bluuebunny/crossref_metadata_2025 huggingface dataset:
Immunoglobulin-Like Transcript 2 (ILT2) Is Not Differentially Expressed in MGUS and Myeloma, but Appears To Be Downregulated at an Earlier Stage of Plasma Cell Disease.
Authors: Schreder Martin , Huebl Wolfgang , Koch Gudrun , Strasser-Weippl Kathrin , Zojer Niklas , Ludwig Heinz
Published: April 2020

Background: Immunoglobulin-like transcript 2 (ILT2/CD85j) belongs to the Ig superfamily and has homology to the killer cell inhibitory receptors (KIRs). It is expressed on natural killer (NK) cells, monocytes, macrophages, dendritic cells and (naive) B lymphocytes. A differential expression of ILT2 was described for monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma (MM). Gene expression profiling studies found ILT2 to be downregulated 8.26 fold in myeloma as compared to MGUS, being the most differentially expressed gene between these two subsets. However, as RNA from CD138+ cells was used in this analysis, a varying percentage of normal, non-malignant plasma cells will impact on the results, especially in MGUS cases.

Aims: We aimed to delineate ILT2 expression in different plasma cell subsets (normal compared to monoclonal cells) in MGUS and MM and the eventual prognostic impact of a differential expression level.

Methods: ILT2 expression was measured by flow cytometry using a PE-conjugated antibody (clone HP-F1, Beckman Coulter) in a series of 30 MGUS patients and 91 myeloma patients. Phenotypically normal and malignant plasma cells were defined by differential expression of CD38, CD45, CD19 and CD56. Expression levels are given as mean fluorescence intensity (MFI) after correction for background staining.

Results: ILT2 was not differentially expressed in monoclonal plasma cells from patients with MGUS (MFI median 112.0, range 13.5–274.4) and myeloma (MFI median 96.6, range 0.4–454.5). In contrast, monoclonal cells from MGUS and MM showed a significantly lower expression of ILT2 as compared to phenotypically normal plasma cells in the majority of samples (p=0.007). Results were confirmed by quantitative real time PCR studies in 25 MM patients showing a linear correlation of ILT2 mRNA levels with the intensity of ILT2 protein expression. ILT2 levels did not vary with state of disease and showed no correlation with clinical parameters or prognosis in our series of myeloma patients.

Conclusions: In the majority of patients with monoclonal plasma cell disorders, ILT2 seems to be downregulated at an early stage of disease, i.e. upon transformation from a normal plasma cell to the MGUS/MM stage. The expression level of ILT2 in monoclonal plasma cells is neither correlated with the state of disease (MGUS versus newly diagnosed myeloma versus advanced disease) nor to prognosis of myeloma patients or other clinical parameters.
Induction of Cyclin D1 by HGF, IGF-1 and IL-6 in a Human Myeloma Cell Line with a t(11:14) Translocation.
Authors: Hov Håkon , Våtsveen Thea K. , Waage Anders , Sundan Anders , Borset Magne
Published: April 2020

Almost all patients with multiple myeloma have dysregulation of cyclin D1 -2 or -3. The t(11:14) translocation juxtapose the CCND1 locus coding for the cyclin D1 protein to the IgH locus. This leads to upregulation of the cyclin D1 gene, and thus to increased proliferative capacity. Despite the presence of IgH translocations, the myeloma cells are highly dependent of the bone marrow microenvironment for malignant growth. Whether the expression of cyclin Ds is additionally regulated by the microenvironment needs to be further examined. Here we report a myeloma cell line, INA-6, with a t(11;14) translocation in which expression of cyclin D1 is regulated by several cytokines. INA-6 cells were analysed by interphase FISH with probes matching the CCND1 gene (coding for the cyclin D1 protein) and the Ig heavy chain locus. We found co-localisation of the two probes indicating a translocation between chromosome 14 and chromosome 11. We detected a total of five signals for CCND1, indicating the occurrence of three extra copies of chromosome 11. This was confirmed by an analysis with a single probe detecting the CCND1 locus. We further analysed the content of cyclin D1 protein by western blotting after the cells had been washed and grown in serum free media with or without cytokines for 24 hours. INA-6 constitutively expressed cyclin D1. HGF, IL-6 and IGF-1 further enhanced the expression of cyclin D1. In combination with IL-6, HGF had a synergistic effect on cyclin D1 expression. The constitutive cyclin D1 expression is probably caused by the translocation between chromosome 11 and 14. However the increase in number of cyclin D1 genes not co-localized to the IgH chain can also contribute to the basal level of cyclin D1 expression in this cell line as well as post-transcriptional regulation. The increase in cyclin D1 expression after cytokine stimulation can be explained by an increase in transcription from the normal CCND1 copy or the other extra copies. One intriguing possibility is that the translocation itself makes the cell susceptible to cytokine regulation of cyclin D1. At least IGF-1 and IL-6 are known for their ability to enhance immunoglobulin production and may therefore regulate cyclin D1 through the IgH promotor in the t(11:14) translocation.

