Citations

Abstract [Background]: MCL is an aggressive non-Hodgkin lymphoma (NHL) with a median survival of 3-4 years. New agents with mechanisms of action different than standard chemotherapy are needed to improve the outcome of MCL. Recent studies have documented single agent activity of bortezomib and rituximab in MCL. Analogs of rapamycin (temsirolimus) have also shown single agent activity in MCL (J Clin Oncol, June 27, 2005 epub). In order to provide rationale for a clinical trial combining rapamycin analogs with bortezomib or rituximab, we performed in vitro studies of the effect of combinations of these drugs on human MCL cell lines. [Methods]: Two human lymphoma cell lines - Granta 519 and M0258 - were incubated with various concentrations of rapamycin, bortezomib, and rituximab to determine the LD50 of each drug alone. For the experiments with rituximab a secondary goat anti-human (GAH) IgG Fc antibody was used to crosslink cell bound rituximab and induce cell killing. Percent viability was assessed after 48 hours using annexin/propidium iodide staining and flow cytometry. Tests for drug synergy used combinations of rapamycin and bortezomib and the Granta 519 cell line. Fixed ratios of the two drugs were tested and the results were evaluated for synergism (combination index <1 in median effect analysis) in inducing cell death. The drug concentrations used spanned the LD50 of each drug determined from the single-agent studies. In the studies combining rituximab with bortezomib or rapamycin, a single fixed dose of rituximab and GAH Fc was tested with various concentrations of the other drugs to detect additive anti-tumor effects. Studies were performed at least in triplicate. [Results]: All three drugs exhibited single-agent activity in vitro against the two cell lines. The LD50 for rapamycin ranged from 17.5 – 25 micromolar for the Granta 519 cell line and 7.5–10 micromolar for M0258. The LD50 for bortezomib ranged from 2–5 ng/ml in both cell lines. Incubation of the cells with various concentrations of rituximab and GAH Fc had mild cytotoxic activity (reduced viability to 50–70% compared to GAH Fc control). This activity was not concentration dependent indicating saturation of CD20 by rituximab; therefore, a fixed concentration of rituximab was used for the combination experiments. When rituximab was added to bortezemib the % viability decreased by up to 37% (compared to bortezomib alone), and the bortezomib LD50 typically decreased to <1–2 ng/ml (LD50 was 2–5 ng/ml with bortezomib alone). The addition of rapamycin to rituximab increased the cytotoxicity by 23% compared to either drug alone and decreased the rapamycin LD50. When rapamycin and bortezomib were combined as treatment of Granta 519 cells, rapamycin was synergistic with bortezomib with a combination index <1. Sequencing the rapamycin either before or after the bortezomib treatment did not effect synergy in either direction. [Conclusion]: In vitro, rapamycin synergizes with bortezomib to enhance its cytotoxicity in MCL lines. Rituximab enhances the cytotoxicity of both of rapamycin and bortezomib. These in vitro studies provide the rationale to test combinations of these active agents in patients with MCL.

Abstract Background: IL-6 is important for proliferation and inhibition of apoptosis in malignant plasma cells. Understanding the role of IL-6 receptor alpha chain (CD126) in the pathogenesis of plasma cell disorders may help in developing future treatment therapies for these diseases. A previous study has shown that CD126 (alpha subunit of IL-6 receptor) is expressed distinctly in myeloma, monoclonal gammopathy of unknown significance (MGUS), and plasmacytomas when compared to normal. We performed this study in order to confirm and describe the expression of CD126 in different plasma cell disorders. Design and Methods: Using flow cytometry we assessed CD126 expression on clonal plasma cells from patients with Primary Amyloidosis (n=7), monoclonal gammopathy of undetermined significance (MGUS) (n=13), smoldering Myeloma (SMM) (n=19) and active Myeloma (n=22), as well as normal plasma cells (n=9). Plasma cells were identified by their characteristic CD38/45 expression. The expression of CD126 was separately analyzed on the CD45 positive and negative plasma cells. CD 126 expression was considered significant when more than 20% of the cells had expression. Results: CD126 expression was seen distinctly in plasma cell disorder plasma cells and not in normal plasma cells when all plasma cells were studied together. The highest expression percentages were found in Amyloid (28%) followed closely by MGUS 29(%), then SMM (23%), and Myeloma (12%) cells. The CD45 neg subset was similarly positive in the plasma cell disorder group. In this group, MGUS showed the highest expression percentage followed distantly by Amyloid, Myeloma, and SMM. The CD45 pos subset was uniformly positive in expression of CD126. If was found that this subset expressed higher levels of CD126 in all the studied plasma cell disorders and normal plasma cells when compared to the CD45 neg subset. Conclusion: The findings of this study confirm the increased expression of CD126 in plasma cell disorders when compared to normal plasma cells. The higher expression of CD126 in the CD45 pos plasma cell subset has not been previously described. In addition, the CD45 pos subset expressed higher levels of CD126 in all study groups when compared to the CD45 pos subset. This data contributes to the understanding of IL-6 receptor physiology and confirms the important role of the CD45 pos subset in the proliferation of neoplastic plasma cells. The findings are in accordance with the increased proliferative rates seen in the CD45 fraction of malignant plasma cells.

