Citations

Abstract The time in cellular differentiation at which the expression of an oncogene is dysregulated is thought to determine the phenotype of the resulting neoplasia. We tested this assumption in C57BL6/J transgenic mice expressing an HA-tagged c-myc oncogene in B cells under the control of kappa light chain regulatory elements. Two transgenes were engineered that differed by only one nucleotide. The first set of mice carries a wild type HA-MYC transgene, develops pro-B cell tumors, and succumbs rapidly to pronounced lymphosplenomegaly. In the second set of mice, a point mutation in the HA-tag portion of the transgene creates a stop codon that abrogates HA-MYC translation. This stop codon was engineered to be a hotspot for somatic hypermutation. Thus sporadically, in a germinal center B cell, somatic hypermutation may revert the stop codon, allowing translation of HA-MYC. In two independently derived lines, mice spontaneously develop monoclonal gammopathies (50% incidence at 30 weeks (n=35), 80% at 40 weeks (n=35)). Serum protein electrophoresis detects M-spikes that increase in intensity over time, and 6 out of 7 cases tested so far were of IgG1 isotype. Unlike other mouse models of plasma cell neoplasia, no lymphosplenomegaly nor ascites were detected. In analogy to human multiple myeloma, that is a disease of isotype-switched and hypermutated cells homing to the bone, large populations of plasma cells were found in the bone marrow. Bone marrow (but not spleen) lysates reacted for HA and human MYC proteins by western blot and immunohistochemistry, thus indicating that reversion of the stop codon occurred. Remarkably, in two young mice, monoclonal spikes appeared 2 weeks after vaccination with NP-CGG. These spikes were sustained and the monoclonal protein was reactive to the NP antigen. Together, comparison of the two sets of mice demonstrates that activation of the same transgene at distinct B cell developmental stages results in dramatically different tumor phenotypes. In addition, and opposite to most engineered mice, we have created a system where the oncogene is turned on sporadically, as occurs in the human disease. Furthermore, we have developed a model that faithfully reproduces important clinical aspects of monoclonal gammopathy of undetermined significance (MGUS) and its progression to multiple myeloma. This model will be useful to develop immunologic and chemoterapeutic approaches.

Abstract Abstract 3063 Background: The combination of Cyclophosphamide, Bortezomib, and Dexamethasone (CYBOR-D) is proven to be highly active and effective in multiple myeloma. (Reeder, Leukemia 2009) We aim to evaluate the safety and efficacy of this regimen in a separate plasma cell neoplasm, AL Amyloidosis. The primary endpoint of this study is hematologic response. Complete hematologic response is defined as normalization of the free light chain ratio with no evidence of a monoclonal protein by immunofixation. Partial hematologic response is defined as a 50% reduction in M-spike or absolute light chain level (Gertz Am J Heme 2006). Methods: We report a series of patients with symptomatic AL Amyloidosis who received treatment with a combination of Bortezomib (1.3mg/m2 on days 1, 4, 8, and 11 every 28 days or 1.5 mg/m2 weekly), Cyclophosphamide (300 mg/m2 orally weekly) and Dexamethasone (40 mg weekly). We include patients in this study regardless of autologous bone marrow transplant candidacy or previous treatment history. Results: Fifteen patients with AL amyloidosis received two to six cycles of CYBOR-D. The treatment history, bone marrow transplant candidacy prior to treatment, hematological response, and status of transplant after therapy are shown in table 1. Of note, 8 (53%) had symptomatic cardiac involvement all of whom had elevated levels of both cardiac biomarkers (Troponin T and B-natriuretic peptide). Complete hematological response occurred in 11 patients (73.3%) with partial hematological response in 3 patients (20.0%). One patient (6.6%) did not achieve a partial response but did receive autologous bone marrow transplant after treatment with CYBOR-D. Median time to response was 2 months. Six patients (40%) had objective evidence of kidney response to therapy with a greater than 50% decrease in proteinuria. Conclusions: CYBOR-D produces a rapid and complete hematological response in the majority of patients with AL amyloidosis regardless of previous treatment history or bone marrow transplant candidacy. Overall, it is well tolerated with few side effects that included peripheral neuropathy and infectious complications. Two patients originally determined to be not eligible for transplant improved sufficiently on CYBOR-D to become eligible and then went on to receive autologous bone marrow transplant. The retrospective nature and small sample size limit this study, and prospective, randomized studies are needed to further elucidate the role of this regimen in AL amyloidosis. Disclosures: Stewart: Millennium Pharmaceuticals, Inc.: Honoraria, Research Funding; Celgene: Honoraria. Fonseca:Amgen: Consultancy; Bristol-Myers Squibb: Consultancy; Celgene: Consultancy, Research Funding; Genzyme: Consultancy; Onyx: Research Funding; Otsuka: Consultancy; Medtronic: Consultancy.