The different ways to induce cyclin D1 protein in this cell line is a functional example of the collaboration between the dysregulated myeloma cell and the components of its microenvironment in the bone marrow in regulating a key component of cell cycling and a possible oncogene in multiple myeloma.
The Sesquiterpene Lactone Parthenolide Induces Apoptosis and Overcomes the Protective Effect of the Bone Marrow Microenvironment in Human Multiple Myeloma Cells.
Authors: Suvannasankha Attaya , Crean Colin D. , Shanmugam Rajasubramaniam , Abonour Rafat , Boswell H. Scott , Nakshatri Harikrishna
Published: April 2020

Parthenolide is a sesquiterpene lactone, a new class of antitumor agents which target nuclear factor kappa B (NFkB). Although the activation of NFkB has been implicated in the growth and drug resistance of multiple myeloma (MM) cells, the efficacy of parthenolide in MM is unknown. Here we show that parthenolide inhibits the NFkB DNA binding in MM cells in a time- and dose-dependent fashion. Parthenolide inhibits the proliferation of MM cell lines, as well as tumor cells from chemotherapy-resistant MM patients; however, at the effective doses it is not toxic to peripheral blood mononuclear cells or bone marrow stromal cells. Neither exogenous interleukin-6 (IL-6) nor insulin-like growth factor 1 (IGF-1) overcome the parthenolide-induced cytotoxicity. In addition, parthenolide inhibits the proliferation of MM cells adherent to bone marrow stromal cells. Parthenolide has a minimal effect on cell cycle progression but strongly induces apoptosis. Parthenolide activates caspases 8 and 3 more strongly than caspase 9, resulting in the cleavage of poly (ADP)-ribose polymerase (PARP) and XIAP. Z-VAD-FMK partially blunts the PARP cleavage but does not protect MM cells against apoptosis. Parthenolide induces p21 accumulation, while the levels of Bax, IAP2, cyclin D, Bcl-X and p53 or the phosphorylation status of JNK, AKT and ERK are unaffected. In addition, parthenolide augments dexamethasone-induced cytotoxicity. Our study therefore provides the rationale for the future clinical development of parthenolide, or its combination with dexamethasone, in MM therapy.
Expression of CD126 (IL-R alpha) on Plasma Cells in Monoclonal Gammopathies.
Authors: Mahmood Syed T. , Kumar Shaji , Kimlinger Teresa K. , Haug Jessica L. , Timm Michael , Wellik Linda , Kline Michael , Rajkumar S. Vincent
Published: April 2020

Background: IL-6 is important for proliferation and inhibition of apoptosis in malignant plasma cells. Understanding the role of IL-6 receptor alpha chain (CD126) in the pathogenesis of plasma cell disorders may help in developing future treatment therapies for these diseases. A previous study has shown that CD126 (alpha subunit of IL-6 receptor) is expressed distinctly in myeloma, monoclonal gammopathy of unknown significance (MGUS), and plasmacytomas when compared to normal. We performed this study in order to confirm and describe the expression of CD126 in different plasma cell disorders.

Design and Methods: Using flow cytometry we assessed CD126 expression on clonal plasma cells from patients with Primary Amyloidosis (n=7), monoclonal gammopathy of undetermined significance (MGUS) (n=13), smoldering Myeloma (SMM) (n=19) and active Myeloma (n=22), as well as normal plasma cells (n=9). Plasma cells were identified by their characteristic CD38/45 expression. The expression of CD126 was separately analyzed on the CD45 positive and negative plasma cells. CD 126 expression was considered significant when more than 20% of the cells had expression.

Results: CD126 expression was seen distinctly in plasma cell disorder plasma cells and not in normal plasma cells when all plasma cells were studied together. The highest expression percentages were found in Amyloid (28%) followed closely by MGUS 29(%), then SMM (23%), and Myeloma (12%) cells. The CD45 neg subset was similarly positive in the plasma cell disorder group. In this group, MGUS showed the highest expression percentage followed distantly by Amyloid, Myeloma, and SMM. The CD45 pos subset was uniformly positive in expression of CD126. If was found that this subset expressed higher levels of CD126 in all the studied plasma cell disorders and normal plasma cells when compared to the CD45 neg subset.

Conclusion: The findings of this study confirm the increased expression of CD126 in plasma cell disorders when compared to normal plasma cells. The higher expression of CD126 in the CD45 pos plasma cell subset has not been previously described. In addition, the CD45 pos subset expressed higher levels of CD126 in all study groups when compared to the CD45 pos subset. This data contributes to the understanding of IL-6 receptor physiology and confirms the important role of the CD45 pos subset in the proliferation of neoplastic plasma cells. The findings are in accordance with the increased proliferative rates seen in the CD45 fraction of malignant plasma cells.
Unusual Presentation of IgD Lambda Multiple Myeloma with Femoral Head Amyloidosis: A Case Report and Literature Review.
Authors: Pu Jeffrey J. , Yoe Joseph
Published: April 2020

IgD Multiple Myeloma accounts only for 2% of all Multiple Myeloma cases. It has been associated with various conditions and with complications involving many organs. The prognosis for IgD Multiple Myeloma is poor. This case report describes how a patient was diagnosed as IgD Lambda Multiple Myeloma complicated with left femoral head Amyloidosis. Initially, this 71 years old male patient presented with worsening left hip pain, reduced appetite, and weight loss for six months. Laboratory data showed chronic anemia, hypercalcemia, and acute renal failure. Bone marrow biopsy demonstrated sheets of plasma cells with abnormal nuclei. The initial routine serum immunofixation did not show any elevation of Immunoglobulins; and instead, noted decreased immunoglobulin level. Because of this unusual pattern of low Ig G, A, and M level, further work up on IgD investigation was pursued. Serum IgD workup showed a peak of 71 mg/dl and the urine immunofixation also demonstrated large amount of free monoclonal Lambda light chain. Finally, a left total hip arthroplasty was done. Congo Red stain of left femoral head biopsy revealed amyloidosis. This case illustrates association of IgD myeloma with amyloidosis. At the same time, it could easily be misdiagnosed as light chain disease if IgD abnormality was not carefully considered as a differential diagnosis. In addition, a concise review on IgD Multiple Myeloma is given.
Multiple Lung Nodules and a Pancreatic Mass at the Initial Presentation of Multiple Myeloma: A Rare Case.
Authors: Aribandi Lavanya , Makary Adel Z.
Published: April 2020

