Abstract:
The present invention is drawn to diagnosis, prognosis and treatment of multiple myeloma. In this regard, the present invention discloses importance of down-regulation of TP3 gene in multiple myeloma and its use as an independent progostic indicator of multiple myeloma. Additionally, the present invention also discloses novel-TP53 associated genes and demonstrates the clinical relevance of these alterations to disease progression.

Description:
CROSS REFERENCE TO RELATED APPLICATION  
       [0001]    This is a continuation-in-part of pending application U.S. Ser. No. 11/999,766, filed Dec. 7, 2007, which claims the benefit of provisional application claims benefit of provisional application U.S. Ser. No. 60/873,840 filed on Dec. 8, 2006, now abandoned. 
     
    
     FEDERAL FUNDING LEGEND  
       [0002]    This invention was supported in part by National Institutes of Health, Campus Account No: CA55819. Consequently, the federal government has certain rights in this invention. 
     
    
     BACKGROUND OF THE INVENTION 
       [0003]    1. Field of the Invention 
         [0004]    The present invention relates generally to the field of cancer research. More specifically, the present invention relates to correlating TP53 gene status with disease progression and outcome of a large, uniformly-treated population of patients with myeloma. 
         [0005]    2. Description of the Related Art 
         [0006]    The genetic lesions important in the pathogenesis and prognosis of multiple myeloma continue to be elucidated. Gene expression profiles can be used to identify high-risk diseases [1]. However, one of the surprising findings of this study was that variation in TP53 gene expression was not indicative of high-risk disease. 
         [0007]    Using high-resolution array comparative genomic hybridization (aCGH), 87 discrete minimal common regions (MCRs) of recurrent copy number alterations (CNAs) were identified in genomic DNA from purified plasma cells derived from 65 patients with newly diagnosed multiple myeloma (MM). A total of 14 MCRs, including a deletion at chromosome 17p13.1-17p12 where the TP53 gene resides, were found to be associated with poor survival [2]. 
         [0008]    In multiple myeloma (MM), TP53 mutations are rare and may represent late events in disease progression [3-7]. The frequency of TP53 deletions detected by fluorescence in situ hybridization (FISH) is reported to range from 9% to 34% in newly diagnosed cases of multiple myeloma and is related to survival [8-13]. However, the role of TP53 loss in the pathogenesis of multiple myeloma, its relationship to gene expression, and its relevance as a prognostic variable, remain to be elucidated. 
         [0009]    As a transcription factor, TP53 regulates the expression of genes involved in a variety of cellular functions, including cell-cycle arrest, DNA repair and apoptosis [14-19] but the function of TP53 and the signaling pathways regulated by it in multiple myeloma are still not clear. The TP53-dependent expression of 122 target genes identified by PET analysis was recently demonstrated [20]. However, expression of only a few of these 122 previously identified TP53 target genes was correlated with TP53 expression in tumor cells from the cohort of 351 multiple myeloma patients. This suggested that TP53 may regulate a distinct set of genes in multiple myeloma. 
         [0010]    Thus, the prior art is deficient in the knowledge of the relative contribution of TP53 gene status in multiple myeloma. In addition, the prior art is deficient in correlating TP53 gene status with multiple myeloma disease progression and outcome. The present invention fulfills this long-standing need and desire in the art. 
       SUMMARY OF THE INVENTION 
       [0011]    The present invention is directed to a method for identifying a gene as an independent prognostic factor specific for a disease. Such a method comprises isolating plasma cells from individuals within a population; and extracting nucleic acid from the plasma cells. The extracted nucleic acid is then hybridized to a DNA array to determine expression levels of genes in the plasma cells. Subsequently, multivariate regression analyses on data obtained from the hybridization is performed, where said analysis identifies the gene as an independent prognostic factor specific for the disease. 
         [0012]    The present invention is also directed to a method for identifying a gene relevant in prognosis of a disease. Such a method comprises isolating plasma cells from individuals within a population and extracting nucleic acid from the plasma cells. The extracted nucleic acid is then hybridized to a DNA microarray; and a log rank test is performed on the data obtained from the hybridization to identify genes that are up-regulated and down-regulated in the plasma, thereby identifying the gene important for prognosis of the disease. 
         [0013]    The present invention is further directed to a method for determining prognosis of an individual with multiple myeloma, comprising: obtaining plasma cells from the individual and determining expression of TP53 alone or in combination with one or more genes selected from the group consisting of TRIM13, NADSYN1, TRIM22, AGRN, CENTD2, SESN1, TM7SF2, NICKAP1, COPG, STAT3, ALOX5, APP, ABCB9, GAA, CEP55, BRCA1, ANLN, PYGL, CCNE2, ASPM, SUV39H2, CDC25A, IFIT5, ANKRA2, PHLDB1, TUBA1A, CDCA7, CDCA2, HFE, RIF1, NEIL3, SLC4A7, FXYD5, MCC, MKNK2, KLHL24, DLC1, OPN3, B3GALNT1, SPRED1, ARHGAP25, RTN2, WNT16, DEPDC1, STT3B, ECHDC2, ENPP4, SAT2, SLAMF7, MAN1C1, INTS7, ZNF600, L3MBTL4, LAPTM4B, OSBPL10, KCNS3, THEX1. CYB5D2, UNC93B1, SIDT1, TMEM57, HIGD24, FKSG44, C14orf28, LOC387763, TncRNA, C18orf1, DCUN1D4, FANCI, ZMAT3, NOTCH1, BTG2, RAB1A, TNFRSF10B, HDLBP, RIT1, KIF2C, S100A4, MEIS1, SGOL2, CD302, C5orf34, FAM111B and C18orf54. The expression level of the gene(s) is then compared with expression level of the gene in a control individual such that genes that are up-regulated, down-regulated or a combination thereof compared to gene expression levels in plasma cell of a control individual indicates prognosis of the individual. The present invention is still further directed to a kit for prognosis of multiple myeloma, comprising: nucleic acid probes complementary to mRNA of genes described supra; and written instructions for extracting nucleic acid from plasma cells of an individual and hybridizing the nucleic acid to the DNA microarray. The present invention is still further directed to a method of treating an individual with myeloma comprising: administering bortezomid to the individual. 
         [0014]    Other and further aspects, features, and advantages of the present invention will be apparent from the following description of the presently preferred embodiments of the invention. These embodiments are given for the purpose of disclosure. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0015]    So that the matter in which the above-recited features, advantages and objects of the invention as well as others which will become clear are attained and can be understood in detail, more particular descriptions and certain embodiments of the invention briefly summarized above are illustrated in the appended drawings. These drawings form a part of the specification. It is to be noted, however, that the appended drawings illustrate preferred embodiments of the invention and therefore are not to be considered limiting in their scope. 
           [0016]      FIGS. 1A-1C  show that low expression levels of TP53 highly correlated with deletion and adversely affects outcome. In  FIG. 1A , the 194 newly diagnosed multiple myeloma on Total Therapy 2 were divided into two groups based on TP53 deletion. Kaplan-Meier estimates showed 5-year actuarial probabilities of (left panel) 36% being event-free and 52% alive in cases with TP53 deletion and (right panel) 51% event-free and 70% alive in those without TP53 deletion (P&lt;0.005).  FIG. 1B  shows that TP53 deletion is highly correlated with low TP53 expression. TP53 expression levels as measured by Affymetrix microarray signal, relative to TP53 copy number by FISH is displayed. Expression levels in 154 cases with no evidence of deletion (minimum 680; maximum 5,241; median 1,599; mean 1,487) are significantly higher than in 36 cases with monoallelic deletion (minimum 226; maximum 2,600; median 889; mean 1,044) which are higher than in 4 cases with biallelic deletion (minimum 138; maximum 599; median 470; mean 419).  FIG. 1C  shows that low TP53 gene expression is related to outcome. Samples from 351 patients with newly diagnosed MM on Total Therapy 2 were divided into two groups based on TP53 Affymetrix signal being greater than or less than 733 (lowest 10%). Kaplan-Meier estimates showed 5-year actuarial probabilities of 28% being event-free (left panel) and 41% alive in cases (right panel) with TP53&lt;733 and 50% event-free (left panel) and 68% alive (right panel) in those with TP53&gt;733 (P&lt;0.0005). 
           [0017]      FIGS. 2A-2C  show influence of TP53 expression on survival in molecular risk disease, post-relapse survival and survival in an independent cohort.  FIG. 2A  shows that low TP53 expression influences survival in molecular risk classes myeloma. When TP53 expression was put in the context of a recently described risk stratification, Kaplan-Meier estimates of 5-year actuarial probabilities of (left panel) 34% being event-free and (right panel) 52% being alive among cases with low risk cases and TP53 signal &gt;733 compared to (left panel) 55% event-free and (right panel) 69% alive among cases with low risk and TP53 signal &gt;733 (P&lt;0.005). TP53 expression did not influence survival in high risk disease  FIG. 2B  shows that low TP53 expression negatively influences post-relapse survival. The 90 patients in Total Therapy 2 with relapsed multiple myeloma were divided into two groups based in the TP53 Affymetrix signal being less than or greater than 733. Kaplan-Meier estimates show 5-year actuarial probabilities of 14% alive in cases with TP53&lt;733 versus 35% alive in cases with TP53&gt;733 (P&lt;0.05).  FIG. 2C  shows that low TP53 expression negatively influences survival in an independent cohort. The 214 patients newly diagnosed with multiple myeloma enrolled on Total Therapy 3 were divided into two groups based on TP53 expression level being less than or greater than 733. Kaplan-Meier estimates show 2-year actuarial probabilities of (left panel) 63% being event free and (right panel) 66% alive among cases with TP53&lt;733 versus 81% event-free and 88% alive among those with TP53&gt;733 (P&lt;0.05). 
