Zusammenfassend lässt sich feststellen, dass die Kombination von Bortezomib mit Bendamustin und Prednison ein sehr effektives und gut verträgliches Behandlungsregime für Patienten mit neu diagnostiziertem Multiplen Myelom und Leichtketten-induzierter schwerer Nierenschädigung darstellt. Bei der Mehrzahl der Patienten kommt es zu einem raschen hämatolgischen Ansprechen mit nachfolgender deutlicher Verbesserung der Nierenfunktion innerhalb der ersten sechs Wochen. Das BPV Protokoll ist daher ein wirkungsvoller Therapieansatz für die Behandlung von Patienten mit Multiplen Myelom und begleitender Nierenschädigung.

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Proteasome inhibitors bortezomib and carfilzomib are FDA-approved anticancer agents that have contributed to significant improvements in treatment outcomes. However, the eventual onset of acquired resistance continues to limit their clinical utility, yet a clear consensus regarding the underlying mechanisms has not been reached. Bortezomib and carfilzomib are known to target both the constitutive proteasome and the immunoproteasome, two conventional proteasome subtypes comprising distinctive sets of catalytic subunits. While it has become increasingly evident that additional, ‘intermediate’ proteasome subtypes, which harbor non-standard mixtures of constitutive proteasome and immunoproteasome catalytic subunits, represent a considerable proportion of the proteasome population in many cell types, less is known regarding their contribution to cellular responses to proteasome inhibitors. Importantly, previous studies in murine models have shown that individual proteasome subtypes differ in sensitivity to specific proteasome inhibitors. Furthermore, research efforts in our laboratory and others have revealed that proteasome catalytic subunit expression levels and activity profiles are altered when human cancer cells acquire resistance to proteasome inhibitors. We therefore hypothesized that changes in the relative abundances of individual proteasome subtypes contribute to the acquired resistance of cancer cells to bortezomib and carfilzomib. A major obstacle in testing our hypothesis was a lack of chemical probes suitable for use in identifying distinct proteasome subtypes. We addressed this by developing a series of bifunctional proteasome probes capable of crosslinking specific pairs of catalytic subunits colocalized within individual proteasome complexes and compatible with immunoblotting-based detection of the crosslinked subunit pairs. We confirmed the utility of these probes in discerning the identities of individual proteasome subtypes in a multiple myeloma cell line that abundantly expresses catalytic subunits of both the constitutive proteasome and immunoproteasome. Our findings indicate that constitutive proteasomes, immunoproteasomes, and intermediate proteasomes co-exist within these cells and support conclusions drawn from previous studies in other cell types. We also established non-small cell lung cancer cell line models of acquired bortezomib and carfilzomib resistance in which to test our hypothesis. Using immunoblotting and proteasome activity assays, we discovered that changes in the expression levels and activities of individual catalytic proteasome subunits were associated with the emergence of acquired resistance to bortezomib or carfilzomib. These changes were inhibitor-dependent and persisted after the selective pressure of the inhibitor was removed. Finally, results obtained using our bifunctional proteasome probes suggest that the altered abundance of an intermediate proteasome subtype is associated with acquired proteasome inhibitor resistance. Collectively, our results provide evidence linking changes proteasome composition with acquired proteasome inhibitor resistance and support the hypothesis that such changes are involved in resistance mechanisms to these inhibitors.

Introduction: Waldenström's macroglobulinemia is a hematological neoplasm belonging to the group of monoclonal gammopathies, which includes systemic symptoms and those related to an increase in M paraprotein. Objective: To describe a case of cardiac amyloidosis associated with macroglobulinemia. Clinical case: Male patient who was admitted for asthenia, dysphonia, and who, during his evolution, developed progressive dyspnea, heart failure and pleural effusion. Additionally, echocardiography showed myocardial granular pattern, while pleural biopsy was positive for Congo red staining. Subsequently, he received treatment with bortezomib, dexamethasone and rituximab, with favorable evolution. Conclusions: In this disease, early diagnosis is an important advantage for survival. Therefore, its management is palliative of cardiac manifestations. The present case shows a diagnostic challenge, in which the less frequent etiologies of heart failure must be taken into account. / Revisión por pares

