1. Alberto Rocci Ospedale San Giovanni Battista di Torino
PATOGENESI MOLECOLARE E POSSIBILI TARGET TERAPEUTICI NEL MIELOMA MULTIPLO
Alberto Rocci
Ospedale San Giovanni Battista di Torino
Università degli Studi di Torino
Mediterranean School of Oncology
Orvieto, 20 novembre 2009

2. MULTIPLE MYELOMA Accumulation of abnormal
plasma cells in the bone marrow
Production of monoclonal protein
detectable in serum or urine
Organ damage:
kidney, bone, blood

3. Hematological Neoplasia Pathogenesis
Chronic Myeloid Leukemia
BCR/ABL
Mantle Cell Lymphoma
Bcl1
Primary Effusion Lymphoma
HHV-8
Burkitt Lymphoma
c-MYC
Follicular Lymphoma
Bcl2
Multiple Myeloma
multifactorial
pathogenesis ?

4. MICROENVIRONMENT ALTERATIONS IMMUNE SYSTEM IMPAIRMENT
MM PATHOGENESIS
GENOMIC INSTABILITY
MICROENVIRONMENT ALTERATIONS
IMMUNE SYSTEM IMPAIRMENT

5. GENOMIC INSTABILITY IN MULTIPLE MYELOMA

6. BM and PB Lymph Node Naive B lymphocyte Extra GC-maturation
Memory B lymphocyte
B-cell precursor
Marginal zone
Mantle-zone
Germinal Centre
GC-maturation
Memory
B Lymphocyte
plasmacells

7. VDJ RECOMBINATION somatic hypermutation IgH switch recombination
Alterations regarding these three mechanisms are commonly
involved in the pathogenesis of hematological malignancies.
In particular it is involved the 14q32 chromosomal region

8. PRIMARY Translocations
TRASLOCATION %
ONCOGENE
ROLE
t(4p16;14q32) % FGFR GF rec TK
MMSET Transcription regulator
TACC ND
t(6p21;14q32) % CICLINA D3 Cell cycle regulator
t(6p25;14q32) % MUM/IRF4 Regulation of IFN transc.
t(14q32;16q23) 5%-10% c-maf Transcriptional factor
t(14q32;20q12) % b-MAF Transcriptional factor
t(11q13,14q32) %-20% CICLINA D1 Cell cycle regulator MYEOV ND

9. PRIMARY Translocations
Almost all the genetic aberrations identified
in MM are present in MGUS

10. THE MM STORY PROBABLY STARTS HERE
Marginal zone
Mantle-zone
Germinal Centre MM
GC-maturation
Memory
B Lymphocyte
plasmacells

11. Nonhyperdiploid pathway
Two pathway hypotesis
Multiple Myeloma
and MGUS
Nonhyperdiploid pathway
(high prevalence of
IgH translocations)
11q13 (CCND1)
4p16 (FGFR3 and MMSET)
6p21 (CCND3)
16q23 (MAF)
20q11 (MAFB)
50%
Hyperdiploid pathway
(multiple chromosome
trisomies)
Trisomies of chromosome
3,5,7,9,11,15,19,21
50%
Chromosome 13 monosomy/deletion is an early event
that can occur in both groups

12. Cyclin D disregulation
Virtually all MM and MGUS plasmacells have increased levels
of Cyclin D1, D2 or D3, despite the low proliferative rate
Nonhyperdiploid pathway
Cyclin overespression does not lead to a growth improvement,
however it seems that this situation can make plasma cells
more prone to growth stimuli

13. TC classification 2% Bergsagel PL, Blood 2005 FGFR3 MMSET C-MAF MAFB
CCND3
CCND1
CCND2
RB1
4p16
14%
Maf 8%
11q13
16% D1
32% D2
19% D1 + D2 7%
None
6p21 2% 2%
Bergsagel PL, Blood 2005

14. Alteration of Rb pathway
Bergsagel PL and Kuehl WM, JCO 2005

15. ONCOGENIC EVENTS GENOMIC INSTABILITY IgH tx Bergsagel PL, Blood 2005
11q13
6p21
16q23
20q11
4p16
IgH tx
NON-HYPER
DIPLOID
HYPER DIPLOID
55%-60%
DEL13 e/o1q gain
TRISOMY
3, 5, 7, 9, 11,15,19,21
Bergsagel PL, Blood 2005