Extramedullary tumors are a rare manifestation of multiple myeloma. Approximately half of these are present at initial diagnosis and the rest occur during the course of the disease. Pancreas is rarely involved by multiple myeloma and the diagnosis is often made postmortem. Lung lesions are also rarely encountered. We present a rare case of multiple myeloma with asymptomatic extraosseous soft tissue lesions in the form of multiple lung nodules and a pancreatic mass at the initial presentation. Despite his multiple extraosseous lesions, he responded well to chemotherapy and radiation therapy with resolution of pulmonary nodules, pancreatic mass and orbital mass.
Response to Bortezomib in Combination after Relapse o Non-Response to First Treatment with Bortezomib Alone in Myeloma Multiple Patients.
Authors: Rubio-Martinez Araceli , Recasens Valle , Delgado Pilar , Garcia-Zueco Juan Carlos , Rubio-Felix Daniel , Giraldo Pilar
Published: April 2020

Background: Bortezomib has been shown to be effective in multiple myeloma (MM), but there is a limited experience in response to re-treatment.

Aims: To evaluate the efficacy of Bortezomib in refractory/relapsed MM.

Patients and methods: 41 patients treated with Bortezomib (1,3 mg/m2 on days 1,4,8,11 in a 21-day cycle) in second or more line as clinical practice protocol were included. The response was evaluated according EGBMT criteria (Bladé J, Samson D, Reece E et al). Patients that no have reached response after 4 courses or relapsed after CR or PR received a combination of: bortezomib+dexamethasone (group BD) or bortezomib+melphalan+prednisone (group BMP). Adverse effects were registered.

Results: 39 valuable patients (males 43.0%). Mean age 59.9 years (34–82), over 65 years (66.6%). Bortezomib was administered in second line: 10 (25.6%), in third or more: 29 (74.3%). Overall Response: 76.4%: (CR+PR 70.5%, MR 5.9%), (CR 41.1%/CR-IFE negative 14.7%), Mean courses to reached response: 4.7. No relation to response and presence or not chromosomal aberrations. At 32 months on follow-up 9 patients had dead (26.4%) and 15 (44.1%) maintained response without therapy. In 17 patients (43.5%), a combination of BD (10 patients) or BMP (7 patients) were administrated by relapse or progression. Responses: group BD 6 PR, 3 NR; 1NV group BM P 3 PR, 3 NR, 1NV. Adverse events: thrombocytopenia 38.4 (grade III: 17.9), fatigue 38.5%, peripheral neuropathy 33.3, constipation 35.8%, diarrhea 20.5%, ZHV 12.8%, infection 33.3, pyrexia 10.2%, hypotension 5.1%, grade 3 leucopenia 12.8%. In 3 patients (7.6%) the therapy was disrupted by toxicity. We haven’t found any differences in adverse events in patients treated with bortezomib in combination.

Conclusions: Related to the synergism of Bortezomib in combination, the re-treatment induces response (60%) in refractory MM without severe adverse effects. In spite of the scarce follow-up some patients could be benefit in re-treatment with Bortezomib. It is necessary to explore more combinations and to know the results of clinical trials. When there is not response after the 4th course of Bortezomib it is recommendable to use in combination
Use of Immunoglobulin Infusions in the Management of Bortezomib-Induced Peripheral Neuropathy in Multiple Myeloma.
Authors: Teoh Gerrard , Tan Daryl , Hwang William , Koh Liang Piu , Chuah Charles , Ng Heng Joo
Published: April 2020

Bortezomib (VELCADE) is a novel proteasome inhibitor that has shown tremendous clinical efficacy in Asian patients with multiple myeloma (MM). Prior studies have found that about a third (35%) of Caucasian patients develop bortezomib-induced peripheral neuropathy (PNY); and 12% and 5% of these patients require dose-reduction or discontinuation of bortezomib, respectively. Moreover, it has anecdotally been reported that a greater proportion of Asian patients receiving bortezomib develop PNY, and we are concerned that this unwanted effect of bortezomib would greatly limit the use of a drug that would otherwise be highly-effective for Asian MM patients. We therefore analyzed 20 Asian patients with MM who were treated with bortezomib, and found that up to 75% (15 out of 20) of patients developed bortezomib-induced PNY - sensory (75%) and/or motor (50%); confirming the observation that Asian patients are more prone to developing bortezomib-induced PNY. The majority of sensory PNY were mild. Grades 1 or 2 sensory PNY was seen in 45%, grade 3 in 15%, and grade 4 in another 15% of patients. Of these, 80% of patients reported painful neuropathies - 53% requiring dose reduction, and 27% requiring discontinuation of bortezomib. By contrast, motor PNY was more severe - 5% of patients reported grades 1 or 2, 15% with grade 3, and 30% with grade 4 motor PNY. In other words, if PNY develops in an Asian patient with MM, it is more likely to be a mild painful sensory PNY. However, if motor PNY occurs, it is more likely to be severe. For the treatment of PNY, all patients received gabapentin (600 mg to 1,400 mg per day), and 9 patients received L-carnitine (2 or 3 tablets a day). Gabapentin-treated patients reported only minimal effectiveness of this drug in relieving their symptoms, whereas no objective improvements were observed in all L-carnitine-treated patients. Similarly, amitriptyline was given to 3 patients with severe painful PNY and only a non-sustained modest improvement was reported in all these patients. In contrast, improvements of at least 1 grade in both symptoms and function were reported by all 9 patients who received intravenous immunoglobulins (IVIG). In the most significant of these, a patient who was bed-ridden because of grade 4 combined sensorimortor PNY, dramatically recovered (became pain-free, and improved to grade 2 motor weakness) within 2 days of completing IVIG 2.0 gm/kg divided over 4 days. In conclusion, Asian MM patients have indeed significantly higher rates of bortezomib-induced PNY, which unfortunately often leads to dose-reduction and/or discontinuation of bortezomib. Our data demonstrate that IVIG may be a useful agent for the management of these patients; and for facilitating the continued administration of bortezomib.
Bevacizumab Therapy for POEMS Syndrome.
Authors: Ramasamy Karthik , Lang Stephen , Chapell Jackie , Schey Stephen
Published: April 2020

