1. Advances in Biology and Pathophysiology of Multiple Myeloma
Amer G. Rassam, MD

2. History of Multiple Myeloma
First case, a London grocer “Thomas Alexander McBean”
Jumped from a cave in 1844
According to Drs. Thomas Watson and William MacIntyre, Mr. McBean had “Mollities et Fragilitas Ossium”
Mr. McBean died on New Year’s day in 1846

3. History of Multiple Myeloma
Urine sample presented to “Henry Bence Jones”
Large amount of protein was found in the sample
The protein has became known as Bence Jones Protein

4. History of Multiple Myeloma
In 1890s, Paul Unna and Ramon Cajal identified the plasma cell as a cell type and the cause of Multiple Myeloma
Paul Gerson Unna
Santiago Ramon Y. Cajal

5. History of Multiple Myeloma
In 1873, Rustizky introduced the name Multiple Myeloma
In 1922, Bayne-Jones and Wilson identified 2 distinct groups of Bence Jones protein
In 1956, Korngold and Lipari identified the relationship between Bence Jones protein and serum proteins

6. Epidemiology of Multiple Myeloma
Prevalence (at any one time) : 40000
Incidence: diagnosed each year
Median age: 65
Median survival: 33 months
M:F 53:47
1.1% of all cancer diagnosis
2% of all cancer deaths

7. Age Distribution in Multiple Myeloma35 30 25 20 % 15 10 5
<40
40-49
50-59
60-69
70-79
>80
Age

8. Monoclonal Gammopathies – Mayo clinic
Macro 3% (30)
Extramedullary 1% (8)
Other 3% (33)
SMM 4% (39)
LP 3% (37)
AL 8% (90)
MGUS % (659)
MM 16% (172)

9. Immunophenotype of Multiple Myeloma
Marker
Features
CD10
Subset
CD19 & CD20
Rarely expressed
CD28 & CD86
Occurs with progressive disease
CD34
Not expressed by malignant clone
CD38
High expression of most but not all malignant cells
CD56 (N-CAM)
Absent in MGUS and PCL
CD138
Syndecan-1 is over expressed

10. Normal B-cell Development Long-lived plasma cell
Lymph Node
Short-lived plasma cell ::
::...
Lymphoplasmacyte (memory B Cell)
IgM
IgM
Follicle center
Lymphoblast ::
Somatic Hypermutation of Ig Sequences
Stimulation with Antigen
Plasmablast
Naïve B Cell
Isotype Switching
Bone Marrow
::...
G, A, D, E
Long-lived plasma cell
Pre-B cell

11. Mechanisms of Disease Progression in Monoclonal Gammopathies
Kyle RA et al. N Engl J Med Oct 28;351(18):

12. Chromosomal Abnormalities in MM
Translocations (listed in order of frequency)
14q32 with
11q13 (cyclin D, other new fibroblastic growth factors)
4p16 (FGFR3)
6p25 (Interferon regulatory factor 4)
16q23 (C-MAF transcription factor)
8q24 (C-MYC)
18q21 (BCL-2)
1q with
5, 8, 12, 14, 15, 16, 17, 19q, 21, 22
Losses
6q, 13q
Gains
3, 5, 7, 9q, 11q, 12q, 15q, 17q, 18, 19, 21, 22q

13. Chromosome 13 Deletions in MM11 12 13 14 21 22 31 32 33 34
Shaughnessy J et al, Blood, 2000; 96:1505

14. Pathogenesis of Multiple Myeloma
Two pathways involved in the early pathogenesis of MGUS and MM
50% Hyperdiploid
50% non-hyperdiploid
Infrequent IgH Translocations
IgH Translocations
11q13 (cyclin D1)
4p16 FGFR3+ MMSET
6p21 (cyclin D3)
Multiple trisomies of chromosomes 3, 5, 7, 9, 11, 15, 19 and 21
16q (c-maf)
20q11 (mafB)
Hideshima et al, Blood, August 2004,

