Advances in Biology and

Pathophysiology of Multiple Myeloma

Amer G. Rassam, MD
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
 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
 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

1850-1929 1852-1934
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
Epidemiology of Multiple Myeloma

 Prevalence (at any one time) : 40000

 Incidence: 14000 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
Age Distribution in Multiple Myeloma

35
30
25
20
%
15
10
5
0
<40 40-49 50-59 60-69 70-79 >80

Age
 Monoclonal Gammopathies – Mayo clinic
Macro 3% (30)
Extramedullary
1% (8)
SMM 4% (39) Other 3% (33)

LP 3% (37)

AL 8% (90)

MGUS
62% (659)

MM 16% (172)
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
 Normal B-cell Development
Lymph Node
Short-lived
:: Lymphoplasmacyte ::...
IgM
plasma cell
IgM (memory B Cell)

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
 Mechanisms of Disease Progression in
Monoclonal Gammopathies

Kyle RA et al. N Engl J Med. 2004 Oct 28;351(18):1860-73

 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
 Chromosome 13 Deletions in MM

11

12
13

14

21

22

31

32
33
34

Shaughnessy J et al, Blood, 2000; 96:1505

 Pathogenesis of Multiple Myeloma
Two pathways involved in the early pathogenesis of MGUS and MM

50% Hyperdiploid 50% non-hyperdiploid

Infrequent IgH IgH Translocations

Translocations

11q13 4p16 6p21

(cyclin D1) FGFR3+ (cyclin D3)
Multiple trisomies of MMSET
chromosomes 3, 5, 7,
9, 11, 15, 19 and 21 16q23 20q11
(c-maf) (mafB)
Hideshima et al, Blood, August 2004, 607-618
 Pathogenesis of Multiple Myeloma
Prevelance of IgH Translocations

100
90
80
70
60
50
40
30
20
10
0
MGUS MM PPCL HMCLs

Hideshima et al, Blood, August 2004, 607-618

 Prevalence of IgH Translocations

20q11
4p16 or 16q23 4p16

 Lower incidence with 16q23

MGUS/SMM
 de novo MM
11q13 No IgH T

 Rapid progression of
MGUS to MM
6p21

 Extremely poor prognosis

 Translocations in MM

Secondary Primary

c-myc

6p21 11q13 20q11

15% 40% 90%

MM adv MM HMCLs
4p16 16q23

Hideshima et al, Blood, August 2004, 607-618

 Translocation and Cyclin D (TC)
Molecular Classification of MM
Freq of TC in
Primary Gene(s) at newly diag
Group translocation breakpoint D-Cyclin Ploidy MM, %

11q13 CCND1 D1 NH 15
TC1 6p21 CCND3 D3 NH 3

TC2 None None D1 H 37

TC3 None None D2 H=NH 22

FGFR3/
TC4 4p16 MMSET D2 NH>H 16
16q23 c-maf D2 NH 5
TC5 20q11 mafB D2 NH 2
Bergsagel and Kuehl, Immunol Rev, 2003, 194:96-104
 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;100:1113-
1122. Zhan F. et al, Blood. 2002;
99:1745-1757
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
 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
Progression to Plasma Cell Neoplasia
Germinal Intramedullary Extramedullary
center B cell MGUS Myeloma Myeloma HMCL

11q13
6p21
16q23 NON-
HYPER
Primary 20q11 DIPLOID
IgH tx 4p16
Other DEL 13
?p16 p18
N, K-RAS
c-myc
FGFR3
p53

TRISOMY
3, 5, 7, 9, 11, HYPER
15, 19, 21 DIPLOID

Hideshima et al, Blood, August 2004, 607-618

Progression to Plasma Cell Neoplasia
Normal
Plasma Cell
Intra- Extra-
MGUS medulary medullary
myeloma myeloma

IgH translocations

Deletion of 13q

Chromosomal
instability RAS mutations

Dysregulation of c-MYC
p53 mutations
The TC Molecular Classification Predicts
Prognosis and Response to Therapies

Increased PC Lack of Cyclin

Deletion of p53 Labeling Index D1 Expression

Hypodiploidy Monosomy of
chro 13/13q
Bad
prognosis
Activating Monosomy of
Mutations of chro 17
K-Ras

Tumor Cells
t(14;16) TC5 with Abnormal t(4;14) TC4
Karyotype
 The TC Molecular Classification Predicts
Prognosis and Response to Therapies

t(4;14) translocation (TC 4)

Shortened Survival

Standard High-dose
Therapy (42) Therapy (22)

Median OS Median OS
26 months 33 months
Fonseca R et al, Blood. 2003; 101:4569-4575
Moreau et al, Blood. 2002; 100:1579-1583
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; 101:4569-4575