           [0018]      FIGS. 3A-3B  show that TP53 expression and its associated gene expression in 51 paired MM patients on Total Therapy 2 at baseline and disease relapse. In  FIG. 3A , 51 patients had similar TP53 expression levels at baseline and relapse (P=0.455); only eight patients had at least a 2-fold TP53 signal change, five decreased and three increased at relapse. In  FIG. 3B , two-dimensional unsupervised hierarchical cluster analysis of 85 TP53-regulated genes in 51 MM patients with paired gene expression data at baseline and relapse shows that 36 of 51 patients have very similar gene expression patterns of the 85 TP53-regulated genes and these genes cluster closely together (marked by red bracket: BL indicates baseline; RL, relapse). 
           [0019]      FIGS. 4A-4B  show correlation of expression genes with TP53 expression.  FIG. 4A  shows heatmap of 122 TP53 target genes in 351 newly diagnosed multiple myeloma patients on Total Therapy 2, 214 patients on Total Therapy 3 and 90 relapsed multiple myeloma patients on Total Therapy 2.  FIG. 4B  shows the normalized log ratio of the 122 TP53 target genes in the overexpression experiments involving four multiple myeloma cell lines. 
           [0020]      FIGS. 5A-5C  show effect of TP53 expression on MM cell survival. In  FIG. 5A , TP53 (in both nuclear and cytosolic extracts) and cleaved PARP (in nuclear extracts) were evaluated by Western blot performed in OCI-MY5 cells after lentiviral infection of TP53 and empty vector (EV) at 4, 8, 12, and 24 hours. Histone H4 and p-tubulin were used as loading controls.  FIG. 5B  shows effect of overexpression of TP53 on cell viability in JJN3, OCI-MY5, ARP-1, and Delta 47 cells. Cell viability was evaluated by trypan blue exclusion every 12 hours after lentiviral infection of TP53 compared to the EV.  FIG. 5C  shows that overexpression of TP53 induces apoptosis. Cell cycle distribution and apoptosis were evaluated by flow cytometry performed 24 hours after lentiviral infection in JJN3, OCI-MY5, ARP-1, and Delta 47 cells infected with EV or TP53 cDNA. Note that overexpression of TP53 induced a dramatic increase in the percentage of cells with sub-G 0 -phase DNA content (indicative of apoptosis). 
           [0021]      FIGS. 6A-6B  show gene expression profile of 85 TP53-regulated genes in multiple myeloma cell lines and patients. A total of 85 genes were up-regulated (n=50) or down-regulated (n=35) at least 1.5-fold in at least three of four multiple myeloma cell lines, and also exhibited differential expression in a comparison of primary multiple myeloma between the lowest relative to the highest TP53 expressers. In  FIG. 6A , the red in the normalized log ratio (TP53 overexpression vs. empty vector) of the four multiple myeloma cell lines (JJN3, OCI-MY5, ARP-1, and Delta 47) represents induction, and green represents repression.  FIG. 6B  shows differences in gene expression between 36 patients on TT2 with lowest TP53 expression and 36 patients with the highest TP53 expression. 
           [0022]      FIG. 7  shows networks of TP53-regulated genes in multiple myeloma cell lines and patients. Ingenuity Pathways Analysis software was used to analyze the identified genes (n=85). Three networks were identified. The network representing proteins involved in the biological functions of cancer and the cell cycle is shown. The genes written in bold letters with a shaded node were identified by microarray analysis, and the other genes were those related to the regulated genes based on the network analysis. The intensity of a node color indicates the degree of up-regulation (red). The meanings of node shapes are indicated in the figure. 
           [0023]      FIGS. 8A-8B  show networks of TP53-regulated Genes in multiple myeloma cell lines and patients. Ingenuity Pathways Analysis software was used to analyze the identified genes (n=85). Three networks were identified. The main network was shown in  FIG. 7 . The genes written in bold letters with a shaded node were identified by microarray analysis, and the other genes were those related to the regulated genes on the basis of the network analysis. The intensity of a node color indicates the degree of up-regulation (red). The meanings of node shapes are indicated in the figure. The network in  FIG. 8A  represents proteins involved in the biological functions of the cell cycle and cellular movement, assembly, and organization. The network in  FIG. 8B  represents proteins involved in the biological functions of cell morphology and DNA replication, recombination, and repair. 
           [0024]      FIGS. 9A-9C  show gene expression profiles of TP53 regulated genes and their clinical relevance.  FIG. 9A  shows two-dimensional unsupervised hierarchical cluster analysis of 85 (rows) TP53-regulated genes in CD138-enriched plasma cells of newly diagnosed multiple myeloma patients on TT2 (n=351). The right branch consists of multiple myeloma samples that have a gene expression profile associated with a high TP53 expression level (horizontal green bar), and the left branch contains multiple myeloma samples that have a gene expression profile associated with low TP53 expression level (horizontal red bar). Kaplan-Meier estimates of ( FIG. 9B ) EFS and ( FIG. 9C ) OS in newly diagnosed multiple myeloma patients on TT2 show superior 5-year actuarial probabilities of EFS (51% vs. 39%; P=0.0006) and OS (69% vs. 46%; P=0.001) in the right-branch patients whose 85-gene expression profile was associated with a high TP53 expression level. 
           [0025]      FIGS. 10A-10B  show gene expression profiles of TP53-regulated genes and their clinical relevance. Two-dimensional unsupervised hierarchical cluster analysis of 85 (rows) TP53-regulated genes in CD138-enriched plasma cells from ( FIG. 10A , top) patients with relapsed multiple myeloma on TT2 (n=90) and (Figure B, top) newly diagnosed multiple myeloma patients on TT3 (n=214). The right branch consists of multiple myeloma samples that have a gene expression profile associated with high TP53 expression (horizontal green bar), and the left branch contains multiple myeloma samples that have a gene expression profile associated with low TP53 expression (horizontal red bar). ( FIG. 10A  shows Kaplan-Meier estimates of post-relapse survival in ( FIG. 10A , bottom) 90 relapsed-multiple myeloma patients on TT2 showed superior 5-year actuarial probabilities of post-relapse survival (55% vs. 17%; P&lt;0.0001) and in ( FIG. 10A , top) the right-branch patients with an 85-gene expression profile associated with high TP53 expression.  FIG. 10B  shows Kaplan-Meier estimates of (bottom, right hand side) EFS and (bottom, left hand side) OS in newly diagnosed multiple myeloma patients on TT3 showed superior 3-year actuarial probabilities of EFS (88% vs. 68%; P=0.0018) and OS (89% vs. 78%; P=0.0625) in (bottom, right hand side) the right-branch patients with an 85-gene expression profile associated with high TP53 expression. 
           [0026]      FIG. 11A-11C  show overall survival (left panel) and event-free survival (right panels) from start of Total Therapy 2 (TT2, both arms combined) and of Total Therapy 3 (TT3) relative to delTP53.  FIG. 11A : In gene expression profiling-defined low-risk myeloma: In the case of TT2, del-TP53 imparts inferior overall survival and event-free survival, regardless of randomization to control or thalidomide arm. By contrast, neither overall nor event-free survival was adversely affected In the case of TT3.  FIG. 11B : In gene expression profiling-defined high-risk myeloma: Del-TP53 imparts inferior overall and event-free survival in TT3, whereas outcomes were equally poor in both TT2 arms.  FIG. 11C : In the context of gene expression profiling-defined FGFR3-type myeloma (present, FGFR3+; absent, FGFR3−). Among patients treated with TT2, delTP53 was associated with shorter overall and event-free survival regardless of FGFR3 status (FGFR3−: compare c and g curves [p=0.0001; p=0.001]; FGFR3+: compare d and h curves [p=0.05; p=0.08]). In case of TT3, overall survival was inferior and a trend was noted for event-free survival in the absence of FGFR3 (FGFR3−: compare a and e curves [p=0.02; p=0.08]); no difference was observed in the presence of FGFR3 (FGFR3+: compare b and f curves [p=0.24; p=0.16]). Viewed differently, FGFR3+ adversely affected both clinical endpoints in TT2 in the absence of delTP53 (compare curves c and d [p=0.0004; p=0.001]) with trends noted in delTP53′s presence (compare g and h curves [p=0.25; p=0.10]). In the case of TT3, FGFR3+ failed to affect outcomes both in the absence of delTP53 (compare a and b curves [p=0.22; p=0.72]) and in the presence of delTP53 (compare curves e and f [p=0.65; p=0.79]). 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       [0027]    Powerful prognostic models in multiple myeloma based on the expression of 17 genes have been described [1]. This risk-stratification model for newly diagnosed multiple myeloma treated with high-dose chemotherapy was also predictive of the outcome of treating relapsed disease with the single agent bortezomib. The high-risk index based on this model is an extremely powerful prognostic factor with a hazard ratio in excess of 3 [1]. TP53 gene expression, however, was not included in the model. 
         [0028]    It was observed herein that with a 10% cut-off point (rather than the 25% and 75% cut-off points used to identify the genes in our recent expression-based model of high risk), patients with tumors with TP53 expression levels in the lowest 10 th  percentile had a significantly shorter EFS and OS than those in the 90 th  percentile. The present invention demonstrates that low expression levels of TP53 were correlated with mono- or biallelic deletion of the TP53 locus. Multivariate regression analyses revealed that low TP53 expression was an independent adverse prognostic factor and a parameter for predicting shortened survival in both TT2 and TT3, even in the context of high-risk molecular features. But t(4:14) translocation only significant in TT2 and not retained independent significance in TT3 (Table 1), it may imply that bortezomib can overcome negative impact of t(4:14) but can not overcome low TP53 expression and high risk model [24]. Low TP53 expression was able to further dissect the survival of low-risk patients defined by the 17-gene model ( FIG. 2A ). One 18 gene test (17 high risk gene and TP53) can provide more prognostic information than all other tests in combination, including standard laboratory, imaging as well as cellular and other molecular genetic parameters. The R 2  value, a measure of accounting for clinical outcome variability [23], increased from 38.4% to 39.7% (data not shown). These data add to the continued refinement of molecular prognostics in multiple myeloma. 