15. Pathogenesis of Multiple Myeloma
100 90 80 70 60
Prevelance of IgH Translocations 50 40 30 20 10
MGUS MM
PPCL
HMCLs
Hideshima et al, Blood, August 2004,

16. Prevalence of IgH Translocations
4p16 or 16q23
Lower incidence with MGUS/SMM
de novo MM
Rapid progression of MGUS to MM
Extremely poor prognosis

17. Translocations in MM Secondary Primary c-myc 6p21 11q13 20q11 4p16
40% adv MM
90% HMCLs
4p16
16q23
Hideshima et al, Blood, August 2004,

18. Translocation and Cyclin D (TC) Molecular Classification of MM
Group
Primary translocation
Gene(s) at breakpoint
D-Cyclin
Ploidy
Freq of TC in newly diag MM, %
TC1
11q13 6p21
CCND1 CCND3
D D3
NH NH
TC2
None D1 H 37
TC3 D2
H=NH 22
TC4
4p16
FGFR3/MMSET
NH>H 16
TC5
16q23 20q11
c-maf mafB
D2 D2
Bergsagel and Kuehl, Immunol Rev, 2003, 194:96-104

19. Cyclin D Expression in Normal and Malignant Plasma Cells
D1=Green, D2=Red, D3=Blue
PPC
BMPC 6p
11q13 D1
D1+D2
other
4p16
maf
TC1
TC2
TC3
TC4
TC5
Tarte k. et al, Blood. 2002;100: Zhan F. et al, Blood. 2002; 99:

20. Dysregulation of cyclin D1, D2, D3 “a unifying oncogenic event in MM”
MGUS and MM appear closer to normal PCs than to normal PBs
>30% of cells can be in S phase
Expression level of cyclin D1, D2, D3 mRNA in MM and MGUS is distinctly higher than normal PCs
Expression level of cyclin D2 mRNA is comparable with that expressed in normal proliferating PBs

21. Dysregulation of cyclin D1, D2, D3 “a unifying oncogenic event in MM”
Cyclin D1 is not expressed in normal hemopoitic cells
Cyclin D1 expressed in 40% of MM lacking a t(11;14) translocation
Ig translocations that dysregulate cyclin D1 or D3 occur in about 20% of MM tumors
Therefore, almost all MM tumors dysregulate at least one of the cyclin D genes

22. Progression to Plasma Cell Neoplasia
Germinal center B cell
Intramedullary Myeloma
Extramedullary Myeloma
MGUS
HMCL
11q13
6p21
NON-HYPER DIPLOID
16q23
Primary IgH tx
20q11
4p16
Other
DEL 13
?p16
p18
p53
c-myc
N, K-RAS
FGFR3
TRISOMY
3, 5, 7, 9, 11, 15, 19, 21
HYPER DIPLOID
Hideshima et al, Blood, August 2004,

23. Progression to Plasma Cell Neoplasia
Normal Plasma Cell
Intra- medulary myeloma
Extra- medullary myeloma
MGUS
IgH translocations
Deletion of 13q
Chromosomal instability
RAS mutations
Dysregulation of c-MYC
p53 mutations

24. The TC Molecular Classification Predicts Prognosis and Response to Therapies
Increased PC Labeling Index
Lack of Cyclin D1 Expression
Deletion of p53
Monosomy of chro 13/13q
Hypodiploidy
Bad prognosis
Activating Mutations of K-Ras
Monosomy of chro 17
Tumor Cells with Abnormal Karyotype
t(14;16) TC5
t(4;14) TC4

25. t(4;14) translocation (TC 4)
The TC Molecular Classification Predicts Prognosis and Response to Therapies
t(4;14) translocation (TC 4)
Shortened Survival
Standard Therapy (42)
High-dose Therapy (22)
Median OS 26 months
Median OS 33 months
Fonseca R et al, Blood. 2003; 101: Moreau et al, Blood. 2002; 100:

