MMed (Haematology), Faculty of Health Sciences, University of the Witwatersrand / Multiple Myeloma (MM) is a malignancy of plasma cells. The incidence worldwide has been reported to be 3-4/100 000 of the population. The exact aetiology is not known, but several factors have been implicated in the aetio-pathogenesis of the disease. Chromosomal abnormalities are well documented in MM. Their detection is important, as some of the cytogenetic abnormalities such as the 13q deletion are associated with a poor prognosis. Knowledge of the prognostic factors guides the clinician with respect to the appropriate management of the patient. Prior to the use of fluorescence in situ hybridisation (FISH) as a technique for detecting cytogenetic abnormalities in MM, progress was slow in this field because of the difficulty of obtaining analysable metaphases in view of the low proliferative activity of plasma cells. FISH has significantly improved the detection rate over conventional cytogenetics. Objective: The present study set out to determine the proportion of patients with MM who have a detectable chromosome 13q deletion using conventional cytogenetic and FISH analysis. The FISH technique was specifically studied to see if the detection rate of the 13q deletion is improved compared to conventional cytogenetics. Furthermore, the cytogenetic abnormalities detected were correlated with the course of the disease, as well as other parameters of prognostic significance. vi Methods: Bone marrow aspiration specimens were obtained from thirty (30) patients with MM. Both newly and previously diagnosed patients were included. The sample size was however reduced to twenty (20) because of the need to optimise the technique and improve signal detection. Conventional cytogenetic and FISH analysis was performed using the LSI D13S319 DNA probe as the test probe, and the centromeric alpha 11 and 18 as control probes. The analysis was carried out by two observers. Results: In the current study, the detection of chromosomal aberrations was much better with FISH analysis compared to conventional cytogenetics i.e. 25% versus 5%. Of all the patients with chromosomal aberrations, 25% (5/20) had the specific deletion 13q14 (D13S319). Most of our patients (70%) presented with stage III disease. 60% of those were positive for deletion 13q14 (D13S319), i.e 3/5 patients had stage III disease. However, there was no correlation between disease stage and chromosome status, as the majority of the patients presented with advanced stage disease, irrespective of their chromosomal status. Other factors of prognostic significance such as the haemoglobin level, beta-2 microglobulin and creatinine levels were not found to correlate with the presence of the chromosomal aberration but with disease stage. Furthermore, median survival did not correlate with the presence of the chromosomal abnormality. Conclusion: FISH analysis improves the detection rate of chromosomal abnormalities in MM compared to conventional cytogenetics. The prevalence of 13q14 deletion in our patient population is lower than that reported in the

Bortezomib-based induction therapies have shown to increase complete response rates and are used as an upfront therapy for newly diagnosed multiple myeloma patients. The standard treatment uses twice a week bortezomib at 1.3 mg/m^2 with dexamethasone PO on the day of and day after bortezomib, however, peripheral neuropathy is often a dose-limiting factor. For elderly patients with multiple co-morbidities and polypharmacy, we propose an alternate schedule of once a week bortezomib IV at 1.6 mg/m^2 with dexamethasone PO on the day of and day after bortezomib. In this phase II, open-labeled, multi-site study, we hypothesize that patients receiving weekly bortezomib will have comparable efficacy as the standard twice a week schedule with increased convenience and lower toxicity profile, especially related to peripheral neuropathy. METHODS: 50 patients with newly diagnosed symptomatic multiple myeloma who were ineligible for transplant or postponed transplant were enrolled from 12 Veterans Affairs hospitals. One cycle consisted of once a week 1.6 mg/m2 bortezomib IV (days 1, 8, 15, 22) plus dexamethasone PO on the day of and after bortezomib (days 1, 2, 8, 9, 15, 16, 22, 23) for 4 weeks, with the 5th week off of treatment. Responding patients could receive up to 6 cycles. RESULTS: The median age of patients was 71 ± 1.46 years (range: 50-89) with β-2 microglobulin of 5.80 ± 0.46 mg/L and c-reactive protein of 10.61 ± 5.54 mg/L. Patients also had multiple co-morbidities including cardiovascular disease (76%) renal insufficiency (54%) and pulmonary problems (36%) and were receiving a median of 13 concurrent medications at baseline. Of the fifty patients, 43 patients were evaluable for response. Seven patients received <1 cycle or died before response could be evaluated. An objective response rate of 79% was observed in 43 evaluable patients with 14% achieving nCR/CR, and at least VGPR in 44% of patients. The median progression-free survival was 9.6 months and overall survival was 46.5 months. The most common toxicity of all grades was thrombocytopenia (42%), lymphopenia (46%), asthenia (48%), and constipation (38%). Peripheral neuropathy occurred in 24% with grade 3 neuropathy occurring only in 6% of patients. In conclusion, a weekly bortezomib plus dexamethasone regimen is efficacious and safe, with lower neurotoxicity in elderly patients with newly diagnosed multiple myeloma complicated by extensive co-morbidities and polypharmacy.

