1. GAMMAPATIE MONOCLONALI
MALATTIE DEI LINFOCITI B CARATTERIZZATE
DALLA PROLIFERAZIONE DELLE CELLULE CHE
PRODUCONO GLI «ANTICORPI» ( PLASMACELLULE)
E DALLA SINTESI DI UNA IMMUNOGLOBULINA (Ig)
completa / incompleta MONOCLONALE

2. MIELOMA MULTIPLO

3. Policlonalità e monoclonalità
Popolazione plasmacellulare
Eterogeneità di cloni
Clone con cellule tutte uguali di un unico capostipite trasformato
Anticorpopoiesi
Finalizzata e limitata
Eterogeneità di Ig per isotipo e idiotipo
Perdita di finalità e controllo
Ig uguali per isotipo e idiotipo

5. Immunofixation to Determine Type of
Monoclonal Protein
IgG K
IgG kappa M protein

7. BENCE JONES

8. MGUS: MMS (Smouldering) asintomatico MM sintomatico: C = iperCalcemia
asintomatica
< 3 gr% M protein
< 10% BM PC
no CRAB
no MDE (amiloidosi)
incidenza:
1.5% > 50 anni
3% > 70 anni
10% > 80 anni
rischio di evoluzione:
1% anno
MMS (Smouldering)
asintomatico
> 3 gr% M-protein
> 10% BM PC
no CRAB
no MED ( amiloidosi)
Incidenza:
2-3% > 50 anni
16% di tutti i MM all’esordio
rischio di evoluzione:
10% anno x i primi 5 aa
3% anno dopo 5 aa
1% anno dopo 10 aa MM
sintomatico:
3 gr% M-protein
> 30% BM PC
> 10% BM PC
C = iperCalcemia
R = renal failure
A = Anemia
B = Bone lesions

9. Excessive numbers of abnormal plasma cells in the bone marrow
MM is characterized by
Excessive numbers of abnormal plasma cells in the bone marrow
Overproduction of intact monoclonal Igs (IgG, IgA, IgD, or IgE) or Bence Jones protein (free antibody light chains)
Reproduced with permission from the Multiple Myeloma Research Foundation Web site. .org/about_myeloma/index.html.

10. Microambiente midollare
B linfocita CG
MGUS
smoldering
myeloma
symptomatic
intramedullary
extramedullary
Long-lived PC
Microambiente
midollare
Adapted from
Nature Reviews - Cancer , 2002

11. Role of the BM niche in MM pathogenesis.
Role of the BM niche in MM pathogenesis. The blue oval in the center is the MMC, with its close interplay with cellular and acellular components of the BM. The pale orange ovals represent relevant cytokines/chemokines in the BM milieu. Dotted arrows indicate differentiation, whereas solid arrows indicate secretion and/or effect on a target cell. Yellow squares contain a synopsis of the overall effect of cytokines and cell-to-cell contact on the target cell. Key signaling cascades, transmembrane proteins, and intracellular organelles, which are of interest for molecularly targeted therapies, are represented. BMSC, BM stromal cell; CAF, cancer-associated fibroblast; CCL2, chemokine (C-C motif) ligand 2; CTLA4, cytotoxic T-lymphocyte-associated protein 4; CXCL12, chemokine (C-X-C motif) ligand 12; CXCR4, chemokine (C-X-C motif) receptor 4; DKK-1, dickkopf WNT signaling pathway inhibitor 1; ER, endoplasmic reticulum; FN, fibronectin; HGF, hepatocyte growth factor; HIF-1α, hypoxia-inducible factor 1α; ICAM1, intercellular adhesion molecule 1; IGF-1, insulinlike growth factor 1; ITGB1, integrin β1; ITGB2, integrin β2; JNK, c-JUN N-terminal kinase; MAPK1, mitogen-activated protein kinase 1; MDSC, myeloid-derived suppressor cell; MIP-1α, macrophage inflammatory protein 1α; MUC-1, mucin 1; NK-T cells, natural killer T cells; OPG, osteoprotegerin; PD-1, programmed cell death 1; PD-L1, programmed ligand death 1; RANK, receptor activator of NF-κB; RANKL, RANK ligand; RBC, red blood cell; TGF-β, transforming growth factor β; TH17, T helper 17 cell; Treg, regulatory T cell; VCAM1, vascular cell adhesion molecule 1; VEGFA, vascular endothelial growth factor A; WNT, wingless-type. Adapted from Bianchi and Anderson47 with permission.
Giada Bianchi, and Nikhil C. Munshi Blood 2015;125:
©2015 by American Society of Hematology