Abstract Prior studies have demonstrated that MM cells with PTEN mutation and high AKT activity are more sensitive to inhibitors of the PI3K/Akt/mTOR pathway. However, the molecular mechanisms that regulate the differential response to these agents are not well characterized. The objective of this study was to determine proteins that are different between MM cell lines with higher AKT activity (OPM2) and lower AKT activity (MM.1S) in response to the AKT inhibitor, perifosine. Methods: MM cell lines (MM.1S and OPM2) were treated with serial concentration of perifosine (KRX-0401, Keryx, NY, NY, provided by the NCI). Proteomic analysis using the nanoscale BD Clontech antibody-based protein microarray technique was performed using cells treated with perifosine (10uM for 16 hrs) or vehicle (sterile water) as control. Apoptosis was determined using Annexin V/PI FACS analysis at 24 and 48 hrs. The treatment time and concentration were chosen so that it did not induce more than 25% apoptosis to ensure adequate analysis of changes in signaling pathways. The antibody microarray is a technique that detects differences in protein abundance between the treated and control sample with each experiment by hybridizing fluorescently labeled (Cy3 and Cy5) protein mixtures onto slides spotted with 512 human monoclonal antibodies. Two microarray slides were used for each experiment. The slides were scanned using the Axon GenePix 4000B scanner. Two ratios were generated from the spot images for each protein target. The mean of the ratios of Cy5/Cy3 of both slides were analyzed using Clontech software and used to calculate an Internally Normalized Ratio (INR = (Ratio1/Ratio2, ratios 1 and 2 correspond to slides 1 and 2) for each spot on the array. The INR values were input into GeneSpring 6.0 software (Silicon Genetics, CA). The data was normalized to the mean INR of the two cell lines. Proteins whose expression level changed relative to control greater than 1.3 fold were determined. Unsupervised clustering demonstrated a different protein signature between MM.1S and OPM2 in response to perifosine. There were 144 proteins differentially expressed by 1.3 fold between MM.1S and OPM2. Proteins that were downregulated in OPM2 as compared to MM.1S included those in the PI3K pathway and cell cycle regulation such as PTEN, p70S6Kinase, the AKT substrate GSK-3, eEF-2 kinase, eIF-4g, Ku-80, cyclin A, E2F-2, CDK2, CDK7, and c-myc; proteins involved in apoptosis such as p21WAF, caspase 4 and 8, FADD, and PARP; kinases such as PKAc, PKA RI, ERK2, and JNK1; and other proteins regulating apoptosis and proliferation including p53, the NF-kB inhibitor IkB, and the heat shock protein HSP70. The nanoscale protein array is a useful and rapid technique that may be used to identify differences between resistant and sensitive cells to novel therapeutic agents. We identified proteins that are differentially expressed between MM cells sensitive and relatively resistant to the AKT inhibitor perifosine. Further analysis of the role of these proteins in the mechanism of resistance/sensitivity to perifosine is being performed. Future use of inhibitors of NF-kB (bortezomib) or heat shock protein inhibitors in conjunction with perifosine may overcome resistance induced by these proteins in MM cells with low AKT activity. Supported in part by an ASH scholar award and an MMRF grant.