Thalidomid ist eine in der Therapie des fortgeschrittenen refraktären oder rezidivierten multiplen Myeloms (MM) wirksame Substanz, obwohl dosislimitierende Toxizitäten (DLT) ihren Einsatz beschränken können. In der vorliegenden Phase-I-Studie mit 28 Patienten mit rezidiviertem oder refraktärem MM nach konventioneller Chemotherapie oder Hochdosis (HD)-Chemotherapie mit Stammzelltransplantation (SCT) konnte gezeigt werden, dass eine Kombination von niedrig dosiertem Thalidomid mit Bendamustin und Prednisolon (BPT) die Wirksamkeit beibehält oder erhöht und gleichzeitig keine DLT auftritt. Die BPT-Therapie umfasste eine Dosis von Bendamustin (60mg/m2) Tag 1, 8 und 15 und Prednisolon (100mg) Tag 1, 8, 15 und 22, und eine eskalierende tägliche Dosis Thalidomid (50, 100, 200mg). Die Behandlungszyklen wurden alle 28 Tage bis zum Auftreten des maximalen Ansprechens, DLT oder Fortschreiten der Erkrankung wiederholt. 24 Patienten sprachen nach mindestens zwei Zyklen auf die Therapie an (vier komplette, sechs sehr gute partielle und 14 partielle Remissionen). Das mediane progressionsfreie Überleben und Gesamtüberleben für alle Patienten betrug 11 und 19 Monate. Nur leichte oder mittelschwere nicht-hämatologische Nebenwirkungen wurden beobachtet und kein Patient entwickelte dosislimitierende Hämatotoxizitäten. Die BPT-Therapie weist bei Patienten mit rezidiviertem oder refraktärem MM eine gute Verträglichkeit mit einem Ansprechen von über 80% auf. Die maximal tolerierte Dosis von Thalidomid wurde in dieser Studie nicht erreicht.

Background: MY7 clinical trial compared dexamethasone plus melphalan (MD) vs. prednisone plus melphalan (MP) in multiple myeloma treatment and found no statistically significant difference in overall survival (OS) between the two groups. But, patients reacted to treatment differently. We aimed to identify patients who might have benefited from dexamethasone, and characterize them by their baseline demographic and clinical factors. Methods: First, the prognostic model for OS was developed on the MP arm. The estimated coefficients and baseline hazard were applied to the MD arm to derive martingale residuals (MR). Classification and regression tree analysis was done to identify independent predictive factors for OS and MR was used as response variable. All covariates in categorical shape were used as independent variables to develop the predictive model in MD arm. MP arm was divided accordingly. Subgroups with negative mean MR (survived > expected) were candidates for positive responders while those with positive mean MR (survived < expected) were candidates of negative responders. Mean MR in each subgroup and p values from comparison of OS (log rank test stratified by subgroups) were used to combine the appropriate subgroups as the positive responders or negative responders. Results: A total of 97 patients (42%) in MD arm were identified as positive responders and their OS (median of 44.5 months) was significantly longer than that (median of 33 months) in the corresponding subgroups in MP arm (HR = 0.56, 95% CI 0.4-0.8; p = 0.0014). All positive responders had three common baseline characteristics: aged ≤75 years, calcium concentration ≤2.6 mmol/L and Durie-Salmon stages 2 or 3. Among patients with ECOG performance status<2 those with either HGB≥100 mg/dl or HGB<100 mg/dl and WBC≥4,000 and <4 lytic bone lesions were categorized as positive responders. Also, among the patients with ECOG performance status≥2, males with >3 lytic bone lesions were positive responders. Negative responders (HR = 1.56, 95% confidence interval 1.1 – 2.2; p = 0.006) included patients aged >75 or aged ≤75 with calcium concentration >2.6 mmol/L or aged ≤75 with calcium concentration ≤2.6 mmol/L but had Durie-Salmon stage 1. Conclusions: Evaluation of the hypotheses validity warrants further studies. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2008-07-21 13:46:53.748