41 yr old male presented with pain and weakness of upper and lower limbs. He was bed bound with ECOG score 4. Investigations confirmed the diagnosis of POEMS (polyneuropathy, organomegaly, endocrinopathy, M protein, skin changes) syndrome. He had typical features including glomerular hemangiomas on the skin, mild hepatosplenomegaly, sensorimotor polyneuropathy, IgG lambda paraprotein 3.3g/l, elevated FSH, LH and TSH. A course of cyclophosphamide and dexamethasone was given with no clinical response. He was also given a trial of plasma exchange and parenteral Immunoglobulins. Symptoms plateaued and he was followed up with rehabilitation support. He re-presented 18 months later with widespread low-grade lymphadenopathy, stable paraprotein, ascites, poor appetite and weight loss. Lymph node biopsy showed Castleman’s disease like changes along with osteosclerotic lesions in pelvis and raised CSF protein of 3.13g/l with rest of CSF analysis being normal. Bone marrow trephine showed paratrabecular deposits of lambda light chain restricted CD38 positive plasma cells. Ascitic fluid was sterile consistent with a transudate. Vascular endothelial growth factor (VEGF) level prior to treatment was elevated at 4587 pg/ml (Normal: 72–704 pg/ml). Large volume abdominal paracentesis ranging between 2–3 litres of clear fluid was performed weekly. In view of the raised VEGF, 4 doses of Bevacizumab (anti-VEGF) 2.5mg/kg were administered as an intravenous infusion over one hour fortnightly. VEGF level normalised after first dose of bevacizumab (131.2 pg/ml) and remained normal prior to the fourth dose (136.5 pg/ml). There were no infusional reactions or haematologic adverse effects. Frequency of paracentesis decreased to three weekly, his appetite and performance status improved with ECOG score 2. 3 weeks after the fourth dose he was readmitted with tense ascites, pleural effusion, diarrhoea, pyrexia and severe abdominal pain. Meropenem resistant pseudomonas was grown from ascitic fluid. After therapeutic paracentesis and antibiotics a Leveen shunt from abdomen to right internal jugular vein was performed to prevent reaccumulation. Despite shunting, he reaccumulated fluid in the third space and developed respiratory and pre renal failure and succumbed to it. At post mortem there were non-specific changes in the lungs and heart with no evidence of pulmonary embolism or bowel perforation and Leveen shunt remained patent. Bevacizumab promptly reduced VEGF levels with significant reduction in pleural and peripheral effusion with subjective improvement in neurological status. Bevacizumab appears to induce clinical response in a proportion of patients with POEMS syndrome. We suggest that a Phase I study should be considered to identify dose, duration of therapy and safety of Bevacizumab.
Final Results of a Prospective, Non-Interventional Study on Bortezomib (Velcade®, VEL) in the Treatment of Multiple Myeloma (MM) in Office-Based Hematology Units (OBH).
Authors: Knauf Wolfgang Ulrich , Otremba Burkhard , Overkamp Friedrich , Bammer Susanne , Angermund Ralf
Published: April 2020

Objectives

This study was performed to investigate efficacy and tolerability of VEL under routine conditions in patients (pts.) with MM, who have received at least 1 previous line of therapy and are refractory to or have relapsed after their last therapy.

Methods

Pts. were treated up to 24 weeks with the recommended dose of VEL (1.3 mg/m2 day 1, 4, 8, 11 q3weeks). Any further diagnostic and therapeutic instructions were not provided in the protocol. At baseline, demographical and medical history data were collected, including type and number of preceding therapies and concomitant diseases. Adverse events (AEs) were continuously documented. Final data analysis is presented here.

Results

A total of n=50 pts. (27 female, 23 male) were included in 14 German OBHs. Median age was 68 years (yrs.), whereby 19 pts. were > 70 yrs. old. A median of 1295 days (d) (range: 49–6201 d) passed between initial diagnosis and start of VEL therapy. Pts. had received a median of 2 prior treatments.

Most frequently reported concomitant diseases were hypertension in 36.0% of the pts., renal failure in 28.0% and coronary heart disease in 14.0%, as well as heart failure in 8.0%. Overall, 10.0% of the pts. exhibited a PNP at the start of therapy (6.0% grade 1 without pain; 4.0% without indication of the degree of severity).

Up to now assessment of response is available in 39/50 pts., with 2 CR, 22 PR, 7 MR, 6 SD and 2 PD. The overall response rate (CR+PR+MR) was 79,4%. Time to best response (CR+PR+MR) was median 3 cycles (range 1–7), while in 3 pts. best response was achieved after 1 cycle.

At end of study, a total of 458 AEs were documented (9.6% classified grade 3; 2.6% grade 4). The investigators assessed 242 AEs (52.8%) as related to VEL and most frequently documented: thrombocytopenia (18.2%), anemia (16.9%), leukocytopenia (9.9%), neuropathy/paresthesia (9.1%), vomiting/nausea (6.6%), asthenia (5.0%) and diarrhea (4.1%).

A total of 34/458 AEs (5.5%) were classified as serious, with 14 (41.2%) of them related to the VEL therapy according to the investigator’s opinion. 2 pts. (4.0 %) died in the course of the trial (deaths not related to VEL). Safety data are under ongoing assessment.