 The TC Molecular Classification Predicts
Prognosis and Response to Therapies

t(11;14) translocation (TC 1)

Better Survival

Standard High-dose
Therapy (53) Therapy (26)

Median OS Median OS
50 months 80 months
Fonseca R et al, Blood. 2003; 101:4569-4575
Moreau et al, Blood. 2002; 100:1579-1583
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.
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
 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 INK4d

p19

G1 S
p
Phase p p
Phase
p Rb

E2F E2F
Rb
OFF ON
 Novel Therapeutic Strategies targeting Genetic Abnormalities

Silencing of CDK
Targeting the genes
inhibitor mRMA
Directly dysregulated Targeting Cyclin D
expression
By translocation
might be reversed

Targeting FGFR3
Desferroxamine HDAC
by monoclonal
Inhibitors
antibodies

Targeting FGFR3 DNA methyl

Selective CDK
by selective Transferase
inhibitors
tyrosine kinase inhibitor
inhibitor
Interaction of MM cells and their BM milieu

GSK-3β
migration FKHR
Caspase-9 Survival
PKC NF-KB Anti-apoptosis
mTOR Cell cycle
Akt
Bad
TNFα PI3-K
TGFβ Bcl-xL Survival
JAK/STAT3 MCL-1 Anti-apoptosis
VEGF
IL-6 MEK/ERK Proliferation

Bcl-xL Survival
NF-KB IAP Anti-apoptosis
Cyclin-D Cell cycle
IL-6
VEGF MEK/ERK Proliferation
IGF-1 p27Kip1 Anti-apoptosis
SDF-1α

MM
ERK
Smad2

NF-KB
Adhesion
molecules LFA-1
ICAM-1
NF-KB
MUC-1
BMSC
VCAM-1
Fibronectin VLA-4
 Myeloma Cells and BM Microenvironment

Bruno et al, The Lancet Oncology, July 2004, 430-442

 Apoptotic Signaling Pathways
TNFα Velcade
FasL ImiDs, Velcade Dex ZME-2
TRAIL HDAC-I, 2ME-2
JNK

Mitochondria
FADD

Bid
Cytochrome-c Smac

IL-6
Caspase-8 Caspase-9 IGF-1

Caspase-3

PARP

Apoptosis
Hideshima et al, Blood, August 2004, 607-618
Novel biologically based therapies targeting MM cells and the BM
microenvironment

Novel Agents Apoptosis

Growth Arrest
A
Adhesion
B Inhibition of Adhesion Molecule

Proliferation
bFGF
C VEGF
Inhibition of
Cytokines
IL-6
IGF-1 D
VEGF
Angiogenesis
SDF-1α
Drug Resistance
 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
 Novel Agents for Myeloma
Targeting both MM cells and their
interaction with BM microenvironment
 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)
Targeting the bone marrow
microenvironment
 IĸB kinase (IKK) inhibitor (PS-1145)
 p38 MAPK inhibitor (VX-745, SCIO-469)
 TFG-β inhibitor (SD-208)
Targeting circuits mediating MM cell
growth and survival
 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 cell surface receptors
 TNF related apoptosis-inducing ligand (TRAIL) /
Apo2 ligand
 IGF-1 receptor inhibitor ( ADW)
 HMG-CoA reductase inhibitor (statins)
 Anti-CD20 antibody (Rituximab)
Proposed Mechanism of Action of Drugs in Targeting Myeloma
Cells and BM Microenvironment

Kyle RA et al. N Engl J Med. 2004 Oct 28;351(18):1860-73

 Homoeostasis of Healthy Bone Tissue and MM Bone Disease

Bruno et al, The Lancet Oncology, July 2004, 430-442

 Osteoclast Precursor Bone Destruction
Osteoclast

Osteoprotegerin (OPG)

Bone Marrow
stromal Cells
Interferon ɣ MIP1
Osteoblast

T cell

IL7 TNFα
IL6 IL1β
RANKL
Multiple Myeloma
Cells RANK
Effects of Thalidomide on the Myeloma Microenvironment

Bruno et al, The Lancet Oncology, July 2004, 430-442

 Proposed Action of Thalidomide in Myeloma
Mutiple
Myeloma
Modulation of Cytokines
Cells

VEGF
IL6
TNFα
IL1β
Direct Action Bone Marrow
Stromal Cells

T Lymphocytes

IL2 Modulation of
Bone Marrow Vessels ILNɣ Immune System
VEGF
bFGF

Inhibition of Angiogenesis Cytotoxicity of NK Cells

 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, 430-442

 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, 430-442