         [0029]    In addition to identifying TP53 as a poor prognostic factor, this study also provides, for the first time, a comprehensive list of genes that are differentially expressed in association with TP53 expression in MM. The TP53 tumor suppressor gene plays a key role in prevention of tumor formation through transcriptional-dependent and -independent mechanisms. Transcriptional-dependent mechanisms are mainly mediated by TP53 regulation of downstream targets, leading to growth arrest and apoptosis [37]. Recently, a global map of TP53 transcription factor binding sites in the human genome was identified in a colorectal cancer cell line by PET analysis, and 122 TP53 target genes were characterized [20] Their TP53-dependent expression was verified in breast cancer patients [20] however, expression of only a few of these genes was correlated with TP53 expression in multiple myeloma cells. This suggested that TP53 might regulate a distinct set of genes in multiple myeloma. Through cross-validation in human multiple myeloma cell lines and samples from two large cohorts of multiple myeloma patients, a comprehensive panel of 85 putative targets of TP53 were identified that were correlated with clinical outcome. None of the 85 TP53-associated genes were identified in the previous high-risk 70-gene model [1]. This suggests that TP53 and its associated genes may complement our 70-gene model. 
         [0030]    It is noteworthy that 69 of the 85 TP53-regulated genes have a defined function in apoptosis and the cell cycle, DNA repair and chromatin modification, cell growth and differentiation, and transcriptional regulation. Identification and characterization of these genes and their pathways may lead to a better understanding of the critical role of TP53 loss in multiple myeloma. TP53-induced growth arrest is achieved mainly by transactivation of p21 (for G 1 -phase arrest), of 14-3-3σ (for G 2 -phase arrest), or of placenta transforming growth factor-β. TP53 regulates apoptosis in transcriptional-dependent and -independent manners. Under a transcriptional-dependent mechanism, TP53 induces apoptosis by transactivating the genes in both mitochondrial and death receptor pathways, as well as transrepressing cellular survival genes [37]. The results of analysis of TP53-regulated genes showed that TP53 up-regulates death receptor pathway apoptotic genes (e.g., TNFRSF10B) and down-regulates cell cycle genes (e.g., BRCA1, cyclin E, S100A4, and CDCs) in multiple myeloma. 
         [0031]    Of the 85 TP53-associated genes, only four genes, TNFRSF10B, NOTCH1, ZMAT3, and TRIM22, were previously identified among the 122 TP53 target genes. Both TNFRSF10B and NOTCH1 gene products are cell membrane proteins. TNFRSF10B, also named KILLER/DR5, is a member of the tumor necrosis factor-receptor superfamily and plays a key role in the death receptor pathway. It is located in a minimal region of loss at 8p21.3-p12 in MM [2]. TNFRSF10B is a TP53-inducible receptor for the cytotoxic ligand TNFSF10/TRAIL and induces a caspase-dependent apoptotic pathway [38]. The improved recombinant form of the death ligand TRAIL is not cytotoxic for normal human cells and is a good candidate for the treatment of multiple myeloma [39]. NOTCH1 functions as a receptor for membrane-bound ligands Jagged1, Jagged2, and Delta1 to regulate cell-fate determination, and affects the implementation of differentiation, proliferation, and apoptotic programs [41]. Recent results show that NOTCH1 signaling is involved in bone marrow stroma-mediated de novo drug resistance in MM [42]. ZMAT3, also named WIG1, is a TP53-regulated gene that encodes a growth inhibitory zinc finger protein [43]. Wig-1 can bind short-interfering/micro RNAs in vitro, which raises the possibility that it is involved in miRNA-mediated regulation of cell growth and survival, acting to promote TP53-induced cell growth arrest and/or apoptosis [44]. TRIM22, and another TRIM/RBCC family member, TRIM13, were identified as associated with TP53 expression in the present invention. The interferon-inducible protein TRIM22 has been identified as a TP53 target gene, with possible involvement in hematopoietic proliferation and differentiation [45]. TRIM13 is one of most likely candidates for tumor suppressor gene for B-cell chronic lymphocytic leukemia [46]. TRIM13 has also been found to exhibit copy number-sensitive expression in multiple myeloma [2]. The roles of TP53 and these universal target genes in both tumor origin and the tumor response to chemotherapy indicate that these types of studies will be useful in developing a more rational approach to cancer treatments. 
         [0032]    No significant differences were found in TP53 deletion and expression at baseline and in relapsed disease in 51 paired samples, and it is noteworthy that most (36 of 51) paired samples had a gene expression pattern similar to that observed when TP53 is expressed. This result may imply that the current treatment for multiple myeloma has no efficacy in regulating TP53 and expression of its associated genes. The present invention also provides evidence that 90% of TP53 deletions in multiple myeloma are monoallelic deletions. Furthermore, TP53 mutation is not a frequent event in multiple myeloma [3-7]. Consistent with previous studies, TP53 mutation was not detected in 24 newly diagnosed patients. Overexpression of TP53 can induce strong apoptosis in vitro. Taken together, the results presented herein may indicate an ideal strategy for induction of apoptosis in apoptosis-resistant cancer cells through the modulation of TP53 or MM-specific TP53 signaling pathways. 
         [0033]    In conclusion, the present invention demonstrated that low TP53 gene expression is strongly correlated with 17p13 deletion and is an independent adverse prognostic marker in newly diagnosed multiple myeloma treated with autotransplantations. In addition, using expression profiling, the present invention identified multiple myeloma-specific genes associated with TP53 expression in both cultured myeloma cells and primary tumors that correlated with clinical outcome. The data presented herein suggest that low levels of expression of TP53 and its regulated genes are associated with a malignant phenotype in multiple myeloma, and this finding may provide insight into the molecular mechanisms of multiple myeloma and may inform possible novel targets for future therapies for multiple myeloma and other cancers. 
         [0034]    In one embodiment of the present invention there is provided a method for identifying a gene as an independent prognostic factor specific for a disease, comprising: isolating plasma cells from individuals within a population; extracting nucleic acid from the plasma cells; hybridizing the nucleic acid to a DNA array to determine expression levels of genes in the plasma cells; and performing multivariate regression analyses on data obtained from the hybridization, where the analysis identifies the gene as an independent prognostic factor specific for a disease. Further, the low expression of the gene may correlate with poor prognosis, deletion in chromosome, decreased gene copy number, or a combination thereof. The altered gene expression and copy abnormalities may be detected using interphase fluorescent in situ hybridization, metaphase fluorescent in situ hybridization, PCR-based assays, protein-based assays, or a combination thereof. The prognosis may comprise a shorter event-free and overall survival. Additionally, the deletion may be on chromosome 17p13. Furthermore, the gene identified as an independent prognostic factor specific for a disease may include but is not limited to TP53. In case the gene is TP53, the disease may be cancer, where the cancer may include but is not limited to multiple myeloma. 
         [0035]    In another embodiment of the present invention there is provided a method for identifying a gene relevant in prognosis of a disease, comprising: isolating plasma cells from individuals within a population; extracting nucleic acid from the plasma cells; hybridizing the nucleic acid to a DNA microarray; and performing log rank test on the data obtained from the hybridization to identify genes that are up-regulated and down-regulated in the plasma, thereby identifying the gene important for prognosis of the disease. This method may further comprise analyzing nucleic acid obtained from the plasma cells; and performing log rank test on data obtained after analyzing the nucleic acid, where the test correlates the status of the gene with progression and outcome of the disease. The analysis of the nucleic acid may comprise determining mRNA expression of the gene, sequence integrity of the gene, copy number of the gene or a combination thereof. The altered gene expression and copy abnormalities may be detected using interphase fluorescent in situ hybridization, metaphase fluorescent in situ hybridization, PCR-based assays, protein-based assays, or a combination thereof. 
         [0036]    The method may also further comprise performing gene expression profiling to identify genes associated with the gene linked to survival specific for the disease. Examples of the genes thus, identified may include but are not limited to the ones selected from the group consisting of TRIM13, NADSYN1, TRIM22, AGRN, CENTD2, SESN1, TM7SF2, NICKAP1, COPG, STAT3, ALOX5, APP, ABCB9, GAA, CEP55, BRCA1, ANLN, PYGL, CCNE2, ASPM, SUV39H2, CDC25A, IFIT5, ANKRA2, PHLDB1, TUBA1A, CDCA7, CDCA2, HFE, RIF1, NEIL3, SLC4A7, FXYD5, MCC, MKNK2, KLHL24, DLC1, OPN3, B3GALNT1, SPRED1, ARHGAP25, RTN2, WNT16, DEPDC1, STT3B, ECHDC2, ENPP4, SAT2, SLAMF7, MAN1C1, INTS7, ZNF600, L3MBTL4, LAPTM4B, OSBPL10, KCNS3, THEX1. CYB5D2, UNC93B1, SIDT1, TMEM57, HIGD24, FKSG44, C14orf28, LOC387763, TncRNA, C18orf1, DCUN1D4, FANCI, ZMAT3, NOTCH1, BTG2, RAB1A, TNFRSF10B, HDLBP, RIT1, KIF2C, S100A4, MEIS1, SGOL2, CD302, C5orf34, FAM111B and C18orf54. Moreover, the method may correlate the expression of the gene to survival of an individual suffering from the disease, with molecular classification of the disease, with molecular risk stratification of the disease to predict outcome or a combination thereof. Additionally, the low expression of the gene may correlate with the high-risk molecular classification of the disease. Further, the high-risk molecular classification of multiple myeloma maybe characterized by increased combined expression of MMSET, MAF/MAFB and PROLIFERATION signatures. Furthermore, the prognosis may comprise a shorter event-free and overall survival. Example of the gene identified by such a method may include but is not limited to TP53 and the disease may be cancer. Example of the cancer may include but is not limited to multiple myeloma. 