Abstract Abstract 2810 Poster Board II-786 We wished to explore the genetic events associated with disease progression and development of drug resistance in multiple myeloma (MM). To do so 11 patients were studied in whom at least two (range 2-3) temporally distinct samples of tumor DNA and RNA were available. The baseline genetic initiating event was defined for all patients (3 were genetic high risk; one with t(14;16) two with t(4;14)) as well as the gene expression profile (GEP) defined risk score using the Little Rock 70 or 17 gene panel (only one, the t(14;16) was GEP defined high risk). High resolution array CGH and gene expression were then performed on each sample. Of the 8 patients with a “low risk” tumor initiating event and low risk GEP score, 6 patients had no, or only one, copy number abnormality (CNA) change between the two temporally distinct MM samples. In stark contrast the 3 genetic high risk at baseline had between 17 and 40 distinct CNA changes at the time of progression. For all 11 patients 89 CNA were acquired with progression whereas 19 previously abnormal regions disappeared suggesting clones with these abnormalities were extinguished by the therapy received. In total we detected 0-40 CNA changes between the various timepoints, median 1, mean 10.7. The acquisition of new CNA was much more common than the loss of CNA. We then focused more specifically on the t(4;14) patient with the highest number of CNA changes. This patient has a well documented clinical course of having a sustained two year VGPR to Len/dex and then progressing while still taking Len/dex. Comparison of the pre and post-Len/dex samples identified 40 CNA changes(the most of any pair studied to date). Only six CNA were shared between the two samples, which included deletions of chr4, 9, 12, 13, and X plus a t(4;14) translocation. These likely represent the initiating “driver” tumor events. The new CNA we identified originated from both remodeled genomic changes and the emergence of unique changes, indicating a new tumor clone had emerged while the previously dominant clone had regressed (e.g. a deletion of a large segment of chromosome 8 at diagnosis was no longer observed in the relapse sample). The newly acquired CNA encompassed 3968 genes (13.7% of the genes in the genome), however, only 1235 of these genes (4%) were expressed in this patient at diagnosis (1188 in the typical myeloma patient). Since 1235 genes is still a large number we hypothesized that whole genome sequencing (WGS) would help elucidate the mechanism of lenalidomide resistance. We isolated DNA from germline tissue and CD138 purified tumor cells including: diagnostic, first relapse and second relapse samples. Utilizing SOLiD (Applied Biosystems, Foster City, CA) sequencing technology, we have completed fragment library WGS on both the germline and the final tumor samples. Quality control measures report the average number of sequence reads per start point to be less than 1.2, indicating the library is primarily composed of unique molecules. In addition, approximately 40% of the sequence reads map uniquely to the genome. Together these quality measures indicate our sample libraries are complex and provide good representation of the genome. Data on the whole genome sequence of myeloma at diagnosis and at the time of progression will be presented. Disclosures: Bergsagel: Celgene: Consultancy.