12. Pathogenesis of MM. The orange round cell represents a normal B cell, whereas the yellow round cell is a mutated, post–germinal center (GC) B lymphocyte that later differentiates into a long-lived PC (yellow oval).
Pathogenesis of MM. The orange round cell represents a normal B cell, whereas the yellow round cell is a mutated, post–germinal center (GC) B lymphocyte that later differentiates into a long-lived PC (yellow oval). In MM pathogenesis, the initial genetic event (red square) is thought to occur in the GC, facilitated by the processes of somatic hypermutation and isotype switching, and characterizes the founder clone (F). Later genetic mutations occur at the time of transformation to MM (red circle), with de novo mutations (red geometric shapes) acquired during disease evolution and heterogeneously present in different subclones (S1 and S2). The genetic, epigenetic, and biological events occurring in the cancer clones and BM microenvironment during the evolution of premalignant dyscrasia to MM are outlined in the pink, green, and blue boxes, respectively. ECM, extracellular matrix.
Giada Bianchi, and Nikhil C. Munshi Blood 2015;125:
©2015 by American Society of Hematology

13. QUADRI DEL MM E LORO PATOGENESI

14. Myeloma: Clinical Features
Bone pain, often with loss of height
Constitutional weakness, fatigue, and weight loss
Anemia
Renal disease, renal tubular dysfunction
Infections: neutropenia/hypogammaglobulinemia
Hypercalcemia, myeloma cells secrete osteoclast- activating factors
Hyperviscosity
Neurologic dysfunction: spinal cord or nerve root compression

17. INDAGINI NECESSARIE NEL SOSPETTO DI UN MIELOMA MULTIPLO
ELETTROFORESI PROTEINE SIERICHE
DOSAGGIO IMMUNOGLOBULINE
IMMUNOFISSAZIONE SIERICA
ES. URINE, ELETTROFORESI, IMMUNO-
FISSAZIONE URINARIA
PROTEINURIA 24 ORE
Ricerca Proteina di Bence Jones
Free Light Chains ( K / λ )
EMOCROMO
ASPIRATO MIDOLLARE / BIOPSIA OSSEA
CITOGENETICA
FISH
CREATININEMIA
CALCEMIA
Β2 MICROGLOBULINEMIA
RX SCHELETRO IN TOTO
RMN RACHIDE
PET

18. Durie-Salmon Staging System for Myeloma
Stage
Criteria
Myeloma cell mass ( 1012 cells/m2) I
All of the following: Hemoglobin >10 g/dL Serum calcium level 12 mg/dL (normal) Normal bone or solitary plasmacytoma on x-ray Low M component production rate: IgG <5 g/dL
IgA <3 g/dL Bence Jones protein <4 g/24 hr
<0.6 (low) II
Not fitting stage I or III
0.6–1.2 (intermediate)
III
One or more of the following: Hemoglobin <8.5 g/dL Serum calcium level >12 mg/dL Multiple lytic bone lesions on x-ray High M-component production rate: IgG >7 g/dL
IgA >5 g/dL Bence Jones protein >12 g/24 hr
>1.2 (high)
Slide 23. Durie-Salmon Staging System for MM
The Durie-Salmon staging system has been in use since In this system, the clinical stage of disease (stage I, II, or III) is based on several measurements, including levels of M protein, the number of bone lesions, hemoglobin values, and serum calcium levels. Stages are further divided according to kidney function as determined by serum creatinine levels (classified as A or B)
Durie B, Salmon S. Cancer. 1975;36:842
Multiple Myeloma Research Foundation. Available at:
Subclassification Criteria
A Normal renal function (serum creatinine level <2.0 mg/dL)
B Abnormal renal function (serum creatinine level 2.0 mg/dL)
Durie B, Salmon S. Cancer. 1975 18

19. International Staging System
Stage
Criteria
Median Survival I
Serum 2M <3.5 g/dL
Serum albumin ≥3.5 g/dL
62 mo II
Serum albumin <3.5 g/dL OR
Serum 2M 3.5 to <5.5 mg/dL*
44 mo
III
Serum 2M ≥5.5 g/dL
29 mo
Greipp et al. J Clinic Oncol, 2005

20. b2-microglobulin
An elevated b2-microglobulin (≥2.5) is an adverse prognostic factor
IgA subtype as well
Model using b2m ≥2.5, IgA isotype associated to b2m ≥2.5
Median survival >111 mos. (0 factors) vs (1) vs mos. (2)
Facon, T et al. Blood 97: , 2001.