         [0037]    In yet another embodiment of the present invention, there is a method for determining prognosis of an individual with multiple myeloma, comprising: obtaining plasma cells from the individual; determining expression of TP53 alone or in combination with one or more genes selected from the group consisting of TRIM13, NADSYN1, TRIM22, AGRN, CENTD2, SESN1, TM7SF2, NICKAP1, COPG, STAT3, ALOX5, APP, ABCB9, GAA, CEP55, BRCA1, ANLN, PYGL, CCNE2, ASPM, SUV39H2, CDC25A, IFIT5, ANKRA2, PHLDB1, TUBA1A, CDCA7, CDCA2, HFE, RIF1, NEIL3, SLC4A7, FXYD5, MCC, MKNK2, KLHL24, DLC1, OPN3, B3GALNT1, SPRED1, ARHGAP25, RTN2, WNT16, DEPDC1, STT3B, ECHDC2, ENPP4, SAT2, SLAMF7, MAN1C1, INTS7, ZNF600, L3MBTL4, LAPTM4B, OSBPL10, KCNS3, THEX1. CYB5D2, UNC93B1, SIDT1, TMEM57, HIGD24, FKSG44, C14orf28, LOC387763, TncRNA, C18orf1, DCUN1D4, FANCI, ZMAT3, NOTCH1, BTG2, RAB1A, TNFRSF10B, HDLBP, RIT1, KIF2C, S100A4, MEIS1, SGOL2, CD302, C5orf34, FAM111B and C18orf54; and comparing the expression level of the gene(s) with expression level of the gene in a control individual such that genes that are up-regulated, down-regulated or a combination thereof compared to gene expression levels in plasma cell of a control individual indicates prognosis of the individual. 
         [0038]    The individual with poor prognosis may have up-regulated expression of one or more genes selected from the group consisting of CEP55, BRCA1, ANLN, PYGL, CCNE2, ASPM, SUV39H2, CDC25A, TUBA1A, CDCA7, CDCA2, HFE, RIF1, NEIL3, SLC4A7, OPN3, B3GALNT1, SPRED1, DEPDC1, ENPP4, INTS7, L3MBTL4, THEX1, DCUN1D4, FANCI, ZMAT3, NOTCH1, BTG2, RAB1A, TNFRSF10B, HDLBP, RIT1, KIF2C, S100A4, MEIS1, SGOL2, CD302, C5orf34, FAM111B and C18orf54 and may have down-regulated expression of TP53 alone or in combination with one or more genes selected from the group consisting of TRIM13, NADSYN1, TRIM22, AGRN, CENTD2, SESN1, TM7SF2, NICKAP1, COPG, STAT3, ALOX5, APP, ABCB9, GAA, IFIT5, ANKRA2, PHLDB1, FXYD5, MCC, MKNK2, KLHL24, DLC1, ARHGAP25, RTN2, WNT16, STT3B, ECHDC2, SAT2, SLAMF7, MAN1C1, ZNF600, LAPTM4B, OSBPL10, KCNS3, CYB5D2, UNC93B1, SIDT1, TMEM57, HIGD24, FKSG44, C14orf28, LOC387763, TncRNA and C18orf1. The poor prognosis comprises a shorter event-free and overall survival, a high-risk subtype of the multiple myeloma or both. The high-risk subtype of multiple myeloma is further characterized by increased combined expression of MMSET, MAF/MAFB and PROLIFERATION signatures. The gene expression in such a case may be determined by RT-PCR or DNA microarray. Further, the control individual may be a normal healthy individual. 
         [0039]    In still yet another embodiment, there is a kit for prognosis of multiple myeloma, comprising: nucleic acid probes complementary to mRNA of genes described supra; and written instructions for extracting nucleic acid from plasma cells of an individual and hybridizing said nucleic acid to the DNA microarray. 
         [0040]    In still yet another embodiment, there is a method of treating an individual with myeloma comprising: administering bortezomid to the individual. The myeloma may be low-risk myeloma or high-risk myeloma. The individual may have a deletion of TP53 gene. This deletion may be determined by interphase fluorescent in situ hybridization, metaphase fluorescent in situ hybridization, PCR-based assays, protein-based assays, or a combination thereof. The method of treating may also comprise: administering an inhibitor of HSP90 to the individual. The inihibitor of HSP90 may be tanespimycine. 
         [0041]    As used herein, the term, “a” or “an” may mean one or more. As used herein in the claim(s), when used in conjunction with the word “comprising”, the words “a” or “an” may mean one or more than one. As used herein “another” or “other” may mean at least a second or more of the same or different claim element or components thereof. 
         [0042]    The following examples are given for the purpose of illustrating various embodiments of the invention and are not meant to limit the present invention in any fashion. One skilled in the art will appreciate readily that the present invention is well adapted to carry out the objects and obtain the ends and advantages mentioned, as well as those objects, ends and advantages inherent herein. Changes therein and other uses which are encompassed within the spirit of the invention as defined by the scope of the claims will occur to those skilled in the art. 
       Example 1 
     Study Subjects 
       [0043]    Purified plasma cells (PCs) were obtained from newly diagnosed multiple myeloma patients who were treated on NIH-sponsored clinical trials UARK 98-026 (Total Therapy 2, TT2) (n=351) and UARK 03-033 (Total Therapy 3, TT3) (n=214) [1, 21-26]. Both protocols utilized induction regimens, followed by melphalan-based tandem autotransplants, consolidation chemotherapy and maintenance treatment. 
         [0044]    Human multiple myeloma cell lines ARP-1, JJN3, OCI-MY5 and Delta 47 were cultured in RPMI 1640 containing 10% heat-inactivated fetal calf serum (FCS), 2 mM L-glutamine (Gibco, Grand Island, N.Y.), penicillin (100 U/mL) and streptomycin (100 μg/mL) at 37° C. in humidified 95% air and 5% CO 2 . 
       Example 2 
     Fluorescence In Situ Hybridization 
       [0045]    To detect TP53 deletions, a SpectrumRed-labeled DNA probe (LSI p53; Vysis, Downers Grove, Ill.) was combined with a SpectrumGreen-labeled probe (CEP17, Vysis) for the chromosome 17 α-satellite-DNA centromere. The triple color interphase (TRI)-FISH procedure used to analyze the samples has been previously described [27, 28]. Based on FISH studies of normal bone marrow mononuclear cells, the upper limit of normal plus three standard deviations was less than 10% for deletions of TP53; [8] therefore, the background cut-off level of 10% was used for the probes sets. 
       Example 3 
     Gene Expression Profiling 
       [0046]    Bone marrow plasma cells from 565 newly diagnosed (351 TT2 and 214 TT3) patients, and 90 patients with relapsed disease were purified by CD138 (+) selection (29, 30). Gene expressions levels in purified plasma cells and multiple myeloma cell lines were profiled using with the U133plus2.0 array (Affymetrix, Santa Clara, Calif.), and the signals of probe set 201746_ at representing TP53 was used in this analysis. Signal intensities were preprocessed using GCOS1.1 software and normalized by GCOS1.1 software [29-31]. Gene expression data on this patient cohort can be found at the NIH GEO omnibus under accession number GSE2658 [1, 21, 22, 25, 27]. 
       Example 4  
     Over-Expression of the TP53 Gene in MM Cell Lines 
       [0047]    The amplified TP53 cDNA sequence was cloned into the pWPI lentiviral vector, which was a gift from Didier Trono, Md. (National Center for Competence in Research, Lausanne, Switzerland) [32]. Recombinant lentivirus was produced by transient transfection of 293T cells according to a standard protocol [33,34]. Crude virus was concentrated by ultracentrifugation at 26,000 rpm for 90 minutes. Viral titers were determined by measuring the amount of HIV-1 p24 antigen by enzyme-linked immunosorbent assay (ELISA) (NEN Life Science Products, Boston, Mass.). A 99% transduction efficiency of multiple myeloma cell lines was achieved with 3000 ng of lentiviral p24 particles per 10 6  cells. 
       Example 5 
     Western Blotting 
       [0048]    To test TP53 protein levels in multiple myeloma cell lines and for TP53 over-expression studies, nuclear protein was isolated with the Nuclear/Cytosol Fractionation Kit (BioVision Research Products, Mountain View, Calif.). Nuclear protein (30 μg) was separated by electrophoresis on 4-12% SDS-polyacrylamide gels, and Western blotting was performed with the WesternBreeze Chemiluminescent Immunodetection protocol (Invitrogen, Carlsbad, Calif.). Antibodies to anti-poly(ADP-ribose) polymerase (PARP), anti-β-tubulin, and anti-histone 4 were purchased from Upstate Biotechnology (Charlottesville, Va.); anti-p53 was purchased from Chemicon International (Temecula, Calif.). 
       Example 6  
     Evaluation of DNA Binding Activity of TP53 by ELISA 
       [0049]    The DNA binding activity of TP53 was quantified by ELISA using the TransAM p53 transcription factor assay kit (Active Motif North America, Carlsbad, Calif.) according to the manufacturer&#39;s instructions. Briefly, nuclear extracts were prepared as described [33] and incubated in 96-well plates coated with immobilized oligonucleotide (5′-RRRCEEGYYY-3′, R=A or G, Y=C or T, W=A or T; SEQ ID NO: 1) containing a consensus binding site for TP53. TP53 binding to the target oligonucleotide was detected by incubation with a primary antibody specific for TP53, visualized with anti-IgG-horseradish peroxidase conjugate and developing solution, and quantified at 450 nm with a reference wavelength of 655 nm. Background binding was subtracted from the value obtained for binding to the consensus DNA sequence. Each sample was analyzed in duplicate, and the results were expressed as the mean±SEM. 
       Example 7  
     Cell Cycle/DNA Content Analysis 
       [0050]    Cells (1×10 6 ) from each sample were fixed in 75% ethanol at −20° C. overnight. The next day, the cells were washed with cold phosphate-buffered saline, treated with 100 μg RNase A (Qiagen, Valencia, Calif.), and stained with 50 μg of propidium iodide (Roche Applied Science, Indianapolis, Ind.). Flow cytometric acquisition was performed with a three-color FACScan flow cytometer and CellQuest software (Becton Dickinson, San Jose, Calif.). For each sample, 10,000 events were gated. Data were analyzed with Modfit LT software (Verity Software House, Topsham, Me.). 
       Example 8  
     TP53 Mutations Detected by Sequencing Analysis 
       [0051]    Mononuclear cells were obtained from bone marrow specimens and enriched using a Ficoll-gradient centrifugation method. Genomic DNA was used as a template (100 ng/reaction) for PCR analysis using intronic primer pairs (TP53 Ex2-4-F and TP53 Ex7-9-R) covering exons 2-9 of the TP53 gene, where most TP53 mutations were detected [35]. Sequencing primers nested within the PCR products 
         [0000]    
       
