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Abstract Introduction Multiple myeloma (MM) is clinically heterogeneous, and therapeutic response is profoundly influenced by the complex cytokine milieu of the bone marrow microenvironment. Unlike most cancers, MM staging incorporates non–tumor-burden markers such as serum albumin, β₂-microglobulin, and LDH, which are prognostically useful but biologically nonspecific. Although individual cytokines (e.g., IL-6, IL-17, TGF-β) have been linked to disease activity, a comprehensive, systems-level assessment comparing an exhaustive list of cytokines, chemokines, and growth factors across large patient cohorts is lacking. Here, we present evidence for an actionable cytokine panel, using gene expression–derived cytokine bioactivity as a surrogate measure. Methods CD138 enriched bone marrow plasma cell RNA-seq, Seq-FISH, and clinical data were obtained from the MMRF CoMMpass study. Data were TMM-normalized, log₂(x + 1) transformed, and mean-centered. Bioactivity scores for 64 cytokines, chemokines, and growth factors were inferred using CytoSig (National Cancer Institute). CytoSig leverages transcriptomic data from over 20,000 samples treated with individual molecules to model gene expression changes of cytokine regulators, targets, and response elements to provide z-scores. Reverse validation of bioactivity between samples scoring top and bottom quartiles of each cytokine was done using pathway analysis via Gene Set Enrichemnent analysis platform that verifies bioactivity across 7561 well-studied gene sets.(MSigDB C2 2025). Cytokines with upregulation of associated pathways were considered for downstream analyses (Criteria: Normalized enrichment score > 1). Genes were ranked by sign(logFC) × –log₁₀(p), identifying 44 significantly enriched pathways. Univariate Cox regression identified prognostic cytokines. To account for variable correlation and improve prediction, Elastic Net Cox regression (α = 0.5) was used, combining LASSO (L1) and Ridge (L2) penalties. For biological validation, pathway analysis was done between samples with high vs low serum C-Reactive Protein(CRP). Survival kinetics and clinical characteristics were analyzed for the derived model. Results A total of 767 NDMM patients were included (median age 63 years, range 27–93); median overall survival (OS) was 44.4 months (IQR 70.9). Revised International Staging System (R2-ISS) distribution was: Stage I 14.7%, II 24.0%, III 34.7%, and IV 6.4%. Based on the International Myeloma Society–International Myeloma Working Group (IMS–IMWG) definition, 32.2% of patients were classified as high-risk. Supervised analysis identified 30 univariate prognostic cytokines. Elastic Net retained BMP-7, IGF-1, IL-3, NRG1, IL-17A, IL-2, IL-21, and TGF-A (positive coefficients), and IL-4, IL-18, BMP-4, palmitic acid, DHT, and BMP-2 (negative coefficients). In sensitivity analysis, after removing cytokines not passing GSEA validation, the cytokine score (CS) was established using BMP-7, IL-3, TGF-A, IL-17A, BMP-2, IL-18, BMP-4, and IL-4. High serum CRP–associated gene expression was linked to upregulation of IL-17 and BMP pathways and downregulation of IL-4 signaling. Patients with CS ≥ median had higher β2M (p < 0.001) and LDH (p = 0.005); creatinine (p = 0.07) and albumin (p = 0.6) were not significant. CS was higher in patients with del(17p), 1q21 gain, high-risk IGH, t(8;14), and del(1p), and lower in those with hyperdiploidy (all p < 0.01). CS achieved a C-index of 0.67. Median OS was 58.7 months in the high-CS group vs. 102.5 months in the low-CS group (p < 0.001). Adding continuous CS to a model with continuous β2M + continous albumin improved C-index from 0.65 to 0.72. ISS improved from 0.62 to 0.68; R2-ISS from 0.65 to 0.69. A multivariate model with β2M ≥ 5.5, del(1p) + 1q gain, t(4;14), deep del(1p), and del(17p) improved from 0.63 to 0.68 with CS. Discussion These findings require functional validation in patient samples through direct measurement of cytokine levels. BMP-7 remains understudied in MM. Elevated TGF-α, IL-3, and IL-17 promote angiogenesis, bone resorption, and immune dysfunction, while BMP-2 and BMP-4 act as tumor suppressors. IL-18 is being utilised to boost T-cell responses, and IL-4 is consistently reduced in MM. Conclusion This study provides evidence for a robust, clinically translatable cytokine, chemokine, and growth factor panel. IL-17, IL-4, and BMPs emerged as consistently regulated across all analyses. CS is associated with high-risk disease and inferior survival.

