Staging System. Most of the parameters of MBD signalling correlated with traditional markers of bone turnover. CONCLUSIONS: All the signalling pathways were activated in MM with more pronounced osteoclastogenesis in comparison with bone formation but not in MGUS regardless of its risk category, suggesting that MBD is not activated in MGUS until the process of transformation into MM. The parameters of MBD signalling might precede the increase of conventional parameters of bone turnover suggesting their possible role in early indication of anti-resorption therapy.

[Analysis of the relationship of heavy/light chain pairs of immunoglobulin (Hevylite) to the results of gel electrophoresis and nefelometric examination of serum proteins at the time of multiple myeloma diagnosis]. / Analýza vztahu sérových hladin páru tezkých/lehkých retezcu imunoglobulinu (Hevylite) k výsledkum standardní gelové elektroforézy a nefelometrického vysetrení bílkovin séra pri diagnóze mnohocetného myelomu.

BACKGROUND: The diagnostics and treatment of multiple myeloma (MM) requires precise analysis of serum immunoglobulins, which might be limited by the sensitivity of standard examination methods. Hevylite method enables quantitative analysis of heavy/light chain pairs (HLC) of normal and tumor IgG and IgA immunoglobulin and their ratio (HLC-r). The aim of the study was to assess the contribution of Hevylite method in the diagnostics of MM in comparison with nephelometry (NEF), standard protein electrophoresis (SPE), immunofixation electrophoresis (IFE) and the examination of serum free light chains (FLC) of immunoglobulin using Freelite test and heavy/light chain pairs of immunoglobulin (HLC) using Hevylite. METHODS: Using the methods Hevylite, NEF, SPE, IFE and Freelite, we examined a cohort of 134 individuals fulfilling the International Myeloma Working Group (IMWG) criteria. 96 patients were of IgG and 38 of IgA type. RESULTS: The levels of HLC-kappa (K) and HLC-lambda (L), as well as HLC-r were independent of age and gender. Abnormal HLC levels were present in 84-100%, pathological HLC-r was in 92-100% cases based on MIg isotype. We found strong positive correlation between IgG and IgA (NEF) and the sum of HLC IgG-K + IgG-L (Hevylite) (r = 0.80, p < 0.0001) and HLC IgA-K + IgA-L (r = 0.75, p < 0.0001). Very strong positive correlation was between the concentration of MIg (SPE) and the levels of HLC (Hevylite) in IgG-K (r = 0.73), IgG-L (r = 0.76), IgA-K (r = 0.70) and IgA-L (r = 0.89), p < 0,0001. Systematic difference between Hevylite vs. MIg (SPE) was confirmed by Bland-Altmann test in the case of HLC IgA-K and IgA-L (not HLC IgG-K and IgG-L), and in the correlation of HLC with IgG and IgA (NEF). The most significant correlation between SPE (patients with < 15 g/L) vs. Hevylite was found within the analysis of HLC IgG-K+ IgA-K (r = 0.85, p < 0.0001), and in the whole cohort of MM patients, i.e. IgG + IgA-kappa and lambda (r = 0.76, p < 0.0001), confirmed by Bland-Altmann test. Tight positive correlation was between HLC-r and index of monoclonality FLC-K/L in MM of IgG and IgA type MM (p < 0.0001). CONCLUSION: Hevylite method, especially the assessment of HLC-r of IgA type MM is more sensitive in comparison with SPE evaluated by NEF, and increases the diagnostic sensitivity and the extent of tumor mass examination. Despite its limitation in the case of high levels of IgG type MIg, Hevylite technique has a promising potential to enrich the standard analytic tools as it enables to assess the concentration and ratio of the levels of both tumor and physiological immunoglobulins e.g. depth of immunoparesis, valid especially in MM with low levels of MIg.

[Analysis of serum levels of Dickkopf-1 (DKK-1) in monoclonal gammopathy of undetermined significance and multiple myeloma]. / Analýza sérových hladin Dickkopf-1 (DKK-1) u monoklonální gamapatie nejistého významu a mnohocetného myelomu.