Multiple myeloma (MM) is an incurable haematological malignancy characterised by the clonal proliferation of plasma cells (PCs) within the bone marrow (BM). MM PC survival and expansion is dependent upon an adequate supply of oxygen and nutrients, and increased BM angiogenesis is a critical feature of MM progression. While MM PCs express and secrete a number of angiogenic factors, our current understanding of the precise mechanisms by which MM-induced angiogenesis occurs is incomplete. In this study, we collected specimens from patients with MM and the benign precursor condition MGUS, and demonstrated for the first time that circulating levels of the CXCL12 chemokine positively correlate with the degree of BM angiogenesis. Using conditioned media from a MM PC line, the contribution of MM PC-derived CXCL12 to angiogenesis was also examined and found to strongly induce vascular tube formation in vitro. In several other cell types, hypoxia has been shown to up-regulate CXCL12 expression. Studies investigating the hypoxic regulation of CXCL12 in MM PCs revealed that, while acute hypoxia is unable to stimulate CXCL12 expression, prolonged hypoxia significantly up-regulates CXCL12 mRNA and protein expression. To determine the mechanism(s) responsible for this, over-expression and RNA interference technology was employed to create genetically modified MM cells in which either HIF-1α or HIF-2α were overexpressed or knocked down. These studies showed that HIF-2α is the predominant mediator of the hypoxic induction of CXCL12 in MM PCs. The ability of HIF-2α to bind to the CXCL12 promoter was confirmed using EMSA and ChIP analyses. The role of CXCL12 in in vivo angiogenesis and the contribution of HIF-1α and HIF-2α were also examined. In these studies, transduced MM cells, in which HIF-1α, HIF-2α and CXCL12 were over-expressed or knocked down, were implanted into a vessel-poor, subcutaneous environment in immunocompromised mice. Tumour-induced angiogenesis was assessed after two weeks by measuring the haemoglobin content of excised implants. These studies confirmed that over-expression of CXCL12, HIF-1α and HIF-2α each stimulates a strong angiogenic response. Using the well-characterised CXCR4 antagonist, T140, CXCL12 was found to play a key role in the increased angiogenesis observed in response to HIF-1α and HIF-2α over-expression. These novel studies have shown that CXCL12 is an important mediator of angiogenesis in MM patients, and that aberrant CXCL12 expression by MM PCs is due, in part, to its hypoxic up-regulation mediated predominantly by HIF-2. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1365126 / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2009