Conclusion

VEL therapy in an unselected, pretreated group of MM pts. is effective and well tolerated. Findings of this non-interventional study confirm efficacy and safety results of large randomized clinical trials. Thus the use of VEL is also suitable under routine conditions in office-based hematology units.
Thalidomide and Dexamethasone in Newly Diagnosed Multiple Myeloma.
Authors: McHugh Johnny , O’Ceallaigh Cathal , Keane Colm , Otridge Brian W. , O’Gorman Peter
Published: April 2020

PURPOSE: The combination of thalidomide and dexamethasone has been shown to have excellent antimyeloma activity in both relapsed and newly diagnosed patients. This combination offers a potential oral, less toxic alternative to standard regimens. This single-centre retrospective study evaluates the activity of the combination of thalidomide and dexamethasone in patients with newly diagnosed multiple myeloma attending the haematology department of the Mater Misericordiae University Hospital, Dublin.

METHODS: Forty-six patients with newly diagnosed multiple myeloma between April 2000 and April 2006 were treated with thalidomide and dexamethasone as first line treatment. The median age of the patients was 70 years (range 46 to 88 years). The median serum paraprotein level was 32g/l (range 2 to 99g/l). The median bone marrow plasma cell percentage was 40% (range 10% to 99%) The first twenty-two patients were commenced on thalidomide at 200mg od with the dose increased by 200mg every two weeks if tolerated to a maximum of 800mg od. The most recent twenty-four patients were commenced on thalidomide at 100mg od with the dose increased to a maximum of 200mg if tolerated. All patients received dexamethasone 40mg per day on days 1–4, 9–12 and 17–20 ot the first cycle and for a four day pulse every four weeks for subsequent cycles.

RESULTS: The response rate was 67.4% when assessed by Blade criteria (50% reduction in serum myeloma protein and 90% reduction of urine myeloma protein on at least two occasions for a minimum of 6 weeks). A complete response was observed in 10.9% of patients. There was no significant difference in response rates between the higher thalidomide dose group and the lower thalidomide dose group. The main toxicities included constipation in 57.8%, hyperglycaemia in 33.3%, peripheral neuropathy in 22.2%, drowsiness in 15.6%, peripheral oedema in 15.6%, venous thromboembolism in 11.1%, rash in 11.1% and proximal myopathy in 8.9%. Routine anticoagulation was not used although patients with additional risk factors for venous thromboembolism received prophylactic dose low molecular weight heparin and in total 53.3% of patients were receiving either aspirin, warfarin or low molecular weight heparin at the time of treatment. There was no significant difference between the two thalidomide dose groups in terms of frequency of toxicities. However 27.3% of patients in the higher thalidomide dose group had their treatment stopped within one month due to toxicities compared to 4.2% in the lower dose group.

CONCLUSION: The combination of thalidomide and dexamethasone is safe and effective in the treatment of newly diagnosed multiple myeloma. There is less treatment-limiting toxicity and no loss of efficacy with lower doses of thalidomide.
Efficacy of Rituximab in Anti-MAG Neuropathy.
Authors: Singh Jaswinder , Malani Ashok , Festoff Barry , Kambhampati Suman
Published: April 2020

Background: The majority of cases of peripheral neuropathy related to monoclonal gamopathy of unknown significance (MGUS) are of the IgM type. Neuropathy associated with antibodies to myelin-associated-glycoprotein (anti-MAG) accounts for 50% of IgM-related neuropathies. Anti-MAG related neuropathies often improve after treatment with human Ig (IVIG), or a combination of cyclophosphamide (cytoxan) and plasma exchange. But this improvement is often short-lived, expensive, and the repeated doses of cytoxan may predispose patients to an increased risk of infections and secondary malignancies. Therefore, efficacious and less toxic treatment approaches are needed in anti-MAG-related neuropathies. We postulated that Rituximab treatment would eradicate the autoantibody producing B-cell lymphocyte clone in patients with IgM antibody-related neuropathies and thereby reduce the titers of neurotoxic antibodies.

Methods: Two patients followed at the Kansas City Veterans Affair Medical Center neuromuscular clinic with diagnoses of MGUS and IgM antibody-related neuropathies were evaluated by history, physical examination, electrodiagnostic evaluation, and serum testing. Both patients had sensory-motor (mixed) neuropathies characterized by slowly progressive asymmetric weakness, muscle wasting, areflexia, and sensory loss. These patients also had elevated anti-MAG titers and were previously treated with plasma exchange, Cytoxan, IVIG, resulting in a good clinical improvement of their symptoms. The clinical remissions, however, were short lived (3–6 moths). Both the patients were then treated with four weekly IV infusions of Rituximab (375 mg/M2).

Results: During the ensuing 12 months after Rituximab treatment, both patients had subjective and objective sensory and motor neurological improvement, however, the degree of improvement was variable. We noticed no change in the titers of anti-MAG levels despite clinical improvement. Based on our experience we postulate that the clinical improvement may not correlate with changes in the anti-MAG titers. Moreover, it could be possible that the recovery of anti-MAG titers may lag behind the clinical improvement. Results for both the patients are formulated below in the table. The graph depicts the anti-MAG titers and physical strength of one of the treated patient in relationship to the Rituximab treatment.

Conclusion: Rituximab is a relatively safe and efficacious therapy for patients with IgM antibody-directed polyneuropathies. Additional large scale, prospective studies with a longer follow-up are needed to develop Rituximab as a targeted therapy against anti-MAG neuropathies.