BACKGROUND: Several recent studies aim at the detection of biological parameters that enable more precise diagnostics and stratification of monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma (MM). The objective of our study was to assess the potential contribution of serum levels of Dickkopf-1 (DKK-1) in MGUS and MM from the point of more specific differentiation of both conditions, and the relationship of DKK-1 to selected laboratory parameters, individual forms and clinical stages of both conditions. METHODS AND RESULTS: The analyzed cohort consisted of 46 individuals with MGUS and 152 patients with MM at the time of diagnosis. For the assessment of serum levels of DKK-1 we used ELISA method. We assessed also serum levels of free light chains (FLC) κ and λ using the Freelite system, and ß2-microglobulin (ß2-M) using the Immulite 1000 method. For statistical estimation we used: Pearson χ2-test, U-test according to Mann-Whitney and Kruskal-Wallis test. Our analysis revealed that there was no significant difference between the levels of DKK-1 in MGUS risk groups (0-3) and between the states with different FLC concentration including the κ/λ index of monoclonality. In MM there was a significant relationship of DKK-1 to the level of hemoglobin (p<0.008) but not to the levels of FLC, creatinine or ß2-microglobulin. Within the Durie-Salmon staging system, there were significant differences of DKK-1 between the stages I vs. III (p=0.001) and I vs. II+III (p=0.002). In the International Staging System (ISS) there were significant differences only between stages 1 vs. 2+3 (p=0.045). Although there was no overall significant difference of DKK-1 levels between MGUS and MM, there was a difference between MGUS vs stage III (p=0.001) and II+III (p=0.001) according to Durie-Salmon, and also MGUS vs. stage 2 (p=0.005) and vs. stages 2+3 (p=0,012) according to ISS. There were no significant differences in DKK-1 between MGUS and initial/asymptomatic form of MM (stage I). CONCLUSION: Although there was a significant difference of serum levels of DKK-1 between MGUS and initial/asymptomatic stage of MM when compared to advanced stage MM, and in patients with different Hb levels, we do not find the evaluation of serum levels of DKK-1 useful for routine discrimination of MGUS and MM, and for the specification of temporary stratification systems.

[Bortezomib-based therapy in patients with light chain deposition disease]. / Lécba bortezomibem u pacientu s onemocnením z depozice lehkých retezcu imunoglobulinu.

Light chain deposition disease (LCDD) is a rare systemic condition caused by monoclonal proliferation of terminally differentiated B-lymphocytes with production of free light chains and their deposition in kidneys or other organs. The aim of our study is to show the pitfalls of the diagnostics, and to demonstrate the effect of bortezomib-based therapy on a series of 4 patients with LCDD, from the point of hematological and organ therapeutic response. We include that bortezomib based treatment provides rapid and effective hematological response. It is, however, often accompanied by adverse events, especially within intensive treatment schedules. The most serious adverse effects includes peripheral neuropathy, which might be dose or treatment-limiting. Less intensive regimens ("bortezomib weekly") suggest an alternative with expectation of lower incidence of adverse effects. Autologous stem cell transplantation is a recommended and relatively safe approach in convenient candidates. Organ response is significantly delayed after hematological response, and organ damage by light chain deposits might not be fully reversible.

Prognostic value of hepatocyte growth factor, syndecan-1, and osteopontin in multiple myeloma and monoclonal gammopathy of undetermined significance.