Abstract Background: Although microvessel density increases significantly from monoclonal gammopathy of undetermined significance (MGUS) to multiple myeloma (MM), we have been unable to demonstrate an increase in expression of VEGF by isolated plasma cells between MGUS and MM (add your Blood ref). When MM cell lines are grown in co-culture with marrow derived stromal cells there is upregulation of VEGF and IL6. This effect is thought to be mediated primarily by the stromal cells, although plasma cells can also secrete these cytokines to form an autocrine pathway. We examined if there is differential expression of VEGF when plasma cells derived from various stages of plasma cell disorders (MGUS, smoldering multiple myeloma (SMM), and MM) are studied in co-culture with stromal cells. Methods: Plasma cells were obtained from fresh marrow aspirates from patients with MGUS, SMM or MM. Normal control plasma cells were obtained at the time of orthopedic surgeries. Plasma cells were isolated from whole marrow using a magnetic bead separation technique with antibodies against CD138. The marrow stromal cells were obtained from an established stromal cell line from a patient with MGUS. Plasma cells were then grown in co-culture with stromal cells, with control wells having either only stromal cells or only plasma cells, with RPMI medium containing 10% fetal bovine serum. The supernatant was removed after 48 hour cultures, spun down to remove cells and frozen at −70C. VEGF and IL6 levels were determined using ELISA kits (R&D, Minneapolis, MN). Results: A total of 71 samples were studied including normals (10), MGUS (8), SMM (15) and MM (38). The median VEGF levels with plasma cells alone were 30.2 pg/mL (range; 16–132), with stromal cells alone was 737 pg/ml (316–1826) and with the co-culture was 1057 pg/mL (306–4267), representing a median increase of 41% (−48% to 331%) with co-culture. There was no significant difference between the disease groups in terms of the baseline VEGF secretion by plasma cells or the increase in VEGF with coculture (Figure). The median IL-6 levels with plasma cells alone were 22.3 pg/mL (range; 4–276), with stromal cells alone was 2457 pg/ml (906–5359) and with the co-culture was 5982 pg/mL (301–129,000), representing a median increase of 99% (−67% to 3362%) with co-culture. There was no significant difference between the disease groups in terms of the baseline VEGF secretion by plasma cells or the increase in VEGF with coculture (Figure). Conclusions: In this study we clearly demonstrate the upregulation of VEGF and IL-6 when primary cells are grown in contact with marrow derived stromal cells validating previous observations with cell lines, and once again highlighting the importance of these cytokines and the marrow microenvironment. However, since there is no significant difference between the various groups studied, higher absolute levels of VEGF and IL-6 in MM may be solely related to the effect of an increased tumor burden on marrow stromal cells. However, this does not exclude differences between disease stages in terms of the marrow stromal cells, which we are currently studying. Figure Figure

Abstract The objective of this study was to determine the molecular alterations that occur at the protein level in patients with PTLD in order to identify novel targets of therapy, determine new markers of prognosis, and begin to delineate the pathogenesis of PTLD. Six tumor samples were obtained after informed consent from adult patients with PTLD post solid organ transplant. Four benign lymph nodes were obtained from age-matched controls. Three of the samples and their two controls were obtained from frozen tissue and the other three with two matching controls were obtained form paraffin embedded tissue. Immunohistochemistry using anti-CD19+ antibodies was performed and laser microdissection or slide scraping was used to obtain the tissue. Deparaffinization was performed using xylene and ethanol serial dilutions. Protein quantification was performed and 1ug of protein was obtained for each sample and its control. The nanoscale protein micorarray technique (BD Clontech, CA) was used to measure changes in the patterns of protein expression between PTLD samples and control lymphocytes. This is a new technique that detects differences in protein abundance between the disease and control samples by hybridizing fluorescently labeled (Cy3 and Cy5) protein mixtures onto slides spotted with 512 human monoclonal antibodies. It requires minute amounts of proteins. Two microarray slides were used for each experiment and a control experiment of control versus control was performed for normalization of the data. The slides were scanned using the Axon GenePix 4000B scanner. Two ratios were generated from the spot images for each protein target. The mean of the ratios of Cy5/Cy3 