Abstract It has been suggested that errors in the repair of DNA double strand breaks (DSB) can result in gross chromosomal rearrangements (GCR), including chromosomal amplifications, deletions, inversions, and translocations. To study repair of DNA DSB in vivo, we established a subclone of the U937 cell line designated F5, in which a single copy of the rare-cutting meganuclease I-SceI recognition site has been integrated into chromosome 7. We transfected an I-SceI expression vector into these cells and analyzed misrepair events. We recovered no GCR, but instead found that most DSBs were repaired by small (<50bp) indels (91.8%). We also noticed some DSBs were repaired by large (<50bp) deletions (6.4%) and rare DSBs were repaired by large (100-500 bp) insertions (1.8%). Surprisingly, the nucleotide sequence of these insertions matched distant regions of the genome. To determine if this templated sequence insertion (TSI) was peculiar to I-SceI induced DNA DSB, we repeated the experiment using TALENs to produce DNA DSB. Again, we found insertions that were derived from distant genomic regions. To determine whether this form of DNA repair was restricted to experimentally induced DNA DSB, we analyzed structural variations identified by whole genome sequence (WGS) of two myeloma cell lines (KP6, MC1286PE1), and identified 15 independent TSIs. These TSIs were verified by Sanger sequencing, and lengths of inserted fragment were 38 to 666 bp (median 189 bp). Six insertions were noted to be identical between the 2 cell lines, suggesting that these TSIs were germline polymorphic events. These TSIs were compared to a catalog of known structural variations identified by WGS of 52 healthy individuals; 13 of 15 TSI junctions were identified, suggesting that these represented polymorphic insertions in the human genome. Two TSIs were potential somatic mutations in the KP6 cell line, including one that had 85bp insertion at the junction of an acquired t(6;12) chromosomal translocation. Six TSIs showed the hallmarks of L1 retrotransposon-mediated insertions, with a 5’-TTTT/A-3’ integration site, a target site duplication (TSD), a polyA tract at the insertion site, and a polyadenylation signal. However, the inserted sequence was neither a LINE nor a SINE, but instead was a transcribed, genic region mapping to a distant genomic region. The presence of these L1 ORF1 hallmarks strongly suggests that these insertions were caused by the L1 integrase and reverse-transcriptase acting on nuclear pre-mRNA. A second class of TSI showed no preference for a 5’-TTTT/A-3’ integration site, no TSD, no poly A tract, but instead showed several bp of microhomology at the insertion junctions. This second class is similar to TSI detected at I-SceI induced DNA DSB, and we predict that these TSI were generated by reverse transcription of pre-mRNA creating a “patch” for a spontaneous DNA DSB that occurred in a germ cell. To determine if TSI at I-SceI induced DNA DSB could be repaired by RNA-templated sequences, we cotransfected murine RNA and an I-SceI expression vector into F5 cells. Approximately 10% of the TSI recovered from these experiments contained mouse sequences, indicating that they were derived from mouse RNA. To further support the contention that TSIs were derived from RNA, we again used I-SceI to induce a DNA DSB, and treated the cells with reverse transcriptase inhibitors. The TSI frequency was reduced by 70%. Finally, a subset of insertions were due to telomere repeat sequences, lending further support for the hypothesis that RNA could serve as a template for the repair of DNA DSB. TSI is novel form of potentially mutagenic DNA DSB repair, which should be considered as an alternative to a balanced chromosomal translocation in the interpretation of reciprocal interchromosomal structural variations identified by short-read deep sequencing. Disclosures: No relevant conflicts of interest to declare.