         
               
               
               
             
           
               
                   
                 (TP53-Ex2-4-F: 
                   
               
               
                   
                 5′-CAGCCATTCTTTTCCTGCTC-3′, 
                 (SEQ ID NO: 2) 
               
               
                   
                   
               
               
                   
                 TP53-Ex2-4-R: 
               
               
                   
                 5′-AGGGTGTGATGGGATGGATA-3′, 
                 (SEQ ID NO: 3) 
               
               
                   
                   
               
               
                   
                 TP53-Ex5-6-F: 
               
               
                   
                 5′-GTTTCTTTGCTGCCGTCTTC-3′, 
                 (SEQ ID NO: 4) 
               
               
                   
                   
               
               
                   
                 TP53-Ex5-6-R: 
               
               
                   
                 5′-TTGCACATCTCATGGGGTTA-3′, 
                 (SEQ ID NO: 5) 
               
               
                   
                   
               
               
                   
                 TP53-Ex7-9-F: 
               
               
                   
                 5′-GGAGGCTGAGGAAGGAGAAT-3′ 
                 (SEQ ID NO: 6) 
               
               
                   
                 and 
               
               
                   
                   
               
               
                   
                 TP53-Ex7-9-R: 
               
               
                   
                 5′-TTGAAAGCTGGTCTGGTCCT-3′. 
                 (SEQ ID NO: 7)) 
               
             
          
         
       
     
       Example 9 
     Statistical Analyses 
       [0052]    The Kaplan-Meier method was to estimate OS. OS was defined as the time from the date of registration until death from any cause; survivors were censored at the time of last contact. Significance analysis of microarray (SAM) [36] was used to determine statistically significant expression changes of genes in high- and low-TP53-expressing MM plasma cells. Univariate and multivariate analyses of prognostic factors were performed with the Cox regression. 
       Example 10  
       [0053]    Low TP53 Expression, Highly Correlated with Deletion, is a Significant and Independent Adverse Prognostic Factor in Newly Diagnosed MM 
         [0054]    FISH analyses for TP53 deletion were available for 194 TT2 cohort patients with newly diagnosed disease. TP53 deletion was observed in 40 (20.6%) samples, four of which had biallelic deletion. Patients with TP53 deletion were associated with shorter EFS and OS (P=0.0233 and P=0.0007, respectively;  FIG. 1A , RHS and LHS). However, increased incidence of deletion was not found in 28 cases for which a sample was tested at diagnosis and at disease relapse paired patients with relapsed disease. 
         [0055]    TP53 deletion was highly correlated with low TP53 expression. Comparison of TP53 expression level on the basis of deletion status revealed that TP53 expression was lower in 36 monoallelic deletion cases (P&lt;0.001) and even lower in four biallelic deletion cases (P=0.001) than in 150 nondeletion cases ( FIG. 1B ). 
         [0056]    TP53 expression in the 351 newly diagnosed cases varied from an Affymterix signal output (a quantitative measure of the level of activity of a given gene) from a low of 10 to a high of 5,241. Using a running log-rank test, a 10% cutoff was defined as those cases with a TP53 expression level lower than 733 on the basis of the Affymetrix microarray signal represented by 36 of 351 patients with newly diagnosed disease. Genes with an expression level below 500 typically have an absent-detection call and are not detectable by sensitive quantitative RT-PCR. The cases with low TP53 expression were associated with a shorter EFS and OS (P=0.0004 and P=0.0001, respectively;  FIG. 1C , right and left hand sides). 
         [0057]    With regard to clinical and biological features, patients with a low TP53 expression level had high levels of lactate dehydrogenase (LDH) (P=0.036), increased numbers of bone lesions on magnetic resonance imaging (MRI) (P=0.012), and an increased incidence of deletion of chromosome 13 (P&lt;0.001) and amplification of chromosome 1q21 (P=0.002) (Table 1). In the context of a recently defined molecular subgroup classification [25], the proportion of cases with low levels of TP53 expression was greater in the high-risk molecular subgroups than in the low-risk subgroups. The high-risk molecular subgroups included the MMSET (MS) subtype with a t(4;14) translocation, the MAF/MAFB (MF) subtype with a t(14;16) or a t(14;20) translocation, and the proliferation (PR) subtype; the low-risk groups consisted of subtypes designated hyperdiploid (HY) or low bone disease (LB) or marked by CCND1/CCND3 spike signatures (CD-1 or CD-2) (59% vs. 35%; P=0.023). In the context of molecular risk stratification based on 17 genes [1] TP53 Affymetrix signal &lt;733 was seen in 30 (9.8%) of 305 low-risk and in 6 (13%) of 46 high-risk-disease cases. Low TP53 expression adversely affected both EFS and OS in low-risk but not high-risk disease ( FIG. 2A , right and left hand sides). Given the strong correlation between low TP53 expression and high-risk MM subtypes, whether low TP53 expression levels simply reflected the poor prognostic features of high-risk MM [1] or whether it held independent prognostic significance was investigated herein. In a multivariate analysis, low TP53 gene expression was an independent poor-prognostic factor with respect to both EFS and OS (Table 2). Thus, although associated with a number of high-risk-MM features, reduced TP53 gene expression independently confers a poor clinical outcome. 
         [0058]    With the same cut-off point, a low TP53 gene expression level predicted short post-relapse survival (P=0.0302;  FIG. 2B ) in 90 TT2 patients with relapsed disease and short EFS and OS (P=0.0171 and P=0.0221, respectively;  FIG. 2C , right and left hand sides) in a separate cohort of 214 patients treated on the successor protocol TT3. 
         [0000]    
       
         
               
             
               
               
               
               
             
           
               
                 TABLE 1 
               
             
             
               
                   
               
               
                 Baseline patient characteristics 
               
               
                 according to TP53 expression level 
               
             
          
           
               
                   
                 Low 
                 High 
                   
               
               
                   
                 TP53 (%) 
                 TP53 (%) 
               
               
                 Characteristics 
                 (n = 36) 
                 (n = 316) 
                 P† 
               
               
                   
               
               
                 Age ≧ 65 yr 
                 29 
                 22 
                 NS 
               
               
                 Female sex 
                 51 
                 42 
                 NS 
               
               
                 Caucasian race 
                 94 
                 88 
                 NS 
               
               
                 IgA isotype 
                 20 
                 26 
                 NS 
               
               
                 Creatinine at least 2.0 mg/dl 
                 20 
                 10 
                 NS 
               
               
                 (221 umol/liter) 
               
               
                 MRI focal bone lesions, at least 3 
                 77 
                 55 
                 NS 
               
               
                 CRP at least 8.0 mg/liter 
                 49 
                 34 
                 NS 
               
               
                 LDH at least 190 IU/liter 
                 49 
                 31 
                 .036 
               
               
                 β 2 -microglobulin 
                 60 
                 59 
               
               
                 Less than 3.5 mg/L 
               
               
                 At least 3.5 and less than 5.5 mg/L 
                 14 
                 20 
                 NS 
               
               
                 ≧5.5 mg/L 
                 26 
                 21 
               
               
                 ALB less than 3.5 g/dl 
                 17 
                 14 
                 NS 
               
               
                 Hb less than 10 g/dl 
                 23 
                 26 
                 NS 
               
               
                 BMPC (by aspiration) 33% or greater 
                 61 
                 66 
                 NS 
               
               
                 Chromosomal abnormalities 
                 40 
                 34 
                 NS 
               
               
                 (defined by G-banding) 
               
               
                 Deletion of chromosome 13 
                 84 
                 46 
                 &lt;.001  
               
               
                 Amplification of 1q21 
                 75 
                 42 
                 .002 
               
               
                 High risk model (17 gene)* 
                 19 
                 14 
                 NS 
               
               
                 Subgroups with poor prognosis* 
                 59 
                 35 
                 .023 
               
               
                 (Proliferation/MMSET/FGFR3/ 
               
               
                 MAF/MAFB) 
               
               
                   
               
               
                 Abbreviations: 
               
               
                 MRI, magnetic resonance imaging; 
               
               
                 CRP, C-reactive protein; 
               
               
                 LDH: lactate dehydrogenase; 
               
               
                 NS: not significant. 
               