Abstract The CoMMpass study (NCT01454297) is a prospective, longitudinal observational trial involving 1,141 newly diagnosed, treatment-naïve multiple myeloma (NDMM) patients. Bone marrow aspirates from the study participants were collected, separated into CD138 negative and CD138 positive fractions for comprehensive molecular characterization of tumor (using bulk RNA sequencing and whole genome sequencing) and tumor immune microenvironment using 3' single-cell RNA sequencing (scRNA-seq). To support exploration of this rich multi-omic dataset, we developed CoMMpass Explorer (CE), an intuitive interactive platform that enables real-time analysis of clinical and genomic data from these study participants. CE provides four main views: Overall Summary for clinical feature distribution and Kaplan-Meier curves; Mutational Profile for visualizing and comparing somatic mutations; Tumor Profile for differential expression and gene set enrichment; and Immune Microenvironment for comparing cell type abundance and cell cycle dynamics between cohorts using scRNA-seq data. A central feature of CE is cohort building, where users can filter and stratify patients by clinical, genomic, and survival data elements to create custom cohorts for analysis. We validated CE by reproducing findings from two prior CoMMpass-based studies. In the first study by Simhal et al, we stratified patients using transcript-level expression by WEE1 into tertiles and confirmed that high WEE1 expression is associated with poorer progression-free survival across multiple genomic subgroups. In the second study by Manojlovic et al, we replicated mutation frequencies between African American and Caucasian patients by creating race-based cohorts. We further demonstrate CE's utility by identifying and comparing two NDMM cohorts of patients at baseline who have not received autologous stem cell transplant: cohort 1 includes patients that received up-front triplet therapy (N=342) and cohort 2 includes those who did not receive a triplet up-front (N=235). While survival differences between these two cohorts were not statistically significant (p>0.05), CE revealed elevated epithelial-mesenchymal transition (EMT) pathway activity in cohort 1. Immune profiling showed lower abundance of CD8+ T cells (p < 0.05) and NK cells (p = 0.01), but a higher abundance of B cells (p < 0.05) in cohort 1. Genomic data showed fewer EIF2AK3 mutations and higher transcript-level expression of EIF2AK3 in cohort 1. Notably, patients in cohort 1 with lower transcript-level expression of EIF2AK3 had better survival outcomescompared to patients in cohort 2. CE democratizes access to the CoMMpass multi-omic resource, allowing researchers to interrogate clinical and molecular heterogeneity with ease. By enabling hypothesis generation and replication of published results, CE serves as a valuable tool for identifying meaningful patterns in gene expression, mutation profiles, and immune contexture. It also highlights potential prognostic biomarkers, such as EIF2AK3 expression, that may inform treatment decisions in NDMM, especially in the context of triplet-based regimens.

Abstract Cardiac involvement in AL amyloidosis significantly impacts both short and long-term survival. Achieving cardiac complete response (CarCR) is linked to excellent survival, comparable to that of the general population. We undertook this study to characterize patients with AL amyloidosis who achieved CarCR. Methods: A single-center retrospective study of patients diagnosed with cardiac AL amyloidosis between 2004 and 2023 and achieved a documented CarCR for at least 12 months. Patients were included if they had evidence of cardiac involvement confirmed by cardiac imaging (transthoracic echocardiogram or cardiac magnetic resonance) and Congo red–positive tissue (non-cardiac or heart biopsy), and were evaluable for cardiac response based on baseline NT-proBNP > 650 pg/mL or BNP > 150 pg/mL. CarCR was defined as a reduction in NT-proBNP to less than 350 pg/mL (or BNP less than 80 pg/mL). Heart transplant patients were excluded. Results: Sixty-three patients were included, representing 4.6% of the cardiac evaluable population in the study period. This proportion increased in the second period compared to the first period (7.5% vs 3.2%, P<0.001). The median age at diagnosis of 57 years (ranging from 29 to 79); 63% were male. Lambda light chain disease was evident in 63% of patients. The median difference between the involved and uninvolved light chain (dFLC) at baseline was 429 mg/L (interquartile