Abstract Deletions of chromosome 13 occur in about 50% of multiple myeloma (MM) patients, with monosomy being the most common (85%), and small interstitial deletions, often involving the Rb gene, representing only 15% of cases. In contrast to CLL, where a minimal deleted region (MDR) has been mapped to the DLEU2/miR-15a/16-1 locus, no MDR has been identified in MM. The prognostic significance of monosomy 13 has been overshadowed by its strong association with high-risk MM, mostly t(4;14) and t(14;16) translocations. Genomic analysis of 28 MM tumors from Vk*MYC mice identified recurrent (27%) monosomy of the syntenic chromosome 14, with focal bi-allelic deletions of Rb1 in three independent tumors. One tumor presented a focal monoallelic interstitial deletion of the mirR15a-16.1 cluster. Reasoning that the biological significance of monosomy 13 would be conserved between human and murine MM, we carried out genetic crosses between Vk*MYC and mice heterozygous for Rb1 (MYC/Rb1), for the DLEU2/miR-15a/16-1 locus (MYC/MDR) or for the miR-15a/16-1 cluster only (MYC/MIR). All of the MYC/Rb1 mice died around one year of age of pituitary tumors without a significant plasma cell expansion compared to the Vk*MYC mice alone. In contrast, both the MYC/MDR+/- and MYC/MIR+/- mice exhibited a progressive monoclonal plasmacytosis affecting secondary lymphoid organs, with associated shorter overall survival. The development of extra-medullary MM was further accelerated in MYC/MDR -/- and MYC/MIR -/- mice, and was reminiscent of that observed in Vk*MYC crossed with Emu-BCL2 mice. As previously shown for the CLL-like disease that develops in the MIR and MDR mice, the MM phenotype is more pronounced in the MYC/MDR than the MYC/MIR, and in the homozygous than the heterozygous mice. Although BCL2 has been proposed as a target of the miR-15a/16-1, it has not been identified among genes whose expression is altered in MIR null B lymphocytes, where instead miR-15a/16-1 deletion promotes proliferation. In contrast, we found significant BCL2 upregulation in some MM tumors from MYC/MIR and MYC/MDR, suggesting that miR-15a/16-1 deletion in MM provides a survival signal that renders plasma cells less dependent on the BM microenvironment. We propose that selection for monosomy 13 in MM is driven in at least in part by loss of one copy of the miR cluster. Disclosures: No relevant conflicts of interest to declare.

Abstract The search for novel and clinically effective anti-myeloma therapies has been hampered by a paucity of good pre-clinical animal models. Most established animal models of multiple myeloma (MM) fail in one or more crucial features to resemble human MM, frequently exhibiting extramedullary tumors or lacking a competent immune system. In addition, competing models are either too expensive or time consuming to generate and maintain. Finally, no model has been shown to reliably predict both drug response and drug inactivity. We have previously described a C57Bl6/J transgenic mouse model in which the expression of the human c-myc oncogene is activated in post-germinal B cells by somatic hypermutation. These mice (Vk*myc) spontaneously develop monoclonal gammopathies and plasma cell expansion beginning at 20 weeks of age. However, in contrast to other models, their plasma cells cannot be found in secondary lymphoid tissues. Now, we report that this model closely reproduces the clinical behavior of human MM. Serum protein electrophoresis (SPEP) as well as ELISA for serum IgG demonstrate that the incidence and quantity of monoclonal paraproteinemia are greatly elevated in the Vk*myc mice as compared to age matched wild type C57Bl6/J controls (50 weeks mean IgG 1.92g/dL Vk*myc vs 0.2g/dL controls; peak IgG levels up to 7.5g/dL). As these mice age, their paraproteins continue rising and remain far higher than that of controls at every time point. Mice with significant paraproteinemia demonstrate marrow with up to 50% plasma cells with evidence of a low proliferative index, similar to what is observed in human MM and unlike what is seen in other models of MM. Anemia is observed, with a mean hemoglobin of 8.9g/dL in the Vk*myc mice vs 13.4g/dL in the wild type. Vk*myc mice analyzed show marked bone thinning with a 20% reduction in total bone volume and in the number of trabeculae per unit area as shown by microCT. In addition a 15% reduction in bone mineral density was demonstrated in affected mice. We next demonstrated the efficacy of 3 drugs, used commonly in clinical practice to treat myeloma (melphalan, dexamethasone and bortezomib). These were given as single courses of daily IP injections for 5 days, for the first two drugs, and bi-weekly IP for 4 weeks for the third. As early as two weeks post treatment, a statistically significant reduction in serum paraprotein levels was observed in the treated mice versus vehicle treated controls. The reductions were maximal at 21d post treatment in the melphalan (−77.2%±39 p<0.02) and dexamethasone (−67.4%±29 p<0.02) groups and at 28d in the bortezomib group (−68.9%±9 p<.001). No reduction was seen in the vehicle treated controls at any time point. As with human myeloma, the effect of one course of treatment was transient in nature. In contrast, treatment of VK*myc mice with 3 drugs that have not shown clinical activity against myeloma as single agents (hydroxyurea, vincristine and fludarabine) did not reduce serum monoclonal proteins. We conclude that our Vk*myc model closely reproduces the clinical characteristics of human MM. We have also shown that this model responds to drugs known to be clinically active, while showing no response to drugs that have little or no effect against human MM. To our knowledge, this is the first time that this level of fidelity to human MM has been demonstrated in a pre-clinical animal model. Our model therefore represents a unique and powerful tool for pre-clinical anti-myeloma drug development.