               
                 *High risk model [1] and PR/MS/MF subgroup designation [25] have been described elsewhere. 
               
               
                 †Chi-square was used to compare the clinical and biological parameters between cases with the lowest 10% of TP53 expression and the other 90% of cases with higher expression levels. 
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
               
             
               
               
               
               
               
               
               
             
               
               
               
               
               
               
               
             
           
               
                 TABLE 2 
               
             
             
               
                   
               
               
                 Multivariate analysis of clinical characteristics affecting OS and EFS. 
               
             
          
           
               
                   
                 Overall Survival 
                 Event-Free Survival 
               
             
          
           
               
                   
                 Variable 
                 n/N (%) 
                 HR (95% CI) 
                 P 
                 HR (95% CI) 
                 P 
               
               
                   
                   
               
             
          
           
               
                 TT2 
                 Creatinine &gt;= 2.0 mg/dL 
                 37/334 (11%) 
                 1.75 (1.07, 2.84) 
                 0.024 
                 1.70 (1.19, 2.43) 
                 0.004 
               
               
                   
                 LDH &gt;= 190 U/L 
                 114/334 (34%)  
                 1.81 (1.24, 2.66) 
                 0.002 
                 1.44 (1.13, 1.82) 
                 0.003 
               
               
                   
                 Cytogenetic 
                 108/334 (32%)  
                 1.77 (1.20, 2.62) 
                 0.004 
                 NS 
                 NS 
               
               
                   
                 abnormalities 
               
               
                   
                 Randomization to 
                 166/334 (50%)  
                 NS 
                 NS 
                 0.75 (0.60, 0.93) 
                 0.009 
               
               
                   
                 Thalidomide 
               
               
                   
                 t(4; 14) 
                 47/334 (14%) 
                 1.81 (1.15, 2.85) 
                 0.010 
                 1.87 (1.35, 2.57) 
                 &lt;.001 
               
               
                   
                 17 gene-defined 
                 50/334 (15%) 
                 2.47 (1.58, 3.85) 
                 &lt;.001 
                 2.15 (1.56, 2.96) 
                 &lt;.001 
               
               
                   
                 GEP high-risk 
               
               
                   
                 TP53 high-risk 
                 35/334 (10%) 
                 2.01 (1.22, 3.30) 
                 0.006 
                 1.44 (1.00, 2.07) 
                 0.049 
               
               
                 TT3 
                 Age &gt;= 65 
                 50/176 (28%) 
                 2.32 (1.04, 5.22) 
                 0.041 
                 NS 
                 NS 
               
               
                   
                 B2M &gt; 5.5 mg/L 
                 38/176 (22%) 
                 NS 
                 NS 
                 3.33 (1.68, 6.62) 
                 &lt;.001 
               
               
                   
                 Creatinine &gt;= 2.0 mg/dL 
                 58/176 (33%) 
                 3.54 (1.54, 8.16) 
                 0.003 
                 NS 
                 NS 
               
               
                   
                 Cytogenetic 
                 30/176 (17%) 
                 2.42 (1.08, 5.39) 
                 0.031 
                 NS 
                 NS 
               
               
                   
                 abnormalities 
               
               
                   
                 17-gene High-risk 
                 20/176 (11%) 
                 3.19 (1.32, 7.68) 
                 0.010 
                 3.97 (1.98, 7.97) 
                 &lt;.001 
               
               
                   
                 TP53 high-risk 
                 50/176 (28%) 
                 2.32 (1.04, 5.22) 
                 0.041 
                 2.51 (1.13, 5.57) 
                 0.024 
               
               
                   
               
               
                 The multivariate model uses stepwise selection with entry level 0.1 and variable remains if meets the 0.05 level. A multivariate P value greater than 0.05 indicates a variable forced into the model, with significant variables chosen by stepwise selection. 
               
               
                 HR indicates hazard ratio; 
               
               
                 95% CI, 95% confidence interval; 
               
               
                 P, probability value from Wald Chi-square test in Co x  regression; 
               
               
                 NS, not statistically significant at the 0.05-level on multivariate analysis; 
               
               
                 LDH, lactate dehydrogenase; 
               
               
                 GEP, gene expression profile. 
               
               
                 PI, proliferation index [25], 
               
               
                 *17 gene-defined GEP high-risk has been described elsewhere. 1   
               
               
                 †Variables for which P &gt; 0.05: age, race, sex, isotype, hemoglobin, C-reactive protein, MRI lesions, and albumin 
               
             
          
         
       
     
       Example 11  
     No Significant Increase in Deletion of TP53 or Decrease in Expression of TP53 in Relapsed Disease 
       [0059]    Fifty-one patients had TP53 gene expression data available at both diagnosis and relapse. Consistent with paired FISH results, in these 51 patients, there were also no significant differences in TP53 gene expression at baseline compared with expression at relapse, only eight patients have at least a 2-fold change in TP53 expression level, five having a decreased level and three an increased level at relapse ( FIG. 3A ). 
         [0060]    Interestingly, 36 of 51 patients had very similar gene expression patterns of the 85 TP53-associated genes at baseline and relapse. When the gene expression data on the 51 paired baseline and relapse cases were combined and unsupervised hierarchical clustering was performed, the data clustered closely together ( FIG. 3B ). 
       Example 12  
     TP53 Mutation is a Rare and Late Event in MM 
       [0061]    TP53 mutations were detected by sequencing exons 2-9 in 44 patients, 24 of whom had newly diagnosed disease and 27 had relapsed disease; in 7 of the 44 cases, there were paired baseline and relapse samples. No mutations were detected in 24 newly diagnosed cases or the seven paired baseline-relapse samples, whereas mutations were detected in exons 7, 8 and 9 in 5 of 20 unpaired relapsed-disease samples. 
       Example 13  
     Effects of Overexpressing TP53 on MM Cell Growth and Survival 
       [0062]    Recently, PET analysis in a colorectal cancer cell line identified 122 TP53 target genes, whose TP53-dependent expression was verified in breast tumors [20]. However, expression of only a few of the previously identified TP53 target genes was correlated with TP53 expression in multiple myeloma cells ( FIG. 4A ). This suggested that TP53 might regulate a distinct set of genes in multiple myeloma. To elucidate the TP53 regulatory networks in multiple myeloma, lentiviral transduction was used to overexpress TP53 in four multiple myeloma cell lines: OCI-MY5, JJN3, ARP-1 and Delta 47. 
         [0063]    Stable expression of TP53 in OCI-MY5 cells was confirmed by Western blot 24 hours post-lentiviral infection ( FIG. 5A ). To verify that TP53 was capable of activating target genes, TP53 DNA binding activity was examined. These studies confirmed that TP53 overexpression was correlated with increased DNA binding activity at 24 hours post-lentiviral infection. The effect of TP53 overexpression on multiple myeloma cell proliferation and viability was also examined. TP53 overexpression decreased cell viability in the four multiple myeloma cell lines within 24 hours (viability 60%-67%, measured by trypan blue exclusion), and massive cell death occurred within 36 hours (viability 15%-26%), compared with 90% viability of control multiple myeloma cells infected with empty vector. At 48 hours post-lentiviral transduction, virtually all cells expressing TP53 had died, while the control cells continued to proliferate ( FIG. 5B ). 
         [0064]    Cell proliferation and apoptosis were quantitatively assessed by flow cytometry. The results showed that TP53 expression induced strong apoptosis at 24 hours after infection ( FIG. 5C ). Analysis of apoptotic mechanisms revealed that TP53 overexpression in multiple myeloma cells was also associated with cleavage of PARP, an apoptotic marker ( FIG. 5A ). 
         [0065]    On the basis of analysis of protein expression and DNA binding activity, TP53-regulated genes expressed 24 hours post-lentiviral infection were identified herein. Additionally, gene expression profiling showed that at 24 hours there were significantly increased numbers of probe sets, which had a 1.5-fold or greater change between TP53-expressing and -nonexpressing OCI-MY5 cells (data not shown). Therefore, gene expression was profiled in the four multiple myeloma cell lines (JJN3, OCI-MY5, ARP-1 and Delta 47) at 24 hours post-lentiviral infection to identify TP53-regulated genes. 
       Example 14  
       [0066]    Identification and Classification of Genes Associated with TP53 Expression in MM 
         [0067]    Gene expression profiling revealed that a total of 85 genes were affected by TP53 overexpression (50 being up-regulated and 35 down-regulated) of 1.5-fold or greater in at least three of the four multiple myeloma cell lines. Consistent with TP53 cellular functions, 69 of the 85 genes in multiple myeloma were found involved in apoptosis, cell cycle regulation, cell growth and differentiation, DNA repair and chromatin modification, and transcription regulation (Table 3;  FIG. 6A ). To identify the most relevant biological mechanisms, pathways, and functional categories of the 85 genes affected by TP53 expression, Ingenuity Pathways Analysis software (Ingenuity Systems, Mountain View, Calif.) was used. Three networks were identified, representing proteins involved in cancer and the cell cycle ( FIG. 7 ); cell cycle and cellular movement, assembly, and organization ( FIG. 8A ); and cell morphology and DNA replication, recombination, and repair ( FIG. 8B ). 
         [0068]    The 85 genes associated with TP53 overexpression also exhibited differential expression in primary multiple myeloma when the lowest relative to the highest TP53 expressers were compared ( FIG. 6B ), suggesting that TP53 may directly or indirectly regulate the expression of these genes. None of the differentially expressed genes were identified in our 70-gene high-risk model [1]. 
         [0069]    From the group of 122 TP53 target genes identified by PET analysis [20], only 11 up-regulated genes were consistently expressed in all four MM cell lines (1.5-fold or greater in at least three of the four MM cell lines;  FIG. 4B ), and only 4 of these 11 genes (ZMAT3, TNFRSF10B, TRIM22, and NOTCH1) were correlated with TP53 expression in primary MM cells. 
         [0000]    
       