16. FROM MGUS TO MULTIPLE MYELOMA
Supervised analysis
263 genes are differentially expressed
between healthy and MGUS
380 genes are differentially expressed
between healthy and MM
74 genes are differentially expressed
between MGUS and MM
There are fewer differences at the gene expression level between MGUS and MM than between healthy and MM or healthy and MGUS
Davies FE et al., Blood 2003

17. SECONDARY Translocations
Occurres as progression event
Rare or absent in MGUS patients
Can be mediated by mechanisms that do not involve
the three B-cell-specific DNA-modification mechanisms
Bergsagel PL and Kuehl WM, JCO 2005

18. ONCOGENIC EVENTS GENOMIC INSTABILITY IgH tx Bergsagel PL, Blood 2005
DEL13 e/o1q gain
NON-HYPER
DIPLOID
HYPER DIPLOID
55%-60%
TRISOMY
3, 5, 7, 9, 11,15,19,21
11q13
6p21
16q23
20q11
4p16
IgH tx
MYC dysregulation (45%)
Secondary (Ig) TLC
Karyotypic abnormalities
DEL 17p
DEL 1p
MAPK pathway activating mutations
N-ras (codon 12,13,61)
K-ras (40%-55%)
FGFR3
NFkB pathway activating mutations
TRAF3
cIAP1/2
CYLD
NIK
RB1 pathway p18INK4c
inactivating muts
TP53
Bergsagel PL, Blood 2005

19. timing of oncogenic events
Disease stages and
timing of oncogenic events
Bergsagel PL and Kuehl WM, JCO 2005

20. GENOMIC INSTABILITY and Prognosis
ONCOGENIC EVENTS
11q13
6p21
20q11
16q23
4p16
IgH
NON-HYPER
DIPLOID
HYPER DIPLOID
55%-60%
Karyotypic abnormalities
Secondary (Ig) TLC
DEL13 e/o1q gain
MAPK pathway activating mutations
N-ras (codon 12,13,61)
K-ras (40%-55%)
FGFR3
TRISOMY
3, 5, 7, 9, 11,15,19,21
TRAF3
cIAP1/2
CYLD
NIK
NFkB pathway activating mutations
RB1 pathway p18INK4c
inactivating muts
MYC dysregulation (45%)
DEL 17p
DEL 1p
TP53

21. GENOMIC ALTERATION AND EFS – OS
Avet-Loiseau H et al., Blood 2007

22. GENOMIC ALTERATIONS AND NEW DRUGS
BORTEZOMIB
LENALIDOMIDE
Del(13q)
T(4;14)
Sagaster V et al, Leukemia 2007

23. GENOMIC ALTERATION AND TARGET THERAPY
Clin Cancer Res 2009
Leukemia 2009

24. GENOMIC INSTABILITY: CONCLUSIONS
MM seems to include several diseases that have differences
in early events, global gene expression patterns,
clinical features, prognosis and response to therapy
IgH translocation are common in half of MM and MGUS
patients whereas other patients display trisomies
Common translocations have a major prognostic role in
patients treated with standard or high dose chemotherapy,
their role in patients treated with novel drugs
is still under investigation

25. MICROENVIRONMENT ALTERATION IN MULTIPLE MYELOMA

26. HOW MICROENVIROMENT SUSTAINS MALIGNANT GROWTH
A TYPICAL CASE OF MM DOES NOT HAVE ALL THESE FEATURES

27. MICROEVIRONMENT AND MM (main actors)
Plasma cell
Osteoclast
Endothelial cell
Hematopoietic cells
Mesenchymal cells
Osteoblast
ECM
Dendritic cells
Natural immunity cells
T-cells
B-cells

28. MM cells and bone marrow interaction
CYTOCHINE-MEDIATED SIGNALING
ADHESION-MEDIATED SIGNALING
Hideshima T & Anderson KC Nat Rev Cancer 2007:
Hideshima T et al., Nat Rev Canc 2007

29. Molecular modification due to cell-to-cell interaction
Hideshima T & Anderson KC Nat Rev Cancer 2007:
Hideshima T et al., Nat Rev Canc 2007