Multiple myeloma (MM) is an incurable haematological malignancy characterised by the clonal proliferation of plasma cells (PCs) within the bone marrow (BM). MM PC survival and expansion is dependent upon an adequate supply of oxygen and nutrients, and increased BM angiogenesis is a critical feature of MM progression. While MM PCs express and secrete a number of angiogenic factors, our current understanding of the precise mechanisms by which MM-induced angiogenesis occurs is incomplete. In this study, we collected specimens from patients with MM and the benign precursor condition MGUS, and demonstrated for the first time that circulating levels of the CXCL12 chemokine positively correlate with the degree of BM angiogenesis. Using conditioned media from a MM PC line, the contribution of MM PC-derived CXCL12 to angiogenesis was also examined and found to strongly induce vascular tube formation in vitro. In several other cell types, hypoxia has been shown to up-regulate CXCL12 expression. Studies investigating the hypoxic regulation of CXCL12 in MM PCs revealed that, while acute hypoxia is unable to stimulate CXCL12 expression, prolonged hypoxia significantly up-regulates CXCL12 mRNA and protein expression. To determine the mechanism(s) responsible for this, over-expression and RNA interference technology was employed to create genetically modified MM cells in which either HIF-1α or HIF-2α were overexpressed or knocked down. These studies showed that HIF-2α is the predominant mediator of the hypoxic induction of CXCL12 in MM PCs. The ability of HIF-2α to bind to the CXCL12 promoter was confirmed using EMSA and ChIP analyses. The role of CXCL12 in in vivo angiogenesis and the contribution of HIF-1α and HIF-2α were also examined. In these studies, transduced MM cells, in which HIF-1α, HIF-2α and CXCL12 were over-expressed or knocked down, were implanted into a vessel-poor, subcutaneous environment in immunocompromised mice. Tumour-induced angiogenesis was assessed after two weeks by measuring the haemoglobin content of excised implants. These studies confirmed that over-expression of CXCL12, HIF-1α and HIF-2α each stimulates a strong angiogenic response. Using the well-characterised CXCR4 antagonist, T140, CXCL12 was found to play a key role in the increased angiogenesis observed in response to HIF-1α and HIF-2α over-expression. These novel studies have shown that CXCL12 is an important mediator of angiogenesis in MM patients, and that aberrant CXCL12 expression by MM PCs is due, in part, to its hypoxic up-regulation mediated predominantly by HIF-2. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1365126 / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2009

Multiple myeloma (MM) is an incurable haematological malignancy characterised by the clonal proliferation of plasma cells (PCs) within the bone marrow (BM). MM PC survival and expansion is dependent upon an adequate supply of oxygen and nutrients, and increased BM angiogenesis is a critical feature of MM progression. While MM PCs express and secrete a number of angiogenic factors, our current understanding of the precise mechanisms by which MM-induced angiogenesis occurs is incomplete. In this study, we collected specimens from patients with MM and the benign precursor condition MGUS, and demonstrated for the first time that circulating levels of the CXCL12 chemokine positively correlate with the degree of BM angiogenesis. Using conditioned media from a MM PC line, the contribution of MM PC-derived CXCL12 to angiogenesis was also examined and found to strongly induce vascular tube formation in vitro. In several other cell types, hypoxia has been shown to up-regulate CXCL12 expression. Studies investigating the hypoxic regulation of CXCL12 in MM PCs revealed that, while acute hypoxia is unable to stimulate CXCL12 expression, prolonged hypoxia significantly up-regulates CXCL12 mRNA and protein expression. To determine the mechanism(s) responsible for this, over-expression and RNA interference technology was employed to create genetically modified MM cells in which either HIF-1α or HIF-2α were overexpressed or knocked down. These studies showed that HIF-2α is the predominant mediator of the hypoxic induction of CXCL12 in MM PCs. The ability of HIF-2α to bind to the CXCL12 promoter was confirmed using EMSA and ChIP analyses. The role of CXCL12 in in vivo angiogenesis and the contribution of HIF-1α and HIF-2α were also examined. In these studies, transduced MM cells, in which HIF-1α, HIF-2α and CXCL12 were over-expressed or knocked down, were implanted into a vessel-poor, subcutaneous environment in immunocompromised mice. Tumour-induced angiogenesis was assessed after two weeks by measuring the haemoglobin content of excised implants. These studies confirmed that over-expression of CXCL12, HIF-1α and HIF-2α each stimulates a strong angiogenic response. Using the well-characterised CXCR4 antagonist, T140, CXCL12 was found to play a key role in the increased angiogenesis observed in response to HIF-1α and HIF-2α over-expression. These novel studies have shown that CXCL12 is an important mediator of angiogenesis in MM patients, and that aberrant CXCL12 expression by MM PCs is due, in part, to its hypoxic up-regulation mediated predominantly by HIF-2. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1365126 / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2009

Thesis (M.Med.Sc.)-- University of Adelaide, Dept. of Medicine, 2002. / Bibliography: leaves 86-103.

Thesis (Ph.D.)--University of Adelaide, Dept. of Medicine and The Hanson Centre, Institute of Medical and Veterinary Science, 2004. / "August 2004" Errata inside front cover. Bibliography: leaves 126-159.

Thesis (Ph.D.) - University of Queensland, 2005. / Includes bibliography.