Response to Rituximab Response to Rituximab
Bortezomid-Induced Sweet Syndrome.
Authors: Schmidt-Tanguy Aline A. , Avenel-Audran Martine M. , Lissandre Séverine S. , Dib Mammoun M. , Croue Anne A. , Moles Marie-Pierre M.P. , Ifrah Norbert N. , Hunault-Berger Mathilde M.
Published: April 2020

Bortezomid (VELCADE®) is a potent proteasome inhibitor used in patients with relapsed and/or refractory multiple myeloma (MM). Numerous undesirable effects are known including thrombocytopenia, neuropathy, various gastrointestinal disorders, fatigue, or rare pulmonary complications. Cutaneous complications have also been described. We reported here a case of Bortezomid-induced Sweet syndrome. A 72-year-old man received Bortezomid for a second relapse of MM previously treated with VAD (vincristine, adriamycin, dexamethasone), double high dose melphalan and autologous transplant, and thalidomide. Bortezomid was given at the dose of 1.3 mg/m2 on days 1, 4, 8, and 11 every 21 days. Dexamethasone was associated with the first cycle at the dose of 20mg/d given on days 1, 2, 4, 5, 8, and 9. On day 11 of the third cycle, a partial response was observed. However, the patient presented a painful skin eruption without any fever. Centimetric erythematous, oedematous papulo-nodular plaques were observed on his back and a periorbital oedema. Spontaneous partial regression was noted on the first day of the following cycle but major analgesic drug were necessary. These cutaneous lesions on the back and the dorsal of fingers recurred on the fourth and fifth cycles with a maximum on day 11. Histopathological examination of a lesion showed oedeme of the dermis and a perivascular polymorphic dermal infiltrate of lymphocytes, neutrophils and eosinophils with some leukocytoclasia, but without parietal necrosis or vasculitis. This findings were consistent with neutrophilic dermatosis. During the sixth Bortezomid cycle, the administration of dexamethasone 20 mg/d on days 1, 2, 4, 5, 8, 9, 11, and 12 prevents the reoccurrence of the skin lesions but the periorbital oedema persists. A variety of cutaneous manifestations has been described in MM. Sweet syndrome has been described in two untreated MM or in some patients receiving granulocyte-colony stimulating factor. Bortezomid has been associated with rash, pruritus, erythema, periorbital oedema, urticaria, alopecia, skin nodules. Few cases of non-necrotising cutaneous vasculitis with perivascular lymphocytic infiltrates have also been reported. Bortezomid-induced Sweet syndrome has been reported in three other patients at the second and third injection of the second cycle for two of them while the eruption occurred after the first injection in the third case. The recurring skin lesions after each bortezomid cycle strongly suggests Bortezomid responsibility’s in the occurrence of Sweet syndrome. Unlike classic hypersensitivity type reactions, this vasculitis rash may not necessary prompt cessation of drug as the administration of dexamethasone prevents its recurrence.
Engineering Mesenchymal Cells with Interleukin 7 Gene: In Vitro Effects on Naive T Cell Population.
Authors: Sportoletti Paolo , Del Papa Beatrice , De Ioanni Mariangela , Moretti Lorenzo , Bonifacio Elisabetta , Fettucciari Katia , Zei Tiziana , Falzetti Franca , Di Ianni Mauro , Tabilio Antonio
Published: April 2020

T cell homeostasis is regulated by several molecules among which Interleukin 7 (IL-7) plays an essential role for survival and homeostatic proliferation of peripheral naive T cells. In a previous study we demonstrated whether human mesenchymal cells could be engineered with IL-7 gene to produce functional level of this cytokine. Now we analysed the impact of different quantities of IL-7 produced by mesenchymal cells on survival and proliferation of a negative immunoselected naive (CD3+/CD45RA+) T cell population. Co-cultivation of peripheral naive T cells with mesenchymal cells producing low (16 pg/ml) or high (1000 pg/ml) IL-7 levels or in presence of exogenous IL-7 (0,01 ng/ml and 100 ng/ml) maintained the CD3+/CD45RA+ naive T cell phenotype. The chemokine receptor CCR7+ expression was also maintained among this T cell population. Naive T cell molecular characteristics were maintained as assessed by the Vβ spectratyping complexity score which shows the maintenance of a broad T cell repertoire. No Th1 or Th2 differentiation was observed as assessed by IFNγ or IL-4 accumulation. In contrast only mesenchymal cells producing high IL-7 amount caused increases in the activation (CD25 31.2%±12 vs 10%±3.5, p<0.05), proliferation (CD71 17.8±7% vs 9.3%±3, p<0.05), apoptosis (assessed by annexin V: 18.6%±5 vs 14.9%±2.6, p>0.05) and phase S cell cycle (15% vs 6.9%, p>0.05). Exogenous IL-7 did not exert any significant effect. In conclusion, we demonstrated that IL-7 produced by mesenchymal cells has a dose-independent effect on naive T cell survival while exerts a dose-dependent effect on activation/proliferation. Due to continuous production of IL-7 by engineered cells, our system emerge as more efficacious than the exogenous IL-7.
Degranulation of T-Cells Specific for the CMV-Proteins pp65 and IE-1 in Allogeneic Stem Cell Recipients.
Authors: Ganepola Susanne S. , Fuhrmann Stephan S. , Uharek Lutz L. , Thiel Eckhard E. , Volk Hans Dieter H.D. , Kern Florian F.
Published: April 2020

Infection and disease with human cytomegalovirus (HCMV) is still an important cause for morbidity and mortality after allogeneic stem cell transplantation (allo SCT). Specific T-cells (CTL) are crucial for the control of CMV infection. In addition to cytokine production, degranulation is an interesting marker of T-cell function. Recent studies in patients after solid organ transplantation revealed that high levels of IE-1-specific CTL correlate with a protection from CMV disease. However, the functionality of these cells is less clear. As demonstrated in AIDS suffering patients, CTL activity is more related to a protection than to a cytokine secretion. Here we address the question, whether CD4 and CD8 T-cells have different abilities to degranulate or to produce cytokines depending on the type of immunosuppression and the CMV target protein.