30. HGF/MET in Multiple Myeloma
β-actin
Normal
BM Cells
Normal
PB Cells
Primary
myeloma cells
Börset M et al, Blood 1996
Seidel C et al, Blood 1998

31. RESULTS: MET and PFS - OS beta2microglobulin and
The two groups display
no differences about
beta2microglobulin and
albumin levels or
FISH feature
Rocci A. et al, ASH 2009

32. MICROEVIRONMENT AND MM (How does it plays)
IL-6
TNF-
RANK-L
VEGF
TGF-
Prostaglandins
Multiple role and indipendence to growth stimuli
resistance to apoptosis
homing and migration
angiogenesis
replication and proliferation
resistance to inhibition stimuli

33. IL-6 induces expression
MULTIPLE ROLE OF IL-6
IN MALIGNANT PC
IL-6 induces expression
and secretion of VEGF
Hideshima T and Anderson KC, Nat Rev Cancer 2002

34. ROLE OF VEGF IN Myeloma VEGF fibronectin BMSCs Blood vessel Osteoclast
Laminin,
fibronectin
BMSCs
VEGF
IL-6 MM
cell
IL-6
VEGF
VEGF, IL-6
VEGF
Osteoclast
Increase of
bone-resorbing
activity
Blood vessel
angiogenesis
Inhibition of
maturation
Proliferation,
migration
Dendritic Cell
MM PC
Lin et al. Cancer Res 2002

35. BONE DISEASE Reduction in Increased in new bone formation
Scheletal involvment is observed in approximately 80%
of newly diagnosed multiple myeloma patients
Very debilitating aspect of multiple myeloma due to pain
Dangerous due to pathological fractures
Increased in
bone resorption
(osteoclast activity)
Reduction in
new bone formation
(osteoblast activity)
The development of lytic lesion is related
to an uncoupled bone remodelling:

36. Bone Physiology OSTEOBLAST OSTEOCLAST Bone Formation Bone Resorption
PTH, Vit. D3,
Vit. K, IL-11,
estrogeni
Bone Resorption
TNF, IL-1,
IL-6, PGE2,
IFN, RANKL

37. Bone in Multiple Myeloma
TNF, IL-1,
IL-6, PGE2,
IFN, RANKL
Bone Resorption
OSTEOCLAST
Bone Formation
PTH, Vit. D3,
Vit. K, IL-11,
estrogeni
OSTEOBLAST

38. MICROEVIRONMENT AND MM (role of RANK/RANKL)
RANK is found on the surface of
osteoclast precursors
Osteoclast
RANKL
RANK
HBMSC
Myeloma Cells
+ve
B. Myeloma
OPG
RANKL is expressed on marrow stromal cells
and osteoblasts
RANKL binds to RANK Inducing osteoclast formation
OPG is produced by osteoblasts and
can antagonize RANKL activity
Myeloma cells
- downregulate expression of OPG
- upregulate expression of RANKL
Myeloma cells produce DKK-1
that antagonize the Wnt signaling,
vital for osteoblast differentiation

39. DRUGS ACTIVITY ON BONE
Terpos E. et al, Leukemia 2007

40. Despite the absence of a peculiar molecular signature,
CONCLUSIONS
Despite the absence of a peculiar molecular signature,
malignant plasma cells display many genomic alterations
usefull to divide myeloma patients in several groups
Genomic alterations are similar in MGUS and MM,
highlighting the essential role of microenvironment
in disease maintenance and progression
Several genetic alteration, cytokine overespression or
microenvironment alteration can be used as a target
for anti myeloma therapy, HOWEVER…
Treatment paradigm in MM:
concurrent targeting of both tumor cells and bone marrow
microenvironment to overcome drug resistance

41. IMiDs in myeloma treatment
Richardson P. et al, JCO 2004

42. Reduce growth factors: Antiangiogenic effects:
Bortezomib in myeloma treatment
modified from Armand et al., Oncologist 2007
PROTEASOME
INHIBITOR
Triggers MM cell
apoptosis by the
accumulation
of improperly folded
proteins
Reduce growth factors:
Decrease cytokine levels
Antiangiogenic effects:
reduce cell adesion
and IL-6 production
Bone remodelling:
Reduce resorption
Increase formation
Increase Immunity:
disrupts tumor-DC interaction
and enhances DC-mediated immunity