range [IQR] 143-708). While all patients had cardiac involvement, 63% also presented with extra-cardiac involvement [kidneys (52%), liver (16%), autonomic nerves (14%), luminal gastrointestinal tract (11%), and peripheral nerves (10%)]. The median baseline NT-proBNP for the entire cohort was 1977 pg/mL (IQR 1393-3026). The median troponin T (n=43) was 0.02 ng/mL (IQR <0.01-0.05) and the median high-sensitivity troponin T (n=19) was 49 ng/L (IQR 38-79 ng/L). Cardiac stage distribution, according to the European modification of the Mayo 2004 staging model, was as follows: 59% stage II, 39% stage IIIa, and 2% stage IIIb. At baseline, echocardiogram features included a median left ventricular (LV) ejection fraction of 63%, a median intraventricular septum thickness of 14 mm, and a median average LV longitudinal strain of -12%. The most common first-line therapies were autologous stem cell transplantation (ASCT; with or without induction, 54%), bortezomib-containing therapy (22%), and daratumumab-containing therapy (13%). Hematological complete response rates at 3-month, 6-month, and best response prior to CarCR were 32%, 49% and 76%, respectively. At CarCR, the median NT-proBNP was 265 pg/mL (IQR 220-307) with a median time from treatment onset to CarCR achievement of 20.6 months. At CarCR, 33% of patients were on loop diuretics. The CarCR rate at 6, 12, 24, 36, 48 and 60 months from treatment onset was 10%, 39%, 81%, 90%, 95% and 96%, respectively. Temporary increase of NT-proBNP above 350 pg/mL with return to CarCR was documented in 46% of patients. Echocardiogram parameters also improved significantly at the time of CarCR, with average left ventricular longitudinal strain showing the greatest median improvement in relation to baseline (from -12% to -17%, p<0.001). However, echocardiographic parameters did not fully normalize in all patients. Cardiac progression was seen in 14% of patients, at a median of 7.6 years from the initial time of CarCR. In addition, subsequent clone-directed therapy was given in 44% of patients at a median of 4.6 years from the initial treatment. With a median follow-up of 9.5 years, eight patients (13%) died, 4 due to causes unrelated to AL. We compared the survival of patients who achieved CarCR to the general U.S. population, matching for age, sex, and the year treatment. The observed survival of CarCR patients was similar to that of the general population (p=0.35). Conclusion: Patients with persistent CarCR >12 months in AL amyloidosis are uncommon and demonstrate excellent outcomes. The achievement of hematological CR was required in 3 out of 4 patients reaching a CarCR. Echocardiographic changes of amyloid infiltration may still persist in this highly favorable cohort, indicating that “complete” response refers primarily to functional and prognostic improvement, not necessarily a full restoration to pre-disease cardiac morphology and function. Achieving CarCR is associated with a low risk of cardiac progression, but the need for subsequent clone-directed therapy remains elevated.

Abstract Background: Gastrointestinal (GI) symptoms are frequent in patients (pts) with systemic light chain amyloidosis (AL), yet their clinical significance remains poorly defined. We investigated the role of symptomatic GI involvement in disease burden, survival, and organ-specific outcomes in a large single-center cohort. Methods From 2010–2025, 4,396 AL pts were evaluated at our center; 560 pts (13%) had provider-attributed symptomatic GI AL. Pts with localized AL or positive biopsy without GI symptoms were excluded (n=38). We analyzed relationships between GI symptoms, anatomic/histologic involvement, laboratory parameters, survival, and need for nutritional support using Wilcoxon rank-sum, Chi-square, Kaplan-Meier, and logistic regression tests. Results GI symptoms included early satiety (n=320/57%), diarrhea (n=189/34%), nausea (n=184/33%), abdominal pain (n=148/26%), dysphagia (n=119/21%), vomiting (n=75/13%), GI bleeding (n=74/13%), and heartburn (n=71/13%). Only nausea and GI bleeding were not associated with cardiac (n=366/65%) renal (n=274/49%) or hepatic (n=84/15%) AL, whereas dysphagia, early satiety and heartburn were more frequent with cardiac (all OR=1.7), abdominal pain and diarrhea with hepatic (OR=2 and 1.6, respectively), and vomiting with renal involvement (OR=2; all p<0.04). Autonomic involvement impacted GI symptoms, often without proof of parenchymal GI amyloid. Of the 124 pts with formal autonomic testing, only 44 (35%) had positive GI biopsies as