21. International Staging System Impact of age Predictive of survival
Stage
Age < 65 yrs
Median Overall Survival
Age  65 yrs I
69 months
47 months II
50 months
37 months
III
33 months
24 months

22. Cytogenetics-based prognostic grouping
Risk group
Cytogenetics
Median
Overall Survival
Poor
t(4;14)
t(14;16)
del 17p13
24.7 months
Intermediate
del 13q14
42.3 months
Good
All Others
50.5 months
Nonhyperdiploid worse prognosis than hyperdiploid
Fonseca et al. Blood 2003

23. Del 13: Unfavorable Prognosis
Deletion of chromosome 13 is the single most powerful adverse prognostic factor in patients referred for high-dose therapy
OS 65.1 ± 9.8 vs 26.7 ± 4.1 months
Facon, T et al. Blood 97: , 2001.

24. Risk Factors for MM Low–intermediate risk High risk
Expected OS >6–7 years
t(11;14)
Hyperdiploidy
Low 2M (<3.5 mg/L)
High risk
Expected OS 2–3 years
t(4;14) or t(14;16) by FISH
Del 17p by FISH
Del 13 by cytogenetics
Hypodiploidy
High 2M (≥5.5 mg/L)
High plasma cell labeling index (PCLI) ≥3
IgA isotype
Go through risk factors of MM- usually for newly diagnosed- but use it here to give them information about MM.
Chng. Clin Lymphoma Myeloma. 2005
Stewart. J Clin Oncol. 2005
Barlogie. Blood. 2004
Richardson. Blood. 2005

25. MGUS/Myeloma Classification
Monoclonal Gammopathy of Undetermined Significance (MGUS)
Serum M protein < 3 g/dL
Bone marrow plasma cells < 10%
Absence of anemia, renal failure, hypercalcemia, lytic bone lesions
Asymptomatic Multiple Myeloma
Smoldering Multiple Myeloma
Indolent Multiple Myeloma
Serum M protein > 3 g/dL and/or bone marrow plasma cells ≥ 10%
Bone marrow plasmacytosis
No anemia, renal failure, hypercalcemia, lytic bone lesions
Mild anemia or few small lytic bone
lesions
Stable serum/urine M protein
No symptoms
Presence of serum/urine M protein
Symptomatic Multiple Myeloma
Bone marrow plasmacytosis (> 30%)
Anemia, renal failure, hypercalcemia, or lytic bone lesions

26. MIELOMA MULTIPLO
MALATTIA INCURABILE
100
survival %
years

27. MIELOMA MULTIPLO
Allo-SCT
Alta Dose
chemio
CHT
Talidomide

28. International Staging System Accurate prognostic after treatment
Stage
High-Dose Chemotherapy
Median Overall Survival
Conventional dose chemotherapy I
111 months
55 months II
66 months
40 months
III
45 months
25 months

29. Role of Bone Marrow Microenvironment
MM cells
IL-6
TNF
IL-1
Bone Marrow Stromal Cells
ICAM-1
Bone Marrow Vessels
VEGF
bFGF
IL-2
IFN 
PBMC
CD8+ T Cells
NK Cells
Hideshima et al. Blood 2000
Davies et al. Blood 2001
Gupta et al. Leukemia 2001
Roccaro et al. Cancer Res, 2006
Mitsiades et al. Blood 2002
Lentzsch et al Cancer Res 2002

30. Modulated by Bone Marrow Cell Components
BONE MARROW MICROENVIRONMENT IS AN ACTIVE PART IN THE PATHOGENESIS OF MULTIPLE MYELOMA
BM milieu plays a crucial role in MM cell proliferation GROWTH ADVANTAGE SURVIVAL DRUG RESISTANCE
Modulated by Bone Marrow Cell Components
Osteoblasts
Osteoclasts
Ffibroblasts
ENDOTHELIAL CELLS