Material and Methods: T-cells from 6 healthy CMV exposed donors and 16 allografted patients (11 AML, 3 ALL, 1 NHL, 1 MPS) were stimulated with peptide pools representing the pp65 (UL83) and IE-1 (UL123) proteins. Mobilized CD107 (marker of CTL activity), TNF, IFN-g, and IL-2 production was analyzed by 8-color flowcytometry. Immunosuppression consisted of CSA/MMF (n=4), CSA alone (n=4) and CSA/MTX (n=8), 4/8 patients additionally received ATG for GvHD-prophylaxis as part of the conditioning regimen. In all transplanted patients CMV antigenemia was assessed twice a week.

Results and Conclusion: The responding T-cell population mainly demonstrated an effector phenotype with a low expression of CD28. Frequency of reactive CTL did not correlate with CMV antigenemia. Interestingly, there was no impairment of degranulation or cytokine production found in any of the allogeneic transplanted patients compared with healthy CMV exposed controls, showing that immunosuppression does not target the function of the specific CTL.
The Role of SDF-1/CXCR4 in the Procession of Auto-Stem Cell Transplantation of Multiply Myeloma Patients.
Authors: Li Caixia , Wu De Pei , Zhang Xue Guang
Published: April 2020

CXCR4, receptor of the chemokine stromal derived factor-1 (SDF-1), is expressed on CD34+ cells, and has been implicated in the process of CD34+ cell migration and homing. We studied the mobilization of CD34/CXCR4 cells and the plasma levels of SDF-1 and sgp130 in 22 patients, 11 acute Leukemia, 5 non-Hodgkin’s lymphoma, and 6 multiply myloma respectably, receiving cyclophosphamide (Cy) and plus G-CSF, or Mitoxantrone(Mit) and Cytarabine plus G-CSF for peripheral blood stem cell (PBSC) mobilization and autotransplantation. We observed lower plasma levels of SDF-1 in PBSCs compared with premobilized PB and bone marrow samples. The average levels of SDF-1 and sgp130 were 24.67±5.58ng/ml and 106.2±16.4ng/ml respectively while the level of SDF-1 as well as sgp130 decreased to 14659±2.11ng/ml(p<0.05)and 58.8±29.1ng/ml(p<0.05) respectively on day when PBSC was collected after mobilization. SDF-1 levels in the apheresis collections of the “good mobilizers” (patients who collected a minimum of 2 × 106 CD34+ cells/kg in one to three PBSC collections) were significantly lower than the apheresis collections of the “poor mobilizers” (<2 × 106 CD34+ cells/kg in the three cycles of PBSC collections; 14.82 ± 7.08 ng/ml versus 27.2 ± 8.13 ng/ml; p<0.01). The mean percentage of CD34+ cells expressing CXCR4 in the apheresis collections was decreased in the PBSC collections compared with premobilization values ranging from 32.09±5.39% to 22.4±5.92%. But the mean CXCR4 expression on CD34+ cells of the good mobilizers was not different from the expression on CD34+ cells of poor mobilizers. Furthermore, the levels of sgp130 closely correlated with SDF-1 levels (r = 0.87; p < 0.001); the plasma level of SDF-1 and expression of CXCR4 on the CD34+ cells were gradually decreased in the PB of patients during the procession of mobilization; low plasma levels of SDF-1 turned out with good mobilization outcome, and the levels of SDF-1 correlated with sgp130, suggesting an association of these cytokines in mobilization of CD34+ cells.
Prophylaxis Against Cytomegalovirus Infections with Oral Maribavir in Allogeneic Stem Cell Transplant Recipients: Results of a Randomized, Double-Blind, Placebo-Controlled Trial.
Authors: Winston Drew , van Burik Jo-Anne , Pullarkat Vinod , Papanicolaou Genovefa , Vij Ravi , Vance Estil , Alangaden George , Chemaly Roy , Petersen Finn , Chao Nelson , Klein Jared , Sprague Kellie , Dougherty Carolyn , Villano Stephen , Boeckh Michael
Published: April 2020

Cytomegalovirus (CMV) remains a major threat to recipients of allogeneic stem cell transplants (SCT). Potential toxicities of currently available anti-CMV agents complicate their use in this population. Maribavir (MBV) is an oral antiviral drug with a unique mechanism of action against CMV and a promising safety profile in early clinical studies. This randomized, double-blind, multicenter, dose-ranging study enrolled adult CMV-seropositive recipients of allogeneic SCT. After engraftment, patients were randomized to receive CMV prophylaxis with placebo or MBV at one of three doses for up to 12 weeks. CMV surveillance was performed weekly with both CMV pp65 antigenemia and plasma CMV DNA PCR assays. If CMV was detected, study drug was stopped and preemptive anti-CMV therapy started as per standard practice at each center. A total of 111 patients were enrolled (median age 47 years; 70% myeloablative SCT; 53% related donor). Incidence of CMV infection or disease in the first 100 days post-SCT are shown in the table. The safety profile of maribavir was favorable in this patient population; most adverse events occurred at similar rates in placebo and MBV groups. There was no adverse impact of MBV on neutrophil counts or other laboratory or ECG parameters. Consistent with prior clinical studies, the most notable events that appeared to be associated with MBV were mild-moderate taste disturbance, nausea, and diarrhea. In conclusion, maribavir prophylaxis reduced the rate of CMV infection compared to placebo, with a favorable safety profile in this complex patient population. Phase 3 studies of maribavir in stem cell and solid organ transplant recipients are being planned.

