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Purpose: In myeloma, B cells and plasma cells show a clonal relationship. Clonotypic B cells may represent a tumor-initiating compartment or cancer stem cell responsible for minimal residual disease in myeloma.Experimental Design: We report a study of 58 patients with myeloma at time of diagnosis or relapse. B cells in bone marrow were evaluated by multicolor flow cytometry and sorting. Clonality was determined by light chain and/or immunoglobulin chain gene rearrangement PCR. We also determined aldehyde dehydrogenase activity and colony formation growth. Drug sensitivity was tested with conventional and novel agents.Results: Marrow CD19+ cells express a light chain identical to plasma cells and are therefore termed light chain restricted (LCR). The LCR B-cell mass is small in both newly diagnosed and relapsed patients (≤1%). Few marrow LCR B cells (∼10%) are CD19+/CD34+, with the rest being more differentiated CD19+/CD34− B cells. Marrow LCR CD19+ B cells exhibit enhanced aldehyde dehydrogenase activity versus healthy controls. Both CD19+/CD34+ and CD19+/CD34− cells showed colony formation activity, with colony growth efficiency optimized when stroma-conditioned medium was used. B-cell progenitors showed resistance to melphalan, lenalidomide, and bortezomib. Panobinostat, a histone deacetylase inhibitor, induced apoptosis of LCR B cells and CD138+ cells. LCR B cells are CD117, survivin, and Notch positive.Conclusions: We propose that antigen-independent B-cell differentiation stages are involved in disease origination and progression in myeloma. Furthermore, investigations of myeloma putative stem cell progenitors may lead to novel treatments to eradicate the potential reservoir of minimal residual disease. Clin Cancer Res; 18(22); 6155–68. ©2012 AACR.

PDF file - 87K, Contour plots describing sorting gating strategy and purity of bone marrow populations obtained

PDF file - 90K, Contour plots describing our gating strategy to exclude contamination with monocytes

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PDF file - 31K, DNA sequence analysis of sorted marrow sub-populations

PDF file - 677K, In vitro melphalan chemosensitivity of three MM patients.

PDF file - 29K, Computational modeling of clinical response to therapy.

PDF file - 126K, The duration of melphalan toxicity post-withdrawal.

PDF file - 66K, Loss of membrane motion is an early event in cell death, preceding loss of membrane integrity.

PDF file - 40K, Computational modeling of in vivo response to therapy.

PDF file - 174K, Description of the processing of bone marrow aspirates, as well as the source code for fitting of cell viability measurements into dose/response surfaces.

MOV file - 1415K, Patient-derived MM cells (patient 14) were seeded in single (top left) and co-culture with patient-derived stroma cells (top right). They were tested for chemosensitivity to melphalan (continuous exposure for 24h, at highest concentration of 25uM, lowest concentration of 5uM). Digital image analysis algorithm detects live cells and pseudo-colors them as green. MM cells in single culture are significantly more sensitive than in co-culture, a phenomenon commonly referred to as environment-mediated drug resistance (EMDR). At 1nM, bortezomib shows no toxicity to these cells after a 24h continuous exposure (bottom left), but in combination with melphalan, it cancels EMDR (bottom right).

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PDF file - 67K, The duration of bortezomib activity post-withdrawal.

PDF file - 50K, Loss of membrane motion precedes loss of innate fluorescence in MM fluorescent cell line.

The NCCN Guidelines for Multiple Myeloma provide recommendations for diagnosis, initial workup, treatment, follow-up, and supportive care for patients with various plasma cell neoplasms, including multiple myeloma. These NCCN Guidelines Insights highlight some of the important updates/changes specific to the treatment of patients with multiple myeloma in the 2022 version of the guidelines.