Abstract Lenalidomide is an orally active immunomodulatory drug effective in the treatment of multiple myeloma. We evaluated the toxicity and efficacy of MPR combination in a phase I/II study. Patients with newly diagnosed symptomatic multiple myeloma who were not candidates or refused stem cell transplantation were eligible. Treatment consisted of M and P on days 1 – 4 and R on days 1 – 21 in a 28 day cycle. All patients received aspirin 325 mg a day. Routine antibacterial prophylaxis was not used. Patients were accrued in cohorts of 3 at dose level 0 (M 5mg/m 2/d P 60 mg/m2/d R 10 mg/d) and level 1 (M 8mg/m2/d P 60 mg/m2/d R 10 mg/d). Patients were followed for at least 2 cycles to assess Dose Limiting Toxicity (DLT). G/GM-CSF use was not allowed in the first 2 cycles unless DLT had occurred. DLT was defined as occurrence of at least grade (G) 4 hematologic toxicity, G3 febrile neutropenia, or G 3 non-hematologic toxicity in the first two cycles. Failure to start the next cycle within 7 days of day 1 due to toxicity also constituted DLT. Results: 7 patients have been accrued (4 at dose level 0 {one patient had to be replaced} and 3 at dose level 1). 4 were males. ECOG performance status was 0 or1 (2 and 4 patients). Median age was 74 yrs, range 72 – 85. Between 3 and 10 cycles (median 4) have been administered at the time of this reporting. The following G3 or higher toxicities were encountered and considered at least possibly related to treatment: 2 patients at level 0 had G3 neutropenia. Of the three patients at dose level 1, there was 1 G4 neutropenia, 1 G4 thrombocytopenia, 1 G3 hyperglycemia and 1 G4 vascular access device related thrombosis. Responses were defined by EBMT/IBMTR criteria. 1 had a complete remission (after 3 cycles), 4 had partial remission (at least 50% reduction in monoclonal protein) and 1 had minimal response (after 3 cycles). Due to 3 DLT’s in dose level 1, dose level 0 was chosen for phase II of the study. Conclusion: M 5 mg/m2, P 60 mg/m2 and R 10 mg combination is well tolerated and appears effective in patients with multiple myeloma. These results are similar to the experience reported by Palumbo et al (Blood2005, 106(11):abst 785) although a stricter definition of DLT was used in our study. Escalation of R dose in combination with M 5 mg/m2, P 60 mg/m2 may be possible and improve responses. Updated data will be presented.