of both slides were analyzed using Clontech software and used to calculate an Internally Normalized Ratio (INR = Ratio1/Ratio2) for each spot on the array. The INR values were input into GeneSpring 6.0 software (Silicon Genetics, Redwood City CA). The data were normalized to the mean INR of the control samples. Proteins whose expression fold change relative to control was greater than 1.3 fold were determined. All cases represented monomorphic PTLD. Five were confirmed EBV positive (EBNA positive). The tissues were obtained from multiple organs including liver, gastric, cerebral, renal and lymph nodes. There were 22 proteins upregulated in the frozen sections as compared to the control and 157 proteins upregulated by 1.3 fold in the paraffin embedded sections as compared to control. Most of these proteins were common between the paraffin embedded and frozen sections. Proteins that were dysregulated included: proteins in the PI3K pathway and cell cycle regulation such as p70S6K, VHR, the AKT substrate GSK-3, cyclin C, MCM6, eIF-4E, CDK1, CDK7, eE-F-2 kinase; kinases such as JNKK1, PKC-lambda, RhoA kinase ROKalpha, ERK1, PKAc, PKArIIa and PKCbeta; apoptosis related proteins such as caspase 8, NF-kB, and MDM2; TGF signaling protein p300, and the heat shock protein HSP90. These results provide insight into pathways that are dysregulated in PTLD and can be targeted in future clinical trials with specific inhibitors such as PI3K, PKC, NF-kB or HSP90 inhibitors.

Abstract The bone marrow microenvironment in MM is characterized by the presence of upregulated osteoclast activity (OCL) and increased angiogenesis. We have recently demonstrated that the HSP90 inhibitor 17-AAG (provided by the NCI) and the mTOR inhibitor rapamycin (LC Laboratories, MA) have synergistic inhibitory activity on MM cells. The objective of this study was to determine the effect of rapamycin, 17-AAG and the combination on OCL formation and angiogenesis. Rapamycin (0.01–100nM), 17-AAG (10–1000nM) and the combination was tested using an in vitro human OCL formation assay and a human angiogenesis assay (AngioKit, TCS Cellworks, UK). Nonadherent human marrow mononuclear cells (1 x 105/100 μL) were plated in 96-well plates in the presence or absence of DMSO, rapamycin, 17-AAG or the combination. RANKL (100ng/ml) and MCSF (20ng/ml) were added to all wells except control media and MCSF. After 3 weeks, cells were fixed, and the number of OCL-like multinucleated cells were scored. To test the effect of the agents on early OCL precursors, we added the inhibitory agents on days 1, 7 or 14 of the culture. The AngioKit is comprised of human endothelial cells in a 24 well plate. The endothelial cells proliferate and then migrate through the matrix to form tubular structures and anastomosing tubules by 2 weeks. Two control wells were treated with VEGF (+ve control) and two with suramin (−ve control). The optimized medium and test samples were replaced on days 4, 7, and 9 after initial treatment. On day 11, cultures were fixed and stained with antibodies to CD31 to detect vessel formation. The degree of tubule formation was quantitated using computerized image analysis (Angiosys, TCS Cellworks, UK). Single agent rapamycin (20–100nM) inhibited OCL formation by 35% as compared to control in all tested doses indicating that PI3K/mTOR is an important regulator of OCL formation. The effect was similar on day 7 and day 14 indicating that this pathway is important for early and late OCL formation. 17-AAG 100–600nM significantly inhibited OCL formation with 100nM 17-AAG inducing 12% OCL formation as compared to control, while 300 and 600nM completely abrogated OCLs (0% OCLs). This effect was similar at day 7. However, when 17-AAG was added on day 14, it only induced 50–60% reduction in OCL formation indicating that 17-AAG affects early OCL formation. The combination of the two agents completely inhibited OCL formation on day 1 and 7 and led to a 65% reduction in OCLs when added on day 14 of the culture. Rapamycin showed a marked decrease in angiogenesis (similar to the negative control suramin), even at the lowest level tested of 0.01nM. 17-AAG demonstrated some inhibition of angiogenesis at 10 nM, and completely abrogated angiogenesis at 500–1000nM. In summary, rapamycin and 17-AAG inhibit OCL formation and angiogenesis. The effect of 17-AAG was on early OCL formation while rapamycin was on both early and late OCL. These results are contradictory to previous data indicating that 17-AAG increases OCL activity in MM. Rapamycin had a significant inhibitory effect on angiogenesis even at low doses. These results demonstrate that the use of rapamycin analogues and 17-AAG in clinical trials may have a therapeutic effect, not only on MM cells, but also on the bone marrow microenvironment. Supported in part by an ASH Scholar Award and an MMRF grant.