We present a unique database of tumor samples from 399 multiple myeloma (MM) patients, whose functional genomic landscape was assessed by integrating ex vivo drug sensitivity to 138 drugs, clinical variables, cytogenetics, mutational profiles and transcriptomes. These analyses revealed a novel MM transcriptomic topology that, when associated with ex vivo drug sensitivity, generates “footprints” having both mechanistic and predictive applications. We validated the transcriptomic footprint for the nuclear export inhibitor selinexor in two clinical trials, BOSTON and MCC17814, and showed such a gene signature can accurately classify clinical response and suggest mechanism of resistance. Finally, we propose a novel evolutionary-based therapeutic strategy involving sequential therapy of monoclonal antibody daratumumab and selinexor, based on anti-correlative transcriptomic footprints, which was validated in two clinical trials (STOMP and XPORT-MM-028). Collectively, this database and computational framework can be leveraged to inform underlying biology, and to identify novel therapeutic strategies to improve treatment of MM.

Before 2021, the combination of bortezomib, cyclophosphamide, and dexamethasone (VCd) was one of the most used upfront therapy for systemic immunoglobulin light chain (AL) amyloidosis. Recently, daratumumab in combination with VCd resulted in improved outcomes compared to VCd. However, it's still unclear the role of cyclophosphamide in this combination.We conducted this retrospective single-institutional study to compare the outcomes of upfront bortezomib and dexamethasone with or without cyclophosphamide (VD vs. VCd).Of 136 total patients, 62 received VD and 74 received VCd. The median age was 64 and the median number of organs involved was 2. Hematologic response was achieved among 73.4% patients in the VD arm and 85.9% in the VCd arm at 3 months (P = .15). Best organ response was not different between 2 arms (34.1% vs. 52.9% for VD and VCd arms, respectively; P = .28). After a median follow-up of 24.4 months, 2-year OS for VD and VCd arm was 70.6% and 84.6% respectively. The median overall survival was 70 months for VD arm and not reached for VCd arm (P = .30). There was no statistically significant difference in median time to next therapy (9.3 vs. 13.5 months for VD and VCd arms, respectively. P = .99).the addition of cyclophosphamide to VD was not associated with improved outcomes of patients with AL amyloidosis in this retrospective study.

The spread of multiple myeloma (MM) involves (re)circulation into the peripheral blood and (re)entrance or homing of MM cells into new sites of the BM. Hypoxia in solid tumors was shown to promote metastasis through activation of proteins involved in the epithelial-mesenchymal transition (EMT) process. We hypothesized that MM-associated hypoxic conditions activate EMT-related proteins and promote metastasis of MM cells. In the present study, we have shown that hypoxia activates EMT-related machinery in MM cells, decreases the expression of E-cadherin, and, consequently, decreases the adhesion of MM cells to the BM and enhances egress of MM cells to the circulation. In parallel, hypoxia increased the expression of CXCR4, consequently increasing the migration and homing of circulating MM cells to new BM niches. Further studies to manipulate hypoxia to regulate tumor dissemination as a therapeutic strategy are warranted.