Abstract The study of genomic aberrations in chronic lymphocytic leukemia (CLL) has yielded critical information, now routinely used for the prognostication of patients. An unbiased search for genome wide areas of copy number change is needed to identify possible primary genetic events in CLL and to elucidate their relationship to other known cytogenetic factors, such as deletions of 13q14, 11q23 and 17p13 and trisomy 12. Here we report on a study where we used a 60-mer oligo array-based Comparative Genomic Hybridization (aCGH, 44B platform from Agilent Technologies, Palo Alto, CA). We observed the most common genetic aberrations in CLL and in similar frequencies as would be predicted for CLL (e.g. 44% showing deletions of chromosome 13q14). Among those patients, 45% had no apparent other aberration. Of great interest, small bi-allelic deletions of chromosome 13, which predominantly involved the DLEU1 and DLEU2 locus, were detected in 4 patients (16%). Deletions of 11q23 were observed in 6 cases (24%), and while some involved the ATM locus one did not, casting doubt on the precise gene deregulated by these deletions. Large deletions of the whole 17p-arm were detected in three cases (12%). Trisomy 12 was present in only two cases (8%). No other trisomies were detected and also small regions of copy gain were uncommon. Monosomy of chromosomes 19, X and Y were present in three separate cases. Large deletions of chromosome 2p were seen in two cases, but an additional case had a small deletion involving the ALK gene. This case also had a breakpoint at chromosome 5 involving the NMP1 locus, suggestive of a t(2;5). A recent study (Mayr et al., Blood 2006) indicates that chromosomal translocations in CLL are present in 33% and were associated with a dismal prognosis. In our analysis we detected several breakpoints indicative of translocations. Detailed study is necessary to elucidate possible molecular events associated with these translocations. Other small regions of DNA copy loss were found at several locations throughout the genome. Regions of interest are shown in the table. In summary we show that multiple areas of recurrent genomic gain and loss can be identified in clonal cells of CLL and should lead to further insights into the understanding of disease pathogenesis. Chromosome Location Gene(s) of interest Loss 6q24.3 LATS Loss 10q23.3 LG11 Loss 10q24.2 PAX2, WNT8B, TLX1, POLL, NFKB2 Loss 11p15.4 PPFIBP2 Loss 12p13 TNFRSF1A and 7 Loss 15q22.1 TCF12 Loss 19p13.3 BAX, RUVBL2 Loss 20q11.2 TP53INP2 Loss 20q13.1 WFDC13

Abstract In an attempt to identify novel genetic abnormalities in multiple myeloma (MM) we analyzed 68 MM patient samples and 42 human myeloma cell lines (HMCL) with high-resolution (60kb) array-based comparative genomic hybridization (aCGH). We concentrated on bi-allelic genomic deletions with the expectation that these regions might contain novel tumor suppressor genes and identified a common abnormality at 14q32. Fine mapping of the 14q32 microdeletion by PCR demonstrated a 45 kb minimal deletion encompassing two genes; TRAF3, a negative regulator of the non-canonical NF-kB pathway, and AMN. To determine the frequency of copy number abnormalities of this region a cohort of 161 patients were screened with a FISH probe mapping to the minimally deleted region. This identified 7 (4.4%) patients with bi-allelic deletion and 19 (11.8%) patients with a single copy of the target region. Sequencing of all TRAF3 coding exons in 62 patients and 42 HMCL identified inactivating mutations in 9 patient samples and 4 HMCL. Overall, the incidence of TRAF3 inactivation, bi-allelic deletion or mutation, is 7/42 (16.7%) in HMCL and 12/62 (19.4%) in patients, making it one of the most common genetic abnormalities identified in MM. Importantly, dysregulation of NF-kB pathways is a common event in MM, but the mechanism for this dysregulation is largely unknown. Although TRAF3 is a negative regulator of the non-canonical NF-kB pathway it has not previously been implicated in cancer. Therefore, we tested the tumor suppressor function of TRAF3 by reintroducing TRAF3 into HMCL harboring TRAF3 abnormalities using an adenovirus gene transfer system. Expression of TRAF3 in HMCL with TRAF3 abnormalities rapidly reversed cellular processing of NFKB2 from p100 (an inactive isoform) to p52 (active) and additionally led to a 60% reduction in cellular proliferation (range, 10–89%) associated with Go/G1 cell cycle arrest and induction of cell death by apoptosis. At 48 hrs post infection the proportion of cells entering S-phase or G2/M declined by 31% (range, 8.1–56.1) and the proportion undergoing apoptosis increased by 28% (range 11.7–47.4%). In contrast, over-expression of TRAF3 in control HMCL without TRAF3 abnormalities had no effect. Overall, TRAF3 is identified as a novel tumor suppressor that regulates the non-canonical NF-kB pathway and is inactivated in ~ 20% of MM patients. Given the involvement of the NF-kB pathway in multiple human malignancies and the near constitutive expression of TRAF3 we propose that inactivation of TRAF3, a novel tumor suppressor identified for the first time in this study, may occur in other cancers. In this regard, we have recently identified a Burkitt lymphoma cell line that does not express TRAF3 and thus has constitutive processing of p100 to p52. The clinical and therapeutic consequences of this finding and its frequency in other tumor types are currently the focus of further investigation. In conclusion, the abnormalities identified in this study represent the first mutations identified that cause constitutive NF-kB activation in MM.