Our aim was to compare serum levels of selected biological parameters in different phases of multiple myeloma (MM) and monoclonal gammopathy of undetermined significance (MGUS) to determine their diagnostic and prognostic potential. A cohort of 234 individuals was assessed for serum levels of hepatocyte growth factor (HGF), syndecan-1/CD(138) (SYN), and osteopontin (OPN). The patients with MM (N = 156) were divided into 3 groups: at the time of diagnosis (N = 45), in relapse/progression (N = 56), and in remission (N = 50). The analysis revealed significant differences of all three parameters in comparison of active and remission phase MM. Moreover, the parameters in active myeloma were significantly higher than in MGUS. Within the comparison of active disease (newly diagnosed and relapsing), there was no significant difference. Similar results were in remission phase MM and MGUS. There was no relationship of pretreatment levels of the parameters to therapeutic response. We conclude that serum levels of HGF, OPN, and SYN correspond to the activity of MM and might become useful in differentiation of MGUS, asymptomatic MM, and overt/symptomatic form of MM. The levels of all three parameters behave accordingly with MM activity. Pretreatment measurement without the assessment of their kinetics, however, has no relationship to therapeutic response.

A drug repurposing strategy for overcoming human multiple myeloma resistance to standard-of-care treatment.

Despite several approved therapeutic modalities, multiple myeloma (MM) remains an incurable blood malignancy and only a small fraction of patients achieves prolonged disease control. The common anti-MM treatment targets proteasome with specific inhibitors (PI). The resulting interference with protein degradation is particularly toxic to MM cells as they typically accumulate large amounts of toxic proteins. However, MM cells often acquire resistance to PIs through aberrant expression or mutations of proteasome subunits such as PSMB5, resulting in disease recurrence and further treatment failure. Here we propose CuET-a proteasome-like inhibitor agent that is spontaneously formed in-vivo and in-vitro from the approved alcohol-abuse drug disulfiram (DSF), as a readily available treatment effective against diverse resistant forms of MM. We show that CuET efficiently kills also resistant MM cells adapted to proliferate under exposure to common anti-myeloma drugs such as bortezomib and carfilzomib used as the first-line therapy, as well as to other experimental drugs targeting protein degradation upstream of the proteasome. Furthermore, CuET can overcome also the adaptation mechanism based on reduced proteasome load, another clinically relevant form of treatment resistance. Data obtained from experimental treatment-resistant cellular models of human MM are further corroborated using rather unique advanced cytotoxicity experiments on myeloma and normal blood cells obtained from fresh patient biopsies including newly diagnosed as well as relapsed and treatment-resistant MM. Overall our findings suggest that disulfiram repurposing particularly if combined with copper supplementation may offer a promising and readily available treatment option for patients suffering from relapsed and/or therapy-resistant multiple myeloma.

Ixazomib, Lenalidomide and Dexamethasone in Relapsed and Refractory Multiple Myeloma in Routine Clinical Practice: Extended Follow-Up Analysis and the Results of Subsequent Therapy.

BACKGROUND: We confirmed the benefit of addition of ixazomib to lenalidomide and dexamethasone in patients with relapsed and refractory multiple myeloma (RRMM) in unselected real-world population. We report the final analysis for overall survival (OS), second progression free survival (PFS-2), and the subanalysis of the outcomes in lenalidomide (LEN) pretreated and LEN refractory patients. METHODS: We assessed 344 patients with RRMM, treated with IRD (N = 127) or RD (N = 217). The data were acquired from the Czech Registry of Monoclonal Gammopathies (RMG). With prolonged follow-up (median 28.5 months), we determined the new primary endpoints OS, PFS and PFS-2. Secondary endpoints included the next therapeutic approach and the survival measures in LEN pretreated and LEN refractory patients. RESULTS: The final overall response rate (ORR) was 73.0% in the IRD cohort and 66.8% in the RD cohort. The difference in patients reaching ≥VGPR remained significant (38.1% vs. 26.3%, p = 0.028). Median PFS maintained significant improvement in the IRD cohort (17.5 vs. 12.5 months, p = 0.013) with better outcomes in patients with 1-3 prior relapses (22.3 vs. 12.7 months p = 0.003). In the whole cohort, median OS was for IRD vs. RD patients 40.9 vs. 27.1 months (p = 0.001), with further improvement within relapse 1-3 (51.7 vs. 27.8 months, p ˂ 0.001). The median PFS of LEN pretreated (N = 22) vs. LEN naive (N = 105) patients treated by IRD was 8.7 vs. 23.1 months (p = 0.001), and median OS was 13.2 vs. 51.7 months (p = 0.030). Most patients in both arms progressed and received further myeloma-specific therapy (63.0% in the IRD group and 53.9% in the RD group). Majority of patients received pomalidomide-based therapy or bortezomib based therapy. Significantly more patients with previous IRD vs. RD received subsequent monoclonal antibodies (daratumumab-16.3% vs. 4.3%, p = 0.0054; isatuximab 5.0% vs. 0.0%, p = 0.026) and carfilzomib (12.5 vs. 1.7%, p = 0.004). The median PFS-2 (progression free survival from the start of IRD/RD therapy until the second disease progression or death) was significantly longer in the IRD cohort (29.8 vs. 21.6 months, p = 0.016). There were no additional safety concerns in the extended follow-up. CONCLUSIONS: The IRD regimen is well tolerated, easy to administer, and with very good therapeutic outcomes. The survival measures in unsorted real-world population are comparable to the outcomes of the clinical trial. As expected, patients with LEN reatment have poorer outcomes than those who are LEN-naive. The PFS benefit of IRD vs. RD translated into significantly better PFS-2 and OS, but the outcomes must be accounted for imbalances in pretreatment group characteristics (especially younger age and stem cell transplant pretreatment), and in subsequent therapies.