Abstract Introduction: The Multiple Myeloma Research Consortium (MMRC) has established a tissue bank for the deposition of bone marrow (BM) samples from patients with multiple myeloma (MM) to be mailed and processed under good laboratory practices (GLP). To date over 300 samples have been collected. The ability for multiple sites to utilize the same GLP protocols for isolation and storage of BM for batch testing can be cost prohibitive and can introduce derived variability. Currently, limited information is available on shipped BM aspirates in regards to cell viability, cell yield, cell purity, and subsequent RNA yield and quality. Materials and methods: To test these determinants we performed a pilot study on behalf of the MMRC where samples were drawn at Mayo Clinic Rochester (MCR) pooled and split into 2 equal aliquots. One-half of each sample was processed following the provided GLP compliant standard operating procedures (SOP’s), immediately after sample procurement, at MCR. The CD138+ cells were stored in TRIZOLTM and the RNA was isolated and analyzed in a single batch. The other half of the aspirate was sent overnight to Mayo Clinic Scottsdale (MCS) where they were processed using an identical protocol. At both locations samples were tested for the following quality determinants; cell yield, RNA yield and integrity, and viability using a 3 color flow cytometric method (CD45, CD38 and 7ADD). Cell counts were performed on the CD138+ fraction to determine plasma cell recovery and a slide based immunofluorescent assay used to determine purity. RNA recovery and integrity were assessed using the Agilent BioanalyzerTM. Lastly, gene expression profiles was compared to determine the “signature” emanating from the shipment of samples. Results: In aggregate, all quality determinants showed similar values when the two sets of samples were compared. Cell viability was similar in both sets of samples as was our ability to collect a highly enriched plasma cell population. The cell yield was very similar (r2=0.52) but slightly lower in the shipped samples (median 71% of locally processed, range 40–140%), probably due to some shipment-associated apoptosis with subsequent loss of cell surface CD138 antigen. The purity of the shipped samples was very similar to that of locally processed (median 94%). Subjective qualitative analysis of the RNA was similar between both groups (shipped yield being 80% of local) with no evidence of degradation in the shipped samples. Details regarding the shipment signatures using gene expression profiling will be presented at the meeting. Conclusion: Here we show that the shipment of samples is feasible with no appreciable loss in cell yield or quality of derived products. % APOPTOTIC+ DEAD PC YIELD PURITY (%) RNA Recovered MCR MCS MCR MCS MCR MCS MCR MCS 8.9 ND 15.2 6.8 93 90 11.4 12.8 6.2 ND 2 2.8 95 99 8 17.2 17.4 8 1.4 1.4 75 88 2.2 0 2.1 18.7 2.8 1.6 96 68 7.2 2 18.1 9.5 1.2 .8 100 94 3.4 .4 5 5.0 8.5 7.2 98 91 12.6 17.8 3.7 5.1 .4 .4 88 87 ND ND 19.5 10.3 1.6 1.2 88 79 .4 3.6 29.1 ND 9.2 1.2 100 56 30.2 1.4 5.6 ND 9.2 7.6 92 88 5.2 16.8 20.3 62.8 2.4 .8 84 61 4.6 0.2 4.6 3.7 10.4 2.4 100 94 29.4 8.4 26.5 13.5 5.8 2.8 ND 97 16.8 5.8 4.5 6.2 2.2 2 100 99 10 4.4 17.5 ND 19.2 12 ND ND 16.4 14

Abstract We have previously demonstrated that the chemokine receptor CXCR4 and its ligand SDF-1 are important regulators of migration in MM. The objective of this study was to investigate the role of the CXCR4 inhibitor AMD3100 (Sigma, MO) on proliferation, survival, migration, adhesion and invasion in MM. MM cell lines (MM.1S, OPM2 and Kas6/1) were exposed to serial dilutions of SDF-1 (1–100nM) in the presence or absence of the CXCR4 inhibitor AMD3100 (20–100uM) incubated for 16 hrs or the CXCR4 inhibitory antibody MAB171 (RDSystems, MN) 10–800uM or its IgG2 isotype control. Inhibition of proliferation was measured using the MTT proliferation assay. Apoptosis was determined using Annexin V/PI FACS analysis. Migration was determined using a transwell migration assay (Costar, Corning, NY). Cells treated with serial concentrations of AMD3100 or vehicle (sterile water) were washed, placed in serum free medium for two hours, then placed in the migration chambers with 1% FCS medium in the presence of SDF–1 20nM (a concentration previously