         
               
             
               
               
               
               
               
               
               
               
               
             
               
               
               
               
               
               
               
               
               
               
             
           
               
                 TABLE 3 
               
             
             
               
                   
               
               
                 Categories of TP53-associated genes in MM cell lines and newly diagnosis primary tumors 
               
             
          
           
               
                   
                 DNA 
                   
                   
                   
                   
                   
                   
                   
               
               
                   
                 Repair/ 
                   
                   
                   
                 Post- 
                   
                 Transport 
               
               
                 Apoptosis and Cell 
                 Chromatin 
                 Cell Growth 
                 Signal 
                 Biosynthesis 
                 translational 
                 Transcription 
                 and Ion 
               
               
                 Cycle 
                 Modifier 
                 Differentiation 
                 Transduction 
                 Metabolism 
                 Modification 
                 Regulation 
                 Channel 
                 Unknown 
               
               
                   
               
             
          
           
               
                 
                   TP53 
                 
                 
                   APP 
                 
                 
                   IFIT5 
                 
                 
                   FXYD5 
                 
                 
                   ARHGAP25 
                 
                 
                   STT3B 
                 
                 
                   SAT2 
                 
                 ZNF600 
                 
                   LAPTM4B 
                 
                 
                   CYB5D2 
                 
               
               
                 
                   TRIM13 
                 
                 
                   ABCB9 
                 
                 
                   ANKRA2 
                 
                 
                   MCC 
                 
                 
                   RTN2 
                 
                 
                   ECHDC2 
                 
                 
                   SLAMF7 
                 
                 L3MBTL4 
                 
                   OSBPL10 
                 
                 
                   UNC93B1 
                 
               
               
                 
                   NADSYN1 
                 
                 
                   GAA 
                 
                 
                   PHLDB1 
                 
                 
                   MKNK2 
                 
                 
                   WNT16 
                 
                 ENPP4 
                 
                   MAN1C1 
                 
                   
                 
                   KCNS3 
                 
                 
                   SIDT1 
                 
               
               
                 
                           
                 
                 CEP55 
                 TUBA1A 
                 
                   KLHL24 
                 
                 DEPDC1 
                   
                 INTS7 
                   
                 THEX1 
                 
                   TMEM57 
                 
               
               
                 
                   AGRN 
                 
                 BRCA1 
                 CDCA7 
                 
                   DLC1 
                 
                   
                   
                   
                   
                   
                 
                   HIGD2A 
                 
               
               
                 
                   CENTD2 
                 
                 ANLN 
                 CDCA2 
                 OPN3 
                   
                   
                   
                   
                   
                 
                   FKSG44 
                 
               
               
                 
                   SESN1 
                 
                 PYGL 
                 HFE 
                 B3GALNT1 
                   
                   
                   
                   
                   
                 
                   C14orf28 
                 
               
               
                 
                   TM7SF2 
                 
                 CCNE2 
                 RIF1 
                 SPRED1 
                   
                   
                   
                   
                   
                 
                   LOC387763 
                 
               
               
                 
                   NCKAP1 
                 
                 ASPM 
                 NEIL3 
                   
                   
                   
                   
                   
                   
                 
                   TncRNA 
                 
               
               
                 
                   COPG 
                 
                 SUV39H2 
                 SLC4A7 
                   
                   
                   
                   
                   
                   
                 
                   C18orf1 
                 
               
               
                 
                   STAT3 
                 
                 CDC25A 
                   
                   
                   
                   
                   
                   
                   
                 DCUN1D4 
               
               
                 
                   ALOX5 
                 
                 SEPP1 
                   
                   
                   
                   
                   
                   
                   
                 FANCI 
               
               
                 
                           
                 
                 RIT1 
                   
                   
                   
                   
                   
                   
                   
                 CD302 
               
               
                 
                           
                 
                 KIF2C 
                   
                   
                   
                   
                   
                   
                   
                 C5orf34 
               
               
                 
                   BTG2 
                 
                 S100A4 
                   
                   
                   
                   
                   
                   
                   
                 FAM111B 
               
               
                 
                   RAB1A 
                 
                 MEIS1 
                   
                   
                   
                   
                   
                   
                   
                 C18orf54 
               
               
                 
                           
                 
                 SGOL2 
               
               
                 
                           
                 
               
               
                 
                   HDLBP 
                 
               
               
                   
               
               
                 Up-regulated genes appear in bold, down-regulated genes in plain; previously known TP53 targets are marked by italics and underlining. 
               
             
          
         
       
     
       Example 15  
       [0070]    Clinical Relevance of Genes Associated with TP53 Expression 
         [0071]    Using the 85 genes identified as associated with TP53 overexpression and the expression data derived from the 351 TT2 patients with newly diagnosed multiple myeloma, unsupervised hierarchical clustering was performed. This resulted in two primary tumor clusters that were significantly associated with TP53 expression ( FIG. 9A ). The subtype associated with lower TP53 expression had a significantly shorter EFS (P=0.0006;  FIG. 9B ) and OS (P=0.0010;  FIG. 9C ). 
         [0072]    With regard to clinical and biological features, the subtype of patients associated with low TP53 expression had high levels of creatinine (P=0.011) and LDH (P=0.017), low levels of albumin (P=0.041), an increased number of bone lesions on MRI (P=0.001), and an increased incidence of chromosomal abnormalities defined by G-banding (P=0.002), deletion of chromosome 13 (P&lt;0.001), and amplification of chromosome 1q21 (P=0.002) (Table 4). 
         [0073]    By the same unsupervised hierarchical clustering, the subcluster of multiple myeloma associated with lower TP53 expression levels had a significantly shorter post-relapse survival (P&lt;0.0001;  FIG. 10A ) in 90 TT2 cases with relapsed disease and short EFS (P=0.0012) and OS (P=0.0533) in a separate cohort of 214 patients treated on the successor protocol TT3 ( FIG. 10B ). 
         [0074]    Taken together, these findings strongly argue that the 85 novel TP53-regulated genes of MM identified by gene expression profiling in vivo and in vitro are functional in TP53-mediated tumorigenesis and that their expression characteristics in vivo can potentially be used as molecular gauges of tumor aggressiveness and clinical outcome. 
         [0000]    
       
         
               
             
               
               
               
               
             
               
               
               
               
             
           
               
                 TABLE 4 
               
             
             
               
                   
               
               
                 Baseline TT2 patient characteristics according to 
               
               
                 TP53-regulated gene cluster 
               
             
          
           
               
                   
                 Cluster 1 
                 Cluster 2 
                   
               
               
                   
                 (%) 
                 (%) 
               
               
                 Characteristics 
                 (n = 98) 
                 (n = 253) 
                 P† 
               
               
                   
               
             
          
           
               
                 Age at least 65 y 
                 21 
                 22 
                 NS 
               
               
                 Female sex 
                 42 
                 44 
                 NS 
               
               
                 White race 
                 91 
                 88 
                 NS 
               
               
                 IgA isotype 
                 30 
                 24 
                 NS 
               
               
                 Creatinine at least 2.0 mg/dL 
                 19 
                 9 
                 0.011 
               
               
                 MRI focal bone lesions, at least 3 
                 72 
                 53 
                 0.001 
               
               
                 C-reactive protein at least 4.0 mg/L 
                 45 
                 32 
                 0.023 
               
               
                 Lactate dehydrogenase at least 190 IU/L 
                 44 
                 30 
                 0.017 
               
               
                 β 2 -Microglobulin at least 4.0 mg/L 
                 38 
                 33 
                 NS 
               
               
                 Albumin less than 3.5 g/dL 
                 45 
                 33 
                 0.041 
               
               
                 Hemoglobin less than 10 g/dL 
                 31 
                 23 
                 NS 
               
               
                 Bone marrow plasma cells (by 
                 47 
                 56 
                 NS 
               
               
                 aspiration) at least 33% 
               
               
                 Chromosomal abnormalities 
                 48 
                 30 
                 0.002 
               
               
                 (defined by G-banding) 
               
               
                 Deletion of chromosome 13 
                 66 
                 43 
                 &lt;0.001  
               
               
                 Amplification of chromosome 1q21 
                 65 
                 36 
                 0.002 
               
               
                 High-risk model (17-gene)* 
                 36 
                 7 
                 &lt;0.001  
               
               
                 Subgroups with poor prognosis* 
                 50 
                 51 
                 NS 
               
               
                 (Proliferation/MMSET/FGFR3/ 
               
               
                 MAF/MAFB) 
               
               
                   
               
               
                 NS indicates not significant. 
               