A rare case of bifocal, extramedullary and hyposecretory relapse of multiple myeloma.

We present a rare extramedullary, bifocal, and hyposecretory manifestation of relapsed MM that could be mistaken for an infection. We stress the importance of complex evaluation including serum, urine, and bone marrow assessment and whole-body imaging.

Prognostic significance of apoptotic index in multiple myeloma patients treated by conventional therapy and novel agents, thalidomide and bortezomib.

OBJECTIVE: To assess the outcome of the measurement of apoptotic index in myeloma patients treated by conventional chemotherapy and novel drugs with biological mechanism of action, thalidomide and bortezomib. PATIENTS AND METHODS: In a cohort of 189 patients with newly diagnosed multiple myeloma from November 1997 through February 2008, we assessed the prognostic significance of plasma cell apoptotic index (PC-AI) using annexin-V. The whole group was subsequently divided according to treatment approach (conventional chemotherapy only vs. inclusion of novel drugs, thalidomide and bortezomib), and curves of overall survival were constructed. RESULTS: In the whole group (n = 189), low levels of PC-AI <4.5% significantly separated patients with unfavorable prognosis (median OS 16 vs. 38 months, P = 0.004). In patients treated with conventional chemotherapy only (n = 139) the results were similar (median OS 10 vs. 25 months, P = 0.02), and the apoptotic index maintained its significance even within the group of 50 patients treated also with novel drugs (median OS 30 vs. 54 months, P = 0.027). PC-AI was found to be independent on both Durie-Salmon staging system and the International Prognostic Index. CONCLUSION: Presented results suggest the use of apoptotic index by flow cytometry measurement as a fast and accessible method for prognostic stratification of myeloma patients in routine practice.

Multiple myeloma: predictive value of Tc-99m MIBI scintigraphy and MRI in its diagnosis and therapy.