Introduction: Autologous stem cell transplantation (ASCT) is the standard treatment for younger patients with newly-diagnosed multiple myeloma (MM). However, due to restrictive exclusion criteria, more than half of eligible patients are usually excluded from transplant-studies. Methods: This retrospective monocentric analysis included 540 patients with MM who received an ASCT between 1996 and 2019. Results: Up to 2005, induction therapy consisted mainly of conventional chemotherapies, e.g. vincristine/doxorubicin/dexamethasone (VAD). In the following years, the triple-combinations based on bortezomib coupled with doxorubicin/dexamethasone (PAD), melphalan/prednisolone (VMP), cyclophposphamide/dexamethasone (VCD) or bendamustine/prednisolone (BPV) became the most popular treatment options. A progressive improvement in PFS was observed in patients treated with the two current induction therapies BPV (47 months) or VCD (54 months) compared to VAD (35 months, p<0.03), PAD (39 months, p<0.01 and VMP (36 months, p<0.01). However, there was no significant difference in median OS (VAD 78, PAD 74, VMP 72, BPV 80 months and VCD not reached). In our analysis, we also included 139 patients who do fulfill at least one of the exclusion criteria for most phase 3 transplant-studies (POEMS/amyloidosis/plasma cell leukemia, eGFR<40 mL/min, severe cardiac dysfunction or poor general condition). Outcome for these patients was not significantly inferior compared to patients who met the inclusion criteria for most of the transplant studies with PFS of 36 vs 41 months (p=0.78) and OS of 78 vs 79 months (p=0.34). Conclusions: Our real world data in unselected pts also stress the substantial value of ASCT during the first line treatment of younger MM pts.:Inhaltsverzeichnis Bibliographische Beschreibung …………………………………………………...………………..……….……………………......2 Inhaltsverzeichnis …………………………………………………………………………………………………………………...…........3 Abkürzungsverzeichnis ………………………………………………………………………………………………………………..…….4 1. Einführung …………………………………………………………………..…………………..…...................................7 1.1. Das multiple Myelom ………………………………………………….……………………………..………………………..7 1.2. Klinik und Diagnostik ……………………………………………………………………………..…………………………….7 1.3. Stadieneinteilung ……………………………………………………………….…………..…………………………………...8 1.4. Remissionsbeurteilung ……………………………………………………………………………………………………….10 1.5. Therapie …………………………………………………………………………………………….……………………………...12 1.5.1. Konventionelle Chemotherapie ……………………………………………………………………………………….…12 1.5.2. Neue Substanzen in der Myelomtherapie …………………………………………………………………………..13 1.5.2.1. Immunmodulatorische Substanzen ……………………………………………………………………………….……13 1.5.2.2. Proteasomen-Hemmer ……………………………………………………………………………………….………………13 1.5.2.3. HDAC Hemmer ……………………………………………………………………………………………………………………13 1.5.2.4. Monoklonale Antikörper …………………………………………………………………………………………………….14 1.5.2.5. BCMA basierte Therapien …………………………………………………………………………………………………..14 1.5.3. Autologe Stammzelltransplantation in der Ära der konventionellen Chemotherapie ………...15 1.5.4. Allogene Stammzelltransplantation …………………………………………………………………………………….15 1.5.5. Autologe Stammzelltransplantation in der Ära der neuen Substanzen ………………………………..16 1.6. Aufgabenstellung der Arbeit ……………………………………………………………………………………………….17 2. Publikation …………………………………………………………………………………………………………………….……18 3. Zusammenfassung der Arbeit ……………………………………………………………………………………………..33 Literatur …………………………………………………………………………………………………………………………………..…..…37 Tabellenverzeichnis …………………………………………………………………………………………………………………………49 Darstellung des eigenen Beitrags …………………………………………………………………………………………………….50 Selbständigkeitserrklärung ………………………………………………………………………………………………………………52 Lebenslauf ……………………………………………………………………………………………………………………………………….53 Verzeichnis der wissenschaftlichen Veröffentlichungen……………………………………………………………………54 Danksagung ……………………………………………………………………………………………………………………………………..56