26. The TC Molecular Classification Predicts Prognosis and Response to Therapies
t(14;16) translocation (TC 5)
Shortened Survival (worse Prognosis)
Standard Therapy (15)
Median OS 16 months
Fonseca R et al, Blood. 2003; 101:

27. t(11;14) translocation (TC 1)
The TC Molecular Classification Predicts Prognosis and Response to Therapies
t(11;14) translocation (TC 1)
Better Survival
Standard Therapy (53)
High-dose Therapy (26)
Median OS 50 months
Median OS 80 months
Fonseca R et al, Blood. 2003; 101: Moreau et al, Blood. 2002; 100:

28. The TC Molecular Classification Predicts Prognosis and Response to Therapies
The TC classification may be clinically useful way to classify patients into groups that have distinct subtypes of MM (and MGUS) tumors.
The TC classification identifies clinically important molecular subtypes of MM with different prognosis and with unique responses to different treatments.

29. The TC Molecular Classification Predicts Prognosis and Response to Therapies
High dose therapy and TC1
Microenvironment-directed therapy and TC2
FGFR3 inhibitor and TC4
maf dominant-negative and TC5

30. Critical role for Cyclin D/Rb pathway in MM
TC1
TC5
TC4
TC3
TC2
Hyperdiploid
11q13 CCND1
16q23 c-maf
4p16
Other
Cyclin D1
6p21 CCND3
20q11 mafB
FGFR3
MMSET
p16
INK4a
p15
INK4b
Cyclin D2
Cyclin D1
Cyclin D3
p18
INK4c
CDK 4, 6
CDK 4, 6
CDK 4, 6
p19
INK4d
G1 Phase
S Phase p p p p Rb
E2F
E2F Rb
OFF ON

31. Novel Therapeutic Strategies targeting Genetic Abnormalities
Targeting the genes
Directly dysregulated
By translocation
Targeting Cyclin D
Silencing of CDK
inhibitor mRMA
expression
might be reversed
Targeting FGFR3
by monoclonal
antibodies
Desferroxamine
HDAC
Inhibitors
Targeting FGFR3
by selective
tyrosine kinase
inhibitor
Selective CDK
inhibitors
DNA methyl
Transferase
inhibitor

32. Interaction of MM cells and their BM milieu
GSK-3β FKHR Caspase-9 NF-KB mTOR Bad
migration
Survival Anti-apoptosis Cell cycle
PKC
Akt
TNFα TGFβ VEGF IL-6
PI3-K
Bcl-xL MCL-1
Survival Anti-apoptosis
JAK/STAT3
MEK/ERK
Proliferation
Bcl-xL IAP Cyclin-D
Survival Anti-apoptosis Cell cycle
NF-KB
IL-6 VEGF IGF-1 SDF-1α
MEK/ERK
Proliferation Anti-apoptosis
p27Kip1 MM
ERK
Smad2
NF-KB
Adhesion molecules
LFA-1
ICAM-1
NF-KB
BMSC
MUC-1
VCAM-1 Fibronectin
VLA-4

33. Myeloma Cells and BM Microenvironment
Bruno et al, The Lancet Oncology, July 2004,

34. Apoptotic Signaling Pathways
TNFα FasL TRAIL
Velcade ZME-2
ImiDs, Velcade HDAC-I, 2ME-2
Dex
JNK
Mitochondria
FADD
Bid
Cytochrome-c
Smac
IL-6 IGF-1
Caspase-8
Caspase-9
Caspase-3
PARP
Apoptosis
Hideshima et al, Blood, August 2004,

35. Novel biologically based therapies targeting MM cells and the BM microenvironment
Novel Agents
Apoptosis Growth Arrest A
Adhesion Molecule B
Inhibition of Adhesion
Proliferation C
bFGF VEGF
Inhibition of Cytokines
IL-6 IGF-1 VEGF SDF-1α D
Angiogenesis
Drug Resistance