BACKGROUND: We assessed the validity of (99m)Tc-MIBI scintigraphy and MRI in the diagnosis and prediction of the effect of therapy in patients with multiple myeloma (MM) and monoclonal gammopathy of unknown significance (MGUS), in whom both examinations were performed within 14 days. MATERIAL AND METHODS: Forty-seven consecutive patients with MM and 5 with MGUS were enrolled in the study. Out of 47 MM patients, 6 were in Durie-Salmon stage I and 41 had active disease in stage II or III. Fifteen patients were examined before and within 2 months of intensive chemotherapy. Anterior and posterior whole-body scans were obtained 10 min after IV administration of 740 MBq (20 mCi) (99m)Tc-MIBI. MRI of Th and LS spine, T1 w.i. and STIR in the sagittal plane were performed. RESULTS: Bone marrow pathological changes in 41 MM patients with active disease were detected in 39 (95%) scintigraphic examinations and in 38 (94%) of MRI. Among 41 MM patients with active disease, 21 showed diffuse patterns of (99m)Tc-MIBI uptake, 8 showed focal patterns and 10 showed both focal and diffuse patterns, while 34 patients exhibited focal lesions in MRI and 4 both focal and diffuse findings. Moreover, 5 of 38 patients had epidural mass and 18 had vertebrae compression. Out of 15 patients after therapy, 13 reached complete remission and 2 had stable disease. Normal (99m)Tc-MIBI scintigraphy was found in 11 (85%) patients with complete remission, 2 presented both focal and diffuse patterns of (99m)Tc-MIBI uptake. Two patients with stable disease also had focal and diffuse radiotracer uptake. MRI findings were normal only in 3 (23%) patients in complete remission. Eight patients exhibited focal lesions and 2 showed partial conversion in MRI. CONCLUSIONS: (99m)Tc-MIBI scintigraphy and MRI are methods of equal sensitivity in detecting active MM and complement each other. The advantage of 99mTc-MIBI scintigraphy is the possibility of whole body examination, which allows superiority in detection of MM in appendicular skeleton and extramedular lesions, and faster response to therapy, while the advantage of MRI is the detection of epidural masses and vertebral compressions influencing the therapeutic strategy.

Relationship of differences in immunoglobulin heavy/light chain pairs (Hevylite), selected laboratory parameters and stratification systems in different immunochemical types of multiple myeloma.

BACKGROUND AND AIMS: Advances in the diagnosis and treatment of multiple myeloma (MM), place increasing demands on accurate stratification of patients as the starting point for optimal individualized therapy. The present study focused on assessing the association between HLC levels and the HLC-r to parameters of MM activity, prognosis and tumor mass volume.The objective was to assess the correlation of immunoglobulin (Ig), heavy/light chain (HLC) pairs (IgG-κ and-λ, IgA-κ and -λ HLC) and the ratio of monoclonal involved-HLC (i-HLC) to polyclonal uninvolved (u-HLC) Ig concentrations assessed by the Hevylite(TM) method with the free light chain κ/λ ratio (FLC-r), selected prognostic laboratory parameters i.e. Hb, platelets, albumin, ß2-microglobulin (ß2-M), Ca, lactate dehydrogenase (LDH), creatinine and the Durie-Salmon (D-S) and International Staging System (ISS), stages (1-3) for MM. METHODS: Hevylite assays were done on the sera of 132 MM patients at the time of diagnosis (IgG 94, IgA 38). HLC-r was calculated in the case of i-HLC-κ from the i-HLC-κ/u-HLC-λ ratio and for i-HLC-λ from the i-HLC-λ/u-HLC-κ ratio. D-S and ISS stages were evenly distributed. RESULTS: Md IgG-κ HLC-r was 64.8 (2.7-2222) and of IgG-λ HLC-r 49.6 (0.7-465.1), in the case of IgA-κ, Md HLC-r was 408.9 (3.4-3966) and for IgA-λ HLC-r the Md was 180.0 (0.1-3110). Normal levels of HLC pairs and HLC-r did not always rule out the diagnosis of MM. HLC-r correlated with FLC-r in IgG (r = 0.244, P = 0.018), but not in the IgA type. For IgG, HLC-r values were significantly different in patients with abnormal vs normal levels of Hb (P < 0.0001), albumin (P < 0.043), ß2-M (P < 0.0001) and creatinine (P = 0.034) but not thrombocyte count, Ca or LDH. For the IgA isotype, we found a significant difference in HLC-r values only for thrombocyte count (P = 0.026) and ß2-M (P = 0.016) but not for Hb, albumin, Ca, LDH or creatinine. For the IgG isotype there was a significant relationship of HLC-r index to stages 1-3 (P = 0.038) and substage A vs B (P = 0.048) according to D-S, and with high significance to stages 1-3 according to ISS (P = 0.005) and between stages 1 vs 3 (P = 0.001). For the IgA isotype, we found significant differences in HLC-r only between stages 1-3 (P = 0.025) according to D-S but not in the case of ISS. There were no significant correlations between i-HLC Ig levels and D-S or ISS stages in both IgG-κ and λ and IgA-κ and λ. Exceptions were significant differences for stages 1 vs 3 (P = 0.012) and 2 vs 3 (P = 0.017) for the IgG-λ isotype. There were no correlations of the HLC-r and u-HLC levels for either D-S or ISS stratifications in all HLC isotypes. CONCLUSION: We found a significant positive contribution of HLC-r using the i-HLC/u-HLC ratio even in the case of i-HLC-λ i.e. i-HLC-λ/u-HLC-κ. Variable results for the relationship of important laboratory parameters and D-S and ISS stratifications (stage 1-3) to HLC-r values in IgG and IgA isotypes make separate interpretation of the Hevylite method results necessary in clinical practice.