Le myélome multiple (MM) est une hémopathie dont la croissance et la prolifération sont liés à une variété de facteurs de croissance, y compris « insulin-like growth factor type 1 » (IGF-1). Bortézomib est le premier inhibiteur protéasome ayant une activité anti-tumorale significative dans le myélome multiple. Nous avons analysé l'impact de l'IGF-1 recombinant associé à l'inhibiteur du protéasome bortezomib sur des lignées humaines de MM, in vivo et sur des cellules de myélome frais humaines ex vivo. Nous avons montré que l'IGF-1 améliore l'activité cytotoxique du bortezomib in vitro, in vivo et ex vivo. Nous avons montré que l'accroissement de la toxicité peut être inhibé par la présence d'un anticorps monoclonal dirigé contre le récepteur de l'IGF-1 (IGF1-R). IGF-1 renforce l'activité cytotoxique des autres inhibiteurs de protéasome, y compris MG115, MG132, PSI et epoxomicin. Nos résultats confirment le fait que l'IGF-1sensibilise des cellules de myélome à l'activité cytotoxique des inhibiteurs du protéasome tels que le bortezomib, en raison du niveau accru du stress de réticulum endoplasmique et l'induction de la une réponse protéine dépliée (UPR) / Multiple Myeloma (MM) is a clonal plasma cell disorder whose growth and proliferation are linked to a variety of growth factors, including insulin-like growth factor type 1 (IGF-1). Bortezomib, the first-in-class proteasome inhibitor, has displayed significant antitumor activity in multiple myeloma. We analyzed the impact of recombinant IGF-1 combined with the proteasome inhibitor bortezomib in MM cell lines, in vivo and on fresh human myeloma cells ex vivo. We found that IGF-1 enhanced the cytotoxic activity of bortezomib in vitro, in vivo and ex vivo. We showed that the enhanced toxicity could be inhibited by the presence of a monoclonal antibody directed against the IGF-1 receptor (IGF1-R). IGF-1 enhances the cytotoxic activity of other proteasome inhibitors, including MG115, MG132, PSI and epoxomicin. Our results support the fact that IGF-1sensitize myeloma cells to the cytotoxic activity of proteasome inhibitors such as bortezomib, as a consequence of enhanced level of endoplasmic reticulum stress and the induction of an unfolded protein response (UPR)

Introduction L’allogreffe de cellules souches hématopoïétiques est un traitement avec un potentiel curatif chez une minorité de patients ayant un diagnostic myélome multiple. Malheureusement, ce traitement est associé à un taux élevé de complications, incluant une probabilité élevée de rechute et/ou de GVH chronique limitant. L’objectif principal de cette étude est de déterminer si un entretien au bortezomib (BTZ) post-allogreffe permet de diminuer l’incidence et la sévérité de la maladie du greffon contre l’hôte (GVH) chronique. Les objectifs secondaires étaient d’évaluer la prise d’immunosuppresseur, de déterminer l’atteinte d’organe et la survie (OS et PFS) chez les patients ayant reçu ou pas du BTZ en entretien. Méthodes Dans cette étude rétrospective, nous avons comparé 46 patients ayant reçu du BTZ en entretien post-allogreffe à 61 patients n’ayant pas reçu d’entretien. Nous avons étudié l’impact du BTZ sur l’incidence et la sévérité de la GVH chronique en utilisant les critères du NIH de 2014. Résultats À 2 ans, l’incidence globale (61.2% vs 83.6%, p=0.001) et modérée/sévère (44.5% vs 77.0%, p=0.001) de GVH chronique était significativement inférieure chez les patients ayant reçu du BTZ en entretien. Les atteintes buccale (43% vs 67%, p=0.018) et ophtalmique (9% vs 41%, p=0.001) étaient diminuées de manière significative lors du diagnostic initial de la GVH chronique chez ces patients ayant reçu un entretien post-allogreffe. Une diminution de l’usage des immunosuppresseurs, dont les corticostéroïdes systémiques (45.1% vs 76.4%, p<0.001), du mycophenolate mofetil (15.5% vs 28.2%, p=0.031) et du tacrolimus (34.5% vs 70.6%, p<0.001) a été observée chez les patients ayant reçu le BTZ. La probabilité d’être vivant et sans immunosuppresseur à 3 ans post-allogreffe était de 77% chez les patients de la cohorte BTZ et 56% dans la cohorte contrôle (p=0.046). Conclusion En conclusion, un entretien avec du BTZ post-allogreffe permet de diminuer l’incidence et la sévérité de la GVH chronique. Ceci devrait donc être considéré comme une option valide chez les patients avec un myélome multiple traités avec une allogreffe. / Background Allogeneic hematopoietic cell transplant (HCT) has curative potential in myeloma but remains hampered by high rates of relapse and chronic GVHD. The primary endpoint of this study was to determine if BTZ maintenance decreases the incidence and severity of chronic GVHD using NIH criteria. The secondary endpoints were to determine the immunosuppression burden, organ involvement and survival (OS, PFS) in patients receiving or not BTZ. Study Design In this retrospective study, we compared the outcome of 46 myeloma patients who received BTZ after upfront tandem auto-allo HCT to 61 patients without maintenance. We explored the impact of bortezomib (BTZ) maintenance on incidence and severity of chronic GVHD using the 2014 NIH criteria. Results At 2 years, incidences of overall (61.2% vs 83.6%, p=0.001) and moderate/severe chronic GVHD (44.5% vs 77.0%, p=0.001) were significantly lower in BTZ recipients who had less mouth (43% vs 67%, p=0.018) and eyes (9% vs 41%, p=0.001) involvement at initial diagnosis. We report a lower use of systemic steroids (45.1% vs 76.4%, p<0.001), mycophenolate mofetil (15.5% vs 28.2%, p=0.031) and tacrolimus (34.5% vs 70.6%, p<0.001) in BTZ recipients. Probability of being alive and off systemic immunosuppressants at 3 years was 77% in BTZ recipients and 56% in controls (p=0.046). Conclusion In summary, BTZ maintenance improved incidence and severity of chronic GVHD and should be considered as a valid option in myeloma patients receiving upfront tandem auto-allo HCT.