Placebo MBV 100 mg BID MBV 400 mg QD MBV 400 mg BID N evaluable 28 27 27 26 p values represent comparison to placebo (stratified by myeloablative or nonmyeloablative SCT) CMV infection or disease based on:     pp65 antigenemia 11 (39%) 4 (15%) 5 (19%) 4 (15%) p=0.046 p=0.116 p=0.053     plasma CMV DNA PCR 13 (46%) 2 (7%) 3 (11%) 5 (19%) p=0.001 p=0.007 p=0.038 Use of preemptive anti-CMV Rx 16 (57%) 4 (15%) 8 (30%) 4 (15%) p=0.001 p=0.051 p=0.002 CMV disease only 3 (11%) 0 0 0 p=0.089 p=0.084 p=0.091
MK-0457, a Novel Multikinase Inhibitor, Inhibits BCR-ABL Activity in Patients with Chronic Myeloid Leukemia (CML) and Acute Lymphocytic Leukemia (ALL) with the T315I BCR-ABL Mutation.
Authors: Bergstrom Donald A. , Clark Jason B. , Xiao Alan , Griffiths Matthew , Falcon Susannah , Pollard John , Freedman Steven J. , Giles Francis
Published: April 2020

Background. MK-0457 (VX-680) is a small-molecule inhibitor of Aurora kinases A, B, and C, FLT3, and JAK-2 with nanomolar level broad spectrum pre-clinical anti-tumor activity. The T315I BCR-ABL mutation mediates high level resistance to imatinib, dasatinib and nilotinib. A Phase I study of MK-0457 is being conducted in patients with refractory hematologic malignancies. The study regime is a 5 day continuous IV regimen given every 2 to 3 weeks.

Methods. Fifteen CML patients received MK-0457 dosed at 8, 12, 16, 20, 24, 28, and 32 mg/m2/hr (11/15 had detectable BCR-ABL T315I). Peripheral blood for biomarker studies was available from patients at the 12 mg/m2/hr dose and above. Specimens were drawn prior to initiation of the infusion and at the end of the infusion (Day 5) during Cycle 1. Patient specimens have been analyzed using flow cytometry assays to measure BCR-ABL inhibition (phospho-CRKL), FLT3 and JAK-2 inhibition (phospho-STAT5) and Aurora kinase inhibition (phospho-histone H3).

Results. MK-0457 has in vitro activity against cells expressing wild-type or mutated BCR-ABL, including the T315I BCR-ABL mutation. In CML and ALL patients with the T315I BCR-ABL mutation, MK-0457 is capable of inhibiting BCR-ABL as measured by the phospho-CRKL assay. The observed decrease in BCR-ABL activity trends with plasma exposure to MK-0457. At dose levels less than 20 mg/m2/hr, plasma exposure of MK-0457 typically does not exceed 1 micromolar and inhibition of BCR-ABL has not been observed. At exposures that exceed 1 micromolar, MK-0457 inhibits BCR-ABL, with pCRKL abundance falling below the lower limit of detection in one patient dosed at 24 mg/m2/hr and decreasing compared to baseline in several other patients. There is also a trend correlating degree of BCR-ABL inhibition as measured by the pCRKL biomarker and clinical response to MK-0457.

Conclusions. MK-0457 inhibits BCR-ABL activity in CML and ALL patients with the BCR-ABL T315I mutation. Objective responses have been observed in patients without demonstrable BCR-ABL inhibition, suggesting that inhibition of Aurora kinase may also contribute to the clinical efficacy of MK-0457 in CML and ALL patients with the BCR-ABL T315I mutation.
Fibrin(ogen) Exacerbates Inflammatory Joint Disease Via a Mechanism Linked to Its αMβ2 Binading Motif.
Authors: Flick Matthew J. , La Jeunesse Christine M. , Talmage Kathryn E. , Witte David P. , Palumbo Joseph , Pinkerton Malinda D. , Thornton Sherry , Degen Jay L.
Published: April 2020

Activation of the hemostatic system is a common pathological feature of severe inflammatory processes. In the context of inflammatory joint disease, articular fibrin deposition is a prominent feature that has been hypothesized to contribute to the derangements in immune/inflammatory processes and tissue reorganization that lead to debilitating and irreversible damage within arthritic joints. We directly examined the role of fibrin(ogen) in the progression of inflammatory joint disease using the well-established experimental setting of collagen-induced arthritis (CIA). Mice with genetically-imposed fibrinogen deficiency (Fib−/−) were found to exhibit significantly reduced macroscopic arthritic disease incidence, progression, and severity in the paws relative to littermate controls throughout the evaluation period. Consistent with the macroscopic observations, qualitative and quantitative histological analysis of distal- and knee-joint sections revealed a significant decrease in all joint disease parameters (e.g., inflammatory cell infiltrates, synovial hyperplasia, edema, and cartilage/bone loss) in Fib−/− mice as compared to fibrinogen-sufficient controls. Fibrin(ogen) has been shown to promote pro-inflammatory activity through engagement of the leukocyte integrin receptor αMβ2 (Mac-1). To determine if fibrinogen/αMβ2 interactions promote the pathogenesis of arthritis, we compared CIA progression in mice expressing fibrinogen that lacks the leukocyte integrin receptor αMβ2 binding motif (i.e., Fibγ390–396A mice). We observed decreased gross and histological inflammatory joint disease in Fibγ390–396A mice relative to control animals. This diminution in arthritic disease severity was comparable to that observed in Fib−/− mice despite the maintenance of normal clotting function in Fibγ390–396A animals. In comparison, CIA studies in mice expressing a mutant form of fibrinogen lacking the platelet integrin receptor αIIbβ3 binding motif showed that this feature of fibrinogen was not an essential driver of arthritis. The reduction in macroscopic and histological arthritic disease observed in CIA-challenged Fibγ390–396A mice was accompanied by reduced local mRNA levels of the pro-inflammatory cytokines TNF α, IL-6, and IL-1β in paws relative to paws from control animals. This data suggests that fibrin(ogen) may function upstream of local production of these critical inflammatory mediators. Consistent with this hypothesis, fibrinogen deficiency did not diminish arthritic disease driven by TNFα-overexpression. Together, these data support the view that local fibrin deposition is an important determinant of inflammatory joint disease and that one mechanism by which fibrin promotes arthritic disease is through leukocyte activation events downstream of αMβ2 engagement.