compared to AL GI pts without proven autonomic involvement (240/436, 55%). Pts with autonomic involvement were more symptomatic than pts with positive GI biopsies, suffering more often from dysphagia (29% vs 19%), diarrhea (41% vs 32%), and gastroparesis (34% vs 9%, all p<0.001). We screened changes in body weight, calcium, VitB12, Hb, PO4, and albumin at diagnosis. Of the 175 pts with documented weight loss in this cohort, pts with GI AL lost more weight compared to those with other organ involvement (21% vs 14% of weight, p=0.002), and had lower phosphate (3.7 vs 4.0 mg/dL, p=0.06). In our cohort of pts with GI symptoms, 298 (53%) had a positive GI biopsy. Biopsy-proven anatomic involvement dictated symptoms (all p<0.05): Of the 20 pts with positive esophageal biopsy, dysphagia was present in 45%; only 33% of the pts without an esophageal biopsy had dysphagia. Similar patterns were seen for the 170 pts with a positive gastric biopsy (n=170) in terms of heartburn (21% vs 11%), for the 165 pts with positive small bowel biopsies in terms of abdominal pain (68% vs 32%), and for the 130 pts with positive colon biopsies and diarrhea (46% vs 33%). Specific histopathological patterns were prognostic. Mucosal involvement (n=161) was an independent risk factor for survival compared to submucosal (n=64) and vascular (n=102) involvement throughout the GI tract (HR 1.83; p=0.03). Three-layer GI infiltration was associated with inferior mOS (2.4 vs 5.1 vs 7.8 y for 3 vs 2 vs 1-layer involvement, HR 3.19/1.56/1; p<0.05). Counterintuitively, vascular involvement had the lowest risk of bleeding in all GI anatomic sites (p=0.02). In the colon, only mucosal involvement was associated with a higher risk of bleeding (OR=5; p=0.04). GI involvement in AL pts did not worsen prognosis (mOS 10.0/6.3y, p=0.02), and pts with isolated GI AL (n=74/13%) had an even better survival (55% surviving at 10 y). Cachexia (n=120; mOS 3.5 vs 7.8 y, p<0.001), need for nutritional support (n=36; mOS 0.9 vs 7.0 y, p<0.001), and diarrhea (mOS 5.8 vs 6.9 y, p=0.06) were risk factors for death. In pts with hematologic response (≥PR), bleeding did not recur within 3 y (n=27), but even with response, diarrhea (n=160) persisted in 39%. Resolution was less frequent without hematologic response (persistence in 69%, OR=3.5). Improvement was most often due to treatment of bacterial overgrowth (11/35 pts; 68%) and loperamide (54/59 pts; 91%). Conclusion In AL, meaningful GI involvement is defined by nausea, diarrhea, occurrence of bleeding, and malnutrition. These are primarily associated with mucosal infiltration. GI symptoms can occur in the face of autonomic involvement. While long-term persistence of GI bleeding is rare after serologic response, cachexia and persistent diarrhea drive morbidity, need for nutritional support, and poor survival.

Background/Objectives: Family history is a known risk factor for multiple myeloma (MM) and its precursor condition, monoclonal gammopathy of undetermined significance (MGUS). Previous genome-wide association studies (GWASs) have identified 35 common loci associated with MM risk and 21 associated with MGUS. The objective of this study was to identify less common and rare genetic loci predisposing to MM/MGUS through whole-exome sequencing (WES)-based linkage analysis. Methods:Multipoint linkage analysis was conducted using the Multipoint Engine for Rapid Likelihood Inference (MERLIN) with the Lander–Green algorithm on germline WES data from 79 pedigrees with 2 or more affected relatives (120 MM, 86 MGUS, and 21 unaffected). Genome-wide linkage was evaluated using 12,946 independent single-nucleotide variants (linkage disequilibrium r2 < 0.05). Results: Significant linkage was observed at chromosome 6q22.33–q24.2 by the non-parametric model (logarithm-of-odds (LOD) = 3.3) and suggestive linkage by the dominant parametric model (heterogeneity LOD (HLOD) = 2.5). Fourteen rare variants within this region were prioritized using family-specific partial LOD scores and in silico functional prediction tools. Nine of these variants, REPS1, THEMIS, TAAR6, AHI1, VNN1, VNN3, MTFR2/FAM54A, LAMA2, and PHACTR2, overlapped immune-regulatory regions in blood cell lines and were not previously identified in GWASs. Conclusions: This study demonstrates the utility of applying a linkage analysis framework to familial WES data for identifying genomic regions and candidate genes that may contribute to MM/MGUS predisposition. These findings provide new insight into the inherited risk and etiology of familial MM and MGUS.