determined to induce maximum migration in MM cells). After 4 hours of incubation, cells that migrated to the lower chambers were counted. Similarly, adhesion was determined using an adhesion assay (EMD Biosciences, CA) with 96 well plated coated with fibronectin and using MM cells treated with serial dilutions of AMD3100 or vehicle in the presence or absence of serial concentrations of SDF-1 (10–30nM). Invasion was determined using the invasion assay (EMD Biosciences, CA). Serial concentrations of SDF-1 induced a bell-shaped migration curve in MM cells with 10–30nM inducing maximum migration (324% compared to untreated control) while higher doses of SDF-1 (100nM) did not induce migration in all MM cells tested. AMD3100 induced a dose dependent inhibition of migration in MM cells treated with 20nM SDF-1. The maximum effect was demonstrated at 25uM with 48% migration as compared to control. Higher doses of AMD3100 (50–100uM) did not further inhibit migration. The anti-CXCR4 antibody demonstrated a dose dependent inhibition of migration. Anti-CXCR4 10uM inhibited migration to 53% and 200uM to 35%. The effects of higher doses of anti-CXCR4 were not significantly different as compared to 200uM. Serial concentrations of SDF-1 (10–100) induced a dose-response increase in adhesion to fribronectin with 10nM increasing adhesion by 202% as compared to untreated cells and 100nM 462% indicating activation of alpha4 beta1 integrin on MM cells. AMD3100 100uM inhibited adhesion at all doses by 55% as compared to control. Using the invasion assay, SDF-1 100nM induced maximal invasion of MM cells. The effect of SDF-1 on invasion was not abrogated by AMD3100. AMD3100 did not induce significant apoptosis or inhibition of proliferation at all tested doses, in the presence or absence of 20–100nM SDF-1. In summary, AMD3100 inhibited migration and adhesion of MM cells, but not invasion indicating that invasion occurs through non-CXCR4 dependent mechanisms. AMD3100 did not induce apoptosis or inhibition of proliferation indicating that its effect is specific on migration and adhesion. Further experiments to test its role on homing of MM cells in vivo are underway. The future use of this novel agent as an inhibitor of homing of MM cells in clinical trials may be warranted. Supported in part by an ASH Scholar Award and an MMRF grant.

Abstract Background: Multiple Myeloma (MM) is characterized by accumulation of malignant plasma cells with relatively low proliferative and apoptotic rates. The proliferative rate of plasma cells, measured in terms of % plasma cells labeled by bromodeoxyuridine (BrdU) using slide based fluorescence microscopy (plasma cell labeling index or PCLI) has been shown to be a powerful prognostic factor in MM. We have previously shown that the % bone marrow plasma cells in apoptosis (PCAP) determined by a flow cytometry method that uses Annexin V staining or 7-amino Actinomycin D (7-AAD) correlates with disease stage in MM. The goal of this study was to examine the prognostic value of the PCAP. Methods: We studied 145 patients with MM including 74 with newly diagnosed MM, 40 with relapsed MM, and 31 with MM on treatment in whom simultaneous measurements of % plasma cell apoptosis and PCLI were available. The PCLI is expressed as the percentage of cytoplasmic immunoglobulin positive plasma cells that have taken up BrdU. The PCLI was characterized as high when >= 1%. Mononuclear cells isolated from bone marrow aspirate, following red cell lysis with ACK solution, are incubated with CD38-PE and either CD138-FITC or CD45-FITC. This is followed by incubation with 7-AAD and the plasma cells are gated using the CD38/CD45 staining pattern. The Annexin method used a similar strategy, with Annexin V in place of 7-AAD. The percentage of plasma cells in apoptosis (PCAP) was categorized as high when >5%, the median value. Results: The median follow up for the entire group was 34 months (range, 0.1 mo to 9 years) and 112 (77%) had died at the time of analysis. Forty seven patients (32%) had a high PCLI (>=1%). The median overall survival for the patients with high PCLI was 14.6 months versus 42.3 months for those with a low PCLI; P = 0.0005 (log rank test). Seventy-five (51.7%) patients had a high PCAP. The median overall survival for those patients was 28.9 