Indiana University-Purdue University Indianapolis (IUPUI) / Patients with the genetic disorder tuberous sclerosis complex (TSC) suffer from neoplastic growths in multiple organ systems. These growths are the result of inactivating mutations in either the TSC1 or TSC2 tumor suppressor genes, which negatively regulate the activity of mammalian target of rapamycin complex 1(mTORC1). There is currently no cure for this disease; however, my research has found that cells harboring TSC2-inactivating mutations derived from a rat model of TSC are sensitive to apoptosis induced by the clinically approved proteasome inhibitor, bortezomib, in a manner dependent on their high levels of mTORC1 activation. We see that bortezomib induces the unfolded protein response (UPR) in our cell model of TSC, resulting in cell death via apoptosis. The UPR is induced by accumulation of unfolded protein in the endoplasmic reticulum (ER) which activates the three branches of this pathway: Activating transcription factor 6 (ATF6) cleavage, phosphorylation of eukaryotic initiation factor 2α (eIF2α), and the splicing of X-box binding protein1 (XBP1) mRNA. Phosphorylation of eIF2α leads to global inhibition of protein synthesis, preventing more unfolded protein from accumulating in the ER. This phosphorylation also induces the transcription and translation of ATF4 and CCAAT-enhancer binding protein homologous protein (CHOP). Blocking mTORC1 activity in these cells using the mTORC1 inhibitor, rapamycin, prevented the expression of ATF4 and CHOP at both the mRNA and protein level during bortezomib treatment. Rapamycin treatment also reduced apoptosis induced by bortezomib; however, it did not affect bortezomib-induced eIF2α phosphorylation or ATF6 cleavage. These data indicate that rapamycin can repress the induction of UPR-dependent apoptosis by suppressing the transcription of ATF4 and CHOP mRNAs. In addition to these findings, we find that a TSC2-null angiomyolipoma cell line forms vacuoles when treated with the proteasome inhibitor MG-132. We found these vacuoles to be derived from the ER and that rapamycin blocked their formation. Rapamycin also enhanced expansion of the ER during MG-132 stress and restored its degradation by autophagy. Taken together these findings suggest that bortezomib might be used to treat neoplastic growths associated with TSC. However, they also caution against combining specific cell death inducing agents with rapamycin during chemotherapy.

Little is known about the signaling pathways that contribute to treatment response in advanced stage head and neck tumors. Increased expression of epidermal growth factor receptor (EGFR) and downstream pathways such as nuclear factor kappa B (NFκB) are implicated in aggressive tumor phenotypes and limited response to therapy. This study explored the rationale for combining the proteasome inhibitor bortezomib with the EGFR inhibitor gefitinib in a subset of head and neck squamous cell carcinomas with high EGFR gene amplification. Drug responses of gefitinib and bortezomib as single agents and in combination within head and neck squamous cell carcinoma cell lines were analyzed using MTS assays. The effects of gefitinib on the activation of EGFR and itsthree major downstream pathways, Akt, STAT3 and MAPK were determined by western blotting. The activation status of NFκB and the effects of bortezomib on the canonical pathway were assessed by DNA binding assays. Resistance to lower doses of gefitinib was associated with elevated EGFR and activated Akt expression. Gefitinib was able to effectively inhibit activation of STAT3, Akt and MAPK in HNSCC to varying degrees depending on EGFR expression status. Bortezomib treatment inhibited TNFα –induced nuclear NFκB/RelA expression but demonstrated variability in levels of baseline nuclear NFκB/RelA expression between sensitive and resistant cell lines. Bortezomib effectively suppresses NFκB/RelA nuclear activation but demonstrates additional modes of cellular toxicity beyond the NFκB pathway in sensitive cell lines. Further understanding of tumor response to the targeted inhibitors gefitinib and bortezomib may provide novel approaches in managing HNSCCs.