               
                 *High-risk model 1  and PR/MS/MF subgroup designation 25  have been described elsewhere. 
               
               
                 †Chi-square was used to compare the clinical and biological parameters between cases in hierarchical cluster 1 (correlated with low TP53 expression) and cluster 2 (correlated with high TP53 expression). 
               
             
          
         
       
     
       Introduction 
       [0075]    In Total Therapy 3 (TT3), bortezomib was added for remission induction prior to and with both consolidation and maintenance therapies after melphalan-based tandem transplantation. Whether TT3, which benefited the FGFR3 molecular subgroup could also overcome the adverse implications of TP53 deletion (delTP53) observed in predecessor Total Therapy 2 (TT2) protocol and in standard chemotherapy regimens was investigated. 
       Patients and Methods 
       [0076]    The details of TT2 and TT3 protocols and their overall results have been reported previously; however, results related to 177 additional patients treated in a TT3 successor protocol to validate bortezomib pharmaco-genomic data have not been reported. The median follow-up times for TT2 and TT3 are 7.2 and 3.9 years, respectively. Both protocols and their revisions had been approved by the Institutional Review Board, and patients had signed a written informed consent in keeping with institutional and federal policies. 
         [0077]    The present invention relates to the prognostic importance of the TP53 suppressor gene deletion, as assessed by GEP analysis, based on an excellent correlation between inter-phase fluorescence in situ hybridization-derived determinations of bi-allelic loss of TP53 and GEP-derived Affymetrix values of less than 727. The comprehensive myeloma data base was interrogated for standard prognostic variables and the presence of metaphase cytogenetic abnormalities (CA), as well as other GEP-derived parameters such as high-risk and molecular subgroup designations. The data base also includes carefully annotated information on initial rate and duration of CR, event-free survival (EFS) and overall survival (OS). All patients had been followed through induction, transplantation and consolidation steps and then at least quarterly for the first year of maintenance and semi-annually thereafter to document disease status. 
         [0078]    The Kaplan-Meier method was used to estimate overall and event-free survival with group comparisons made using the log-rank test. Overall survival and event-free survival were measured from the date of registration until death from any cause and disease relapse or death from any cause, respectively; survivors were censored at the time of last contact. Univariate and multivariate analyses of prognostic factors were carried out using Cox regression models. 
       Results and Discussion 
       [0079]    DelTP53, present in 10% each of TT2 and TT3 protocols, was over-represented in patients with elevated levels of lactate dehydrogenase of at least 190IU/L (45% v 28%, p=0.02) and under-represented in the Hyperdiploidy subgroup (7% v 31%, p&lt;0.001). Examining the prognostic consequences of delTP53 in TT2 (regardless of randomization to thalidomide or control arm), we observed that both OS and EFS were markedly inferior in the low-risk setting, with a trend apparent for OS only in high-risk disease ( FIGS. 11A ,  11 B). However, with TT3 such detrimental effect of delTP53 was not apparent in low-risk myeloma, while delTP53 further aggravated the poor prognosis in high risk disease. Relevant to FGFR3 status (translocation 4;14), TP53 haplo-insufficiency was an adverse feature regardless of FGFR3 translocation status in TT2, with mainly trends apparent in TT3 ( FIG. 11C ). Examining, on the other hand, the impact of FGFR3 translocation by delTP53 status, clinical outcomes were inferior with TT2 in the absence of delTP53, with trends apparent for furthering the poor prognosis in the presence of delTP53 (see  FIG. 11C ). In case TT3 was applied, FGFR3+ failed to affect outcomes both in the absence and presence of TP53 haplo-insufficiency. 
         [0080]    According to multivariate analyses, delTP53 conferred inferior OS and EFS in TT2 but not in TT3 (Table 5). CR rate and duration were not affected by TP53 status in either protocol. Additional adverse parameters for OS and EFS in both protocols included the presence of CA and of elevated levels of beta-2-microglobulin, while GEP-defined high-risk designation also imparted shorter CR duration (p&lt;0.001). The beneficial effect of randomization to thalidomide in TT2 applied to both event-free and overall survival. 
         [0000]    
       
         
               
             
               
               
               
             
               
               
               
               
               
               
             
               
               
               
               
               
               
               
               
               
               
               
             
           
               
                 TABLE 5 
               
             
             
               
                   
               
               
                 Multivariate analysis of features linked to overall and event-free survival by 
               
               
                 protocol 
               
             
          
           
               
                   
                 TT2 
                 TT3 
               
             
          
           
               
                   
                 Overall 
                 Event-free 
                   
                 Overall 
                 Event-free 
               
               
                   
                 Survival 
                 survival 
                   
                 Survival 
                 Survival 
               
             
          
           
               
                   
                   
                 HR (95% 
                 P- 
                 HR (95% 
                 P- 
                 n/N 
                 HR (95% 
                 P- 
                 HR (95% 
                 P- 
               
               
                 Variable 
                 n/N (%) 
                 CI) 
                 value 
                 CI) 
                 value 
                 (%) 
                 CI) 
                 value 
                 CI) 
                 value 
               
               
                   
               
               
                 Randomization to 
                 170/341 
                 0.70 
                 0.041 
                 0.61 
                 &lt;.001 
                 NA 
                 NA 
                 NA 
                 NA 
                 NA 
               
               
                 Thalidomide 
                 (50%) 
                 (0.50, 0.99) 
                   
                 (0.46, 0.80) 
               
               
                 B2M &gt; 5.5 mg/L 
                  70/341 
                 1.70 
                 0.006 
                 1.62 
                 0.003 
                 101/419 
                 2.04 
                 0.002 
                 1.96 
                 0.002 
               
               
                   
                 (21%) 
                 (1.16, 2.48) 
                   
                 (1.18, 2.22) 
                   
                 (24%) 
                 (1.30, 3.19) 
                   
                 (1.29, 2.98) 
               
               
                 LDH &gt;= 190 U/L 
                 115/341 
                 1.45 
                 0.045 
                 NS 
                 NS 
                 101/419 
                 NS 
                 NS 
                 1.54 
                 0.042 
               
               
                   
                 (34%) 
                 (1.01, 2.07) 
                   
                   
                   
                 (24%) 
                   
                   
                 (1.02, 2.32) 
               
               
                 Cytogenetic 
                 110/341 
                 2.03 
                 &lt;.001 
                 1.60 
                 0.002 
                 156/419 
                 2.28 
                 &lt;.001 
                 1.62 
                 0.025 
               
               
                 Abnormalities 
                 (32%) 
                 (1.43, 2.89) 
                   
                 (1.20, 2.13) 
                   
                 (37%) 
                 (1.44, 3.63) 
                   
                 (1.06, 2.47) 
               
               
                 DelTP53 present 
                  35/341 
                 2.81 
                 &lt;.001 
                 2.34 
                 &lt;.001 
                  42/419 
                 1.71 
                 0.058 
                 1.45 
                 0.174 
               
               
                   
                 (10%) 
                 (1.80, 4.38) 
                   
                 (1.58, 3.46) 
                   
                 (10%) 
                 (0.98, 2.99) 
                   
                 (0.85, 2.48) 
               
               
                 GEP high-risk 
                  45/341 
                 2.62 
                 &lt;.001 
                 2.49 
                 &lt;.001 
                  70/419 
                 2.43 
                 &lt;.001 
                 2.49 
                 &lt;.001 
               
               
                   
                 (13%) 
                 (1.71, 4.01) 
                   
                 (1.71, 3.62) 
                   
                 (17%) 
                 (1.50, 3.93) 
                   
                 (1.58, 3.92) 
               
               
                   
               
               
                 Variables considered for stepwise selection: age, albumin, B2M, creatinine, hemoglobin, LDH, CRP, cytogenetic abnormalities, GEP high-risk and delTP53 
               
             
          
         
       
     
         [0081]    One may conclude that, with TT3 and in contrast to TT2, delTP53 was not an independent deleterious feature. When examined in the context of GEP-defined risk, the absence TP53 haplo-insufficiency significantly improved the poor prognosis still observed with TT3 in high-risk myeloma beyond the fate observed after treatment with TT2. FGFR3 status did not confer poor outcomes in TT3 as it did with TT2. As the major difference between the two protocols was the incorporation of bortezomib in TT3 for both induction prior to and consolidation therapy after tandem transplantation as well as its use in the maintenance phase, it is tempting to speculate that the use of this proteasome-inhibiting agent negated the adverse consequences of delTP53 at least in the low-risk setting. The underlying mechanism may involve bortezomib&#39;s synergistic interaction with thalidomide in VTD or with melphalan in VMP or other agents. Such synergy may result from sensitization of tumor cells to DNA-damaging agents via accumulation of cytosolic TP53 or suppression of cellular response to genotoxic stress. Adding tanespimycine, an inhibitor of HSP90, recently shown to augment bortezomib&#39;s efficacy, may overcome the dire prognosis still observed in case delTP53 occurs in the high-risk setting. The currently accruing US Intergroup trial, S0777, performed under the auspices of the Southwest Oncology Group, randomizes newly diagnosed patients between lenalidomide plus dexamethasone and the 3-drug combination of lenalidomide plus dexamethasone plus bortezomib. As state-of-the-art molecular genetic studies are performed as part of this trial, a firm conclusion will be forthcoming whether, in a non-transplant setting, bortezomib indeed overcomes the adverse consequences of TP53 haplo-insufficiency. 
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