Prospective comparison of conventional radiography, low-dose computed tomography and magnetic resonance imaging in monoclonal gammopathies.

AIMS: We carried out a prospective study in order to identify the best imaging approach for patients with newly diagnosed multiple myeloma (MM) and monoclonal gammopathy of undetermined significance (MGUS). METHODS: We assessed the extent of myeloma bone disease (MBD) in 112 individuals - 84 patients with MM and 28 individuals with MGUS. For the detection of osteolytic involvement we used whole-body magnetic resonance imaging (WB-MRI), low-dose computed tomography (LD-CT) and conventional radiography (CR). Each method assessed the presence of osteolytic involvement, compressive fractures and extramedullary involvement in the following regions: skull, spine and chest, pelvis and humerus and femur. We compared the difference in the number and extent of osteolytic involvement, especially the findings in CR negative patients. RESULTS: Conventional radiography showed no superiority in any of the evaluated regions, and failed in the detection of extramedullary massess and spine involvement. WB-MRI was best at imaging the spine including extramedullary involvement, however, detection of osteolytic lesions of the skull was limited in comparison with both CR and LD-CT. Both WB-MRI and LD-CT were comparable in imaging of lesions of pelvis, humerus, femur and the presence of extramedullary masses. LD-CT showed superiority in detection of skull lesions but lower sensitivity in spine compared to WB-MRI. CONCLUSIONS: Our results confirm that relying solely on CR in the diagnostics of MM is insufficient. We suggest that the most suitable method for primary assessment of osteolytic involvement in monoclonal gammopathies should include either whole-body MRI together with CR of the skull or, with an equivalent sensitivity, whole body LD-CT.

Molecular Cytogenetic Analysis of Chromosome 8 Aberrations in Patients With Multiple Myeloma Examined in 2 Different Stages, at Diagnosis and at Progression/Relapse.

BACKGROUND: The genome of multiple myeloma (MM) clonal plasma cells is characterized by genetic changes of prognostic importance. Disease progression is accompanied by a number of secondary chromosomal aberrations including chromosome 8. We focused on the detection of chromosome 8 aberrations in patients with MM who were examined at 2 different phases: diagnosis and progression/relapse. PATIENTS AND METHODS: A total of 62 patients with MM were examined at the time of diagnosis and at relapse/progression. The median age was 64 years (range, 39-78 years); the study included 29 males and 33 females. We analyzed bone marrow samples for detecting aberrations on chromosome 8 by the fluorescence immunophenotyping and interphase cytogenetics as a tool for the investigation of neoplasms (FICTION) and fluorescence in situ hybridization methods with specific probes. RESULTS: Chromosome 8 aberrations were detected in 24 (38.7%) patients at diagnosis and in 29 (46.8%) patients at progression/relapse. Only 5 (8%) patients developed additional chromosome 8 changes at progression/relapse. The aberrations were heterogeneous, involving numerical and structural changes of the MYC gene. Aberrations of the short arm of chromosome 8, involving the genes TRAIL-R1/-R2, were less frequent (4 of 62 patients, 6.4%). All aberrations of chromosome 8 were accompanied with additional changes and with an advanced clinical phase of the disease. This finding significantly influenced the overall survival of patients. CONCLUSION: In the current study, chromosome 8 aberrations were highly heterogeneous, were presented at diagnosis in patients with advanced clinical stage, and were associated with worse overall survival. We have not confirmed the increase of frequency aberration of chromosome 8 in disease progression. The findings demonstrate the importance of fluorescence in situ hybridization examination of chromosome 8 in newly diagnosed patients with MM.