Abstract Abstract 1807 We have recently demonstrated that cereblon (CRBN) mediates the direct anti-myeloma activity of immunomodulatory drugs (IMiDs). However, the genes/pathways downstream of CRBN associated with anti-myeloma activity remain unclear. We, and others, identified interferon regulatory factor 4 (IRF4) as one of the downstream targets of CRBN-associated signaling. Both lenalidomide treatment and CRBN knockdown downregulate IRF4. IRF4 levels return to baseline in IMiD resistant cells surviving CRBN silencing. To determine whether IMiD-induced IRF4 downregulation is critical to anti-MM activity, we overexpressed IRF4 in two IMiD-sensitive human MM cell lines (HMCLs), KMS11 and MM1.S, followed by lenalidomide treatment. Lenalidomide-induced cytotoxicity was greatly impaired in both HMCLs overexpressing IRF4 compared with the control virus infected cells. Further analysis indicated that IRF4 over-expression does not completely prevent lenalidomide-induced growth arrest, but reduces cell death by 70% after lenalidomide treatment. Immunoblotting analysis of KMS11 cells indicated that IRF4 over-expression blocks lenalidomide-induced activation of caspase 8, reduces up-regulation of p21waf and increases CDK6 expression but does not significantly affect lenalidomide-induced MYC down-regulation. Although cereblon and IRF4 are broadly expressed in MM, baseline levels of expression are only weakly correlated (r=0.22) in primary MM patient gene expression analysis. Gene expression studies revealed statistical changes in 1,368 genes when comparing high versus low CRBN expression in primary myeloma samples. Interestingly genes associated with high CRBN expression included cyclin D2, SOCS3 and IL4 while genes associated with low cereblon expression included cyclin D1, FRZB and CD200. In order to understand how CRBN is connected with downstream anti-myeloma signaling, a structure-function study was performed to determine which CRBN domain is required for lenalidomide-induced IRF4 down-regulation and cytotoxicity. Lentiviral constructs expressing wild-type CRBN and a series of mutated CRBN were generated, including mutations at thalidomide binding site (Y384A/W386A), deletion of DDB1 binding region (ΔMid) and truncations at N-terminal and C-terminal. Lentiviruses from these constructs were used to infect IMiDs resistant HMCLs, OCI-MY5 and MM1.S res. Both of these cell lines have very low endogenous CRBN expression and they became sensitive to lenalidomide after introduction of wild-type CRBN. Conversely, introduction of CRBN with mutated thalidomide-binding site or with DDB1 binding region depletion failed to mediate lenalidomide toxicity and down-regulation of IRF4. OCI-MY5 cells expressing either N-terminal or C-terminal truncated CRBN showed substantial reduced responses (more than 50%) to lenalidomide compared with wild-type CRBN expressing cells. Deletion of only 20–30 amino acids at either ends of CRBN greatly impaired the protein function, suggesting that protein folding might be important for CRBN-mediated IMiD response. Our data indicate that IMiD induced myeloma cytotoxicity is largely mediated by modifying CRBN associated E3 ubiqutin ligase and subsequent IRF4 downregulation, suggesting the CRBN-IRF4 axis is a potential target for development of new anti-myeloma drugs. Disclosures: Schmidt: Karyopharm: Research Funding. Stewart:Millenium: Consultancy, Honoraria, Research Funding; Onyx: Consultancy; Celgene: Consultancy.