months versus 40.2 months for those with a low PCAP; P = 0.078. We next examined if there was any correlation between a high PCAP and high PCLI and found none; P = NS by (Fisher’s exact test). Additionally in a multivariate Cox model using both PCLI and PCAP, both were independently prognostic for overall survival. We then developed an index by adding PCLI to log transformed PCAP (PCLI + log PCAP). Using a cutoff of 1.5 for the new index we were able identify a group of patients with poor survival. The 59 patients with a high value for the new index had a median survival of 19.3 months vs 46.1 months for the rest (P < 0.0001, log rank test). Conclusion: The measurement of plasma cell apoptosis has prognostic value in patients with MM. More importantly, we have shown that by combining measures of two important biological characteristics of the plasma cell, namely proliferation and apoptosis, patients with a poor prognosis can be identified. Such a prognostication strategy can help stratify patients in clinical trials as well as shed light on the disease biology.

Abstract The objective of this study was to determine the molecular alterations that occur at the protein level in patients with WM in order to identify novel targets of therapy, determine new markers of prognosis, and begin to delineate the pathogenesis of WM. Five bone marrow samples were obtained after informed consent from patients with symptomatic WM. Two bone marrow samples were obtained from age-matched controls and were pooled. All samples were purified with anti-CD19+ beads with over 90% purity. Protein quantification was performed and 1ug of protein was obtained for each sample and control. The nanoscale protein micorarray technique (BD Clontech, CA) was used to measure changes in the patterns of protein expression between WM samples and control lymphocytes. This is a new technique that detects differences in protein abundance between the tumor and control samples by hybridizing fluorescently labeled (Cy3 and Cy5) protein mixtures onto slides spotted with 512 monoclonal antibodies against human polypeptides. It requires minimal amount of protein. Two microarray slides were used for each experiment and a control experiment of control versus control was performed for normalization of the data. The slides were scanned using the Axon GenePix 4000B scanner. Two ratios were generated from the spot images for each protein target. The mean of the ratios of Cy5/Cy3 of both slides were analyzed using Clontech software and used to calculate an Internally Normalized Ratio (INR = ÷Ratio1/Ratio2, ratios 1 and 2 correspond to slides 1 and 2) for each spot on the array. The INR values were input into GeneSpring 6.0 software (Silicon Genetics, Redwood City CA). The data was normalized to the mean INR of the control samples. Proteins whose expression fold change relative to control was greater than 1.3 fold were determined. All samples were of symptomatic WM. There were 3 females and 2 males. The median age was 61 years (range, 47–83). Four patients were newly diagnosed and one had received prior rituximab, CHOP ad thalidomide therapy. Clustering analysis did not demonstrate a difference between newly diagnosed and treated samples. There were 72 proteins up or downregulated by 1.3 fold in all WM samples as compared to control. These included proteins in the PI3K pathway such as VHR, PTP1B, PI3K (p110alpha) and Rb2. Protein kinases such as PKCi, PKCbeta, PKC gamma, PKC delta, PLCgamma were all upregulated in WM samples. Other proteins included the B-cell specific activator protein PAX-5, the ubiquitin protein UBCH6, the STAT kinase STAT4, the GTPase Rho A-binding kinase ROK alpha, and the apoptosis protein SMAC/DIABLO. We demonstrate that several isoforms of the PKC family of proteins are upregulated in WM. PKC proteins regulate apoptosis, proliferation and migration in many cancer cells. These proteins may be useful targets of therapy in future clinical trials in WM. Other inhibitors that may be useful in WM include ubiqutin/proteosome inhibitors such as bortezomib and PI3K pathway inhibitors such AKT or mTOR inhibitors. Our results also confirm the presence of PAX-5 in WM consistent with previous cytogenetic studies. Supported in part by an ASH scholar award and Research Fund for Waldenstrom.