The relationship between proliferation and apoptosis in patients with monoclonal gammopathy of undetermined significance or multiple myeloma.

Multiple myeloma (MM) is a clonal neoplastic lymphoproliferative disease affecting terminally differentiated B cells i.e. plasma cells characterized by slow proliferation activity and different resistance to apoptosis with latent accumulation of myeloma cells in the bone marrow. This process is induced by failure of normal tissue homeostatic mechanisms. We compared plasma cell proliferation and apoptic indices in various phases of MM and in monoclonal gammophaty of untetermined significance.

Outcome of patients with multiple myeloma and hypertension treated with angiotensin-I-converting enzyme inhibitors during high-dose chemotherapy.

In a retrospective study we have sought to determine whether the administration of angiotensin-I-converting enzyme inhibitors (ACEI) influences the outcome of patients with multiple myeloma (MM). Patients with MM who underwent autologous peripheral blood stem cell transplantation (PBSCT) (n=168) were studied. Patients taking ACEI alone or in combination with other antihypertensive agents during the hospital admission for PBSCT were allocated to the ACEI group (n=25; 15%). Patients from the non-ACEI group (n=143; 85%) were taking other or no antihypertensive medication. Patients taking ACEI had worse overall survival (OS) compared to patients not taking ACEI (38.7 versus 73.3 months after diagnosis; P=0.025). Among patients with hypertension, both OS and progression-free survival were significantly shorter in patients taking ACEI. There were no significant differences between the studied groups in standard prognostic parameters for MM (age, albumin, beta 2-microglobulin, IPI and Durie-Salmon stage, LDH, CRP, performance status) or in engraftment. The mortality in our study has been mostly myeloma related. In conclusion, according to our findings, ACEI administered during PBSCT have adverse effect on survival of patients with MM.

Evaluation of plasma cell propidium-iodide and annexin-V indices: their relation to prognosis in multiple myeloma.

In a group of 117 patients with multiple myeloma (MM) examined at the time of diagnosis, i.e. excluding previous chemotherapy, we analysed the levels of propidium-iodide (proliferative) - PC-PI/CD(138) and annexin-V (apoptotic) - PC-AI/CD(138) indices of myeloma plasmocytes using the method of flow-cytometry to determine their relationship to prognosis. It was revealed that patients with high values of PC-PI/CD(138) had substantially worse overall survival than those with low values. Patients with a level of propidium-iodide index > or = 2,8 % exprimed a median survival of 13 months only in comparison with 42 months in patients with levels < 2,8 % (p = 0,0005). In the PC-AI/CD(138) index a reverse trend was registered. Patients with PC-AI/CD(138) > or = 4,0 % had long overall survival (median was not assessable at the time of evaluation), whereas patients with low apoptosis values < 4,0 % had median overall survival 16 months only (p = 0,01). Based on the sequentional graphic analysis of the curves of overall survival was found that the optimal discrimination level sequestering patients with good and poor prognosis was, in the case of PC-PI/CD(138) value 2,8 %, whereas in the case of PC-AI/CD(138) value 4,0 %. Among patients with good prognosis, there were no statistically significant differences in overall survival according to different levels of proliferative and apoptotic index. We conclude that evaluation of the propidium-iodide and annexin-V index using flow-cytometry is a quick, useful, and easily accessible method for the evaluation of plasma cell kinetics and thus prognosis of the disease, multiple myeloma.