36. Novel Agents for Myeloma
Targeting both MM cells and interaction of MM cells with the BM microenvironment
Targeting circuits mediating MM cell growth and survival
Targeting the BM microenvironment
Targeting cell surface receptors

37. Novel Agents for Myeloma
Targeting both MM cells and their interaction with BM microenvironment
Targeting circuits mediating MM cell growth and survival
Thalidomide and its analogs (Revlimid)
Proteasome inhibitor (Bortezomib)
Arsenic trioxide
2-Methoxyestradiol (2-ME2)
Lysophosphatidic acid acyltransferase-β inhibitor
Triterpinoid 2-cyano-3, 12-dioxoolean-1, 9-dien-28- oic acid (CDDO)
N-N-Diethl-8, 8-dipropyl-2-azaspiro [4.5] decane-2-propanamine (Atiprimod)
VEGF receptor tyrosine kinase inhibitor (PTK787/ZK222584, GW654652)
Farnesyltransferase inhibitor
Histone deacetylase inhibitor (SAHA, LAQ824)
Heat shock protein-90 inhibitor (Geldanamycin,17-AAG)
Telomerase inhibitor (Telomestatin)
bcl-2 antisense oligonucleotide (Genasense)
Inosine monophophate dehydrogenase (VX-944)
Rapamycin
Targeting the bone marrow microenvironment
Targeting cell surface receptors
IĸB kinase (IKK) inhibitor (PS-1145)
p38 MAPK inhibitor (VX-745, SCIO-469)
TFG-β inhibitor (SD-208)
TNF related apoptosis-inducing ligand (TRAIL) / Apo2 ligand
IGF-1 receptor inhibitor ( ADW)
HMG-CoA reductase inhibitor (statins)
Anti-CD20 antibody (Rituximab)

38. Kyle RA et al. N Engl J Med. 2004 Oct 28;351(18):1860-73
Proposed Mechanism of Action of Drugs in Targeting Myeloma Cells and BM Microenvironment
Kyle RA et al. N Engl J Med Oct 28;351(18):

39. Homoeostasis of Healthy Bone Tissue and MM Bone Disease
Bruno et al, The Lancet Oncology, July 2004,

40. Osteoprotegerin (OPG)
Osteoclast Precursor
Bone Destruction
Osteoclast
Osteoprotegerin (OPG)
Bone Marrow stromal Cells
Osteoblast
Interferon ɣ
MIP1
T cell
TNFα IL1β
IL7
IL6
RANKL
Multiple Myeloma Cells
RANK

41. Effects of Thalidomide on the Myeloma Microenvironment
Bruno et al, The Lancet Oncology, July 2004,

42. Proposed Action of Thalidomide in Myeloma
Mutiple Myeloma Cells
Modulation of Cytokines
VEGF IL6 TNFα IL1β
Direct Action
Bone Marrow Stromal Cells
T Lymphocytes
IL2 ILNɣ
Modulation of Immune System
Bone Marrow Vessels
VEGF bFGF
Inhibition of Angiogenesis
Cytotoxicity of NK Cells

43. Mechanism of Action of Bortezomib
Phosphorylation of NFKB inhibitory partner protein IKB leads to degradation of IKB by the proteosome and release of NFKB
NFKB migrates into the nucleus to induce arrest of apoptosis and expression of adhesion molecule
Affinity of Bortezomib for the proteosome inhibits protein degradation, and prevents nuclear translocation of NFKB
Bruno et al, The Lancet Oncology, July 2004,

44. Mechanism of Action of Arsenic Trioxide
Mutated P53:
Arsenic trioxide triggers the caspase cascade by activation of caspases 8 and 10
Functional P53:
The cascade is activated through the mitochondrial apoptotic pathway and the activation of caspase 9
Bruno et al, The Lancet Oncology, July 2004,