31. Modulated by Bone Marrow Cell Components
BONE MARROW MICROENVIRONMENT IS AN ACTIVE PART IN THE PATHOGENESIS OF MULTIPLE MYELOMA
BM milieu plays a crucial role in MM cell proliferation GROWTH ADVANTAGE SURVIVAL DRUG RESISTANCE
Modulated by Bone Marrow Cell Components X
Osteoblasts
Osteoclasts
Ffibroblasts
ENDOTHELIAL CELLS
NEW DRUGS

32. Novel Therapies Targeting the Myeloma Cell in Its Bone Marrow Microenvironment
Targeting MM Cell
17AAG, TRAIL, SAHA, IGF1R
Inhibitors, FTI (eg, R11577),
telomestatin, epothilone B,
oblimersen sodium, rituximab,
CD40 MoAb
Targeting MM Cell BM Microenvironment
Thalidomide, lenalidomide, AS2O3,
PTK787, FTI (e.g.,
R11577), 2ME2, LPAAT
Inhibitors
Bortezomib, NPI-0052
Targeting BM
Microenvironment
IKK inhibitors (eg, PS-1145),
P38-MAPK inhibitors (SC 469)

33. NEW DRUGS IN MM
Bortezomib
NPI-0052
Carfilzomib (PR-171)
Lenalidomide
Pomalidomide

34. Bone marrow stromal cells Bone marrow stromal cells
Bortezomib I.
Plasmacells
VEGF
IL-6 X
II. X
Bortezomib X
IV. X
Bone marrow stromal cells
Angiogenesis
ICAM-1
VCAM-1
Bone marrow stromal cells
III.
Roccaro et al. Cancer Res 2006;1:
Mitsiades et al. Blood 2002;99:4079
Hideshima et al. Cancer Res 2001;61:3071
Hideshima et al. Oncogene 2001;20:4519

35. Lenalidomide in MyelomaC
MM cells
IL-6
TNF
IL-1 B A
Bone Marrow Stromal Cells
ICAM-1
Bone Marrow Vessels
CD8+ T Cells
PKC
NFAT
PI3K
IL-2
CD28
NK Cells
IL-2
IFN 
VEGF
bFGF
Dendritic
Cells D E
Mitsiades et al. Blood 99: 4525, 2002
Lentzsch et al Cancer Res 62: 2300, 2002
LeBlanc R et al. Blood 103: 1787, 2004
Hayashi T et al. Brit J Hematol 128: 192, 2005
Hideshima et al. Blood 96: 2943, 2000
Davies et al. Blood 98: 210, 2001
Gupta et al. Leukemia 15: 1950, 2001

36. MIELOMA MULTIPLO
New Drugs
Allo-SCT
Alta Dose
chemio
CHT
Talidomide

37. New treatment paradigm for patients who are eligible for autotransplantation (ASCT)
Novel agents
Induction therapy
Autograft ± 2
Consolidation
Maintenance

38. Goals of novel agent-based induction therapies
Achieve a rapid and marked reduction in tumor burden, up to the VGPR and CR level
Reverse disease-related complications, such as hypercalcemia, renal failure and anemia
Ameliorate symptoms
Enable the successful collection of PBSCs
Minimize toxicities precluding subsequent ASCT
Cavo et al, Blood 2011; 117:

39. Impact of novel agents incorporated into autologous transplantation on outcomes
Rate of high-quality responses (≥VGPR, CR-nCR) to ASCT
PFS and OS
Novel agents have been frequently incorporated after ASCT as consolidation and/or maintenance therapy
The contribution of different treatment phases to clinical outcomes cannot be easily evaluated

40. Clonality of PC and k:λ FLC ratio → STRINGENT CR (sCR) 1
MORE SENSITIVE TECHNIQUES ARE REQUIRED TO DETECT THE DEPTH OF RESPONSE BEYOND THE LEVEL OF CR
Bone marrow level
Clonality of PC and k:λ FLC ratio → STRINGENT CR (sCR) 1
Multiparametric flow cytometry → IMMUNOPHENOTYPIC CR 2
Qualitative and quantitative RT-PCR → MOLECULAR CR 3,4
Outside bone marrow
MRI 5
PET-CT 6
Durie et al, Leukemia 2006;20:
Paiva et al, Blood 2008;112:
Terragna et al, Blood 2010;116(21). Abstract 861
Ladetto et al, J Clin Oncol 2010;28:
Barlogie, Blood 2006; 108:2134
Zamagni et al, Blood 2010;116(21). Abstract 369

41. MIELOMA MULTIPLO cure Alta Dose chemio New Drugs Allo-SCT CHT
Talidomide