Introduction This study aimed to determine the safety and activity of plerixafor (CXCR4 inhibitor) in combination with bortezomib as a chemosensitization strategy in multiple myeloma (MM). The phase I portion of this study was to determine the maximum tolerated dose (MTD). The phase II portion was designed to assess the toxicity profile and the proportion of overall confirmed response (CR + PR). This was based on preclinical studies demonstrating that plerixafor (Mozobil, Sanofi Corporation, MA) induces de-adhesion of MM cells and sensitization to bortezomib in preclinical animal models. Methods Eligibility criteria included: 1) patients with relapsed or relapsed/refractory MM with 1–5 prior lines of therapy including bortezomib (unless patients were refractory to bortezomib), 2) measurable disease, 3) not receiving chemotherapy > 3 weeks, or biological therapy for MM > 2 weeks prior to study treatment. Phase I included eight cohorts with different doses and two treatment schedules. In cohorts 1–5, patients received plerixafor at the recommended dose subcutaneously (sq) on days 1–6 of each cycle and bortezomib at the recommended dose twice a week on days 3, 6, 10, and 13 every 21 days. Cohort 5b–7 plerixafor was given at the recommended dose sq on days 1, 3, 6, 10, and 13 and bortezomib was given at the recommended dose twice a week on days 3, 6, 10, and 13 every 21 days. For the phase II portion patients received plerixafor at the MTD, 320 mcg/kg sq on days 1, 2, 3, 6, 10, and 13. Bortezomib was given 1.3 mg/m2 sq twice a week on days 3, 6, 10, 13, every 21 days. Dexamethasone was given at 40mg on days of Bortezomib. Patients in both cohorts were assessed after every cycle by IMWG criteria. Patients who had a response or stable disease went on to receive a total of 8 cycles with maintenance therapy for patients with at least a minimal response (MR). Peripheral blood samples were obtained from the patients in the phase I portion of trial at 0, 1, 2, 3, 4 and 24 hours post-dose on days 1 and 3, and time points 0, 2, and 4 hours post-dose on days 6, 10 and 13 of cycle 1. Results Twenty-five patients were enrolled in the phase I portion of trial from June 2009 to May 2011. Median age was 60 years (range, 44–85) and median lines of prior therapy were 2 (range, 1–4) with all but 3 patients receiving prior bortezomib. The median number of cycles on therapy was 3 (1–11). Dose limiting toxicities including insomnia, restlessness, and psychosis were observed in two patients at dose level 6 (plerixafor 0.40 mg/kg and bortezomib 1.3 mg/m2). To further explore the safety of maximum tolerated dose, three additional patients were enrolled at dose level 5b (plerixafor 0.32 mg/kg and bortezomib 1.3 mg/m2). There were no grade 4 toxicities. Grade 3 toxicities included lymphopenia (40%), hypophosphatemia (20%), anemia (10%), hyponatremia (10%), hypercalcemia (10%), and bone fracture due to myeloma bone disease (10%). In the phase II portion, eleven patients have been treated to date. The median age is 65 (56-80), the median lines of prior therapy were 2 (1-4). The median number of cycles on therapy was 4 (1-8). Grade 4 toxicities include lymphopenia (10%) and thrombocytopenia (20%). Grade 3 toxicities include anemia (10%), thrombocytopenia (10%), lymphopenia (20%), hyperglycemia (10%), and hypophosphatemia (10%). Ten patients are evaluable for response, including 1(10%) very good partial response (VGPR) and 3 (30%) partial response (PR), with an overall response rate (VGPR + PR) of 4 (40%) in this relapsed/refractory population. In addition, 4 (40%) patients had stable disease (SD), and 2 (20%) had progressive disease (PD). We also examined in vivo mobilization of plasma cells, CD34+ hematopoietic stem cells and other accessory bone marrow cells. Analysis of these samples showed rapid mobilization of plasma cells at 2 hours post-plerixafor with a rapid return to normal levels at 4 and 24 hours post plerixafor. Similar results were observed on days 1 and 3. Conclusions The combination of plerixafor and bortezomib was generally well tolerated in this study, with minimal neuropathy or other toxicities seen to date. The responses observed are encouraging with 40% PR or better in this relapsed and refractory population including prior bortezomib therapy. This study was supported by R01CA133799-01, and by Sanofi and Millennium/Takeda Corporations. Disclosures: Ghobrial: Onyx: Membership on an entity’s Board of Directors or advisory committees; BMS: Membership on an entity’s Board of Directors or advisory committees; BMS: Research Funding; Sanofi: Research Funding; Novartis: Membership on an entity’s Board of Directors or advisory committees. Munshi:Celgene: Consultancy; Novartis: Consultancy; Millennium: Consultancy. Anderson:celgene: Consultancy; onyx: Consultancy; gilead: Consultancy; sanofi aventis: Consultancy; oncopep: Equity Ownership; acetylon: Equity Ownership. Richardson:Millenium: Consultancy; Celgene: Consultancy; Johnson & Johnson: Consultancy; Bristol-Myers Squibb: Consultancy; Novartis: Consultancy.

Multiple myeloma remains an incurable bone marrow resident malignancy due to the eventual development of drug resistance and minimal residual disease linked to both acquired genetic changes and the dynamic influences of the microenvironment. We and others have shown that adhesion of tumor cells to the extracellular matrix component fibronectin (FN) via integrins leads to cell cycle arrest and protection from chemotherapy or Cell Adhesion-Mediated Drug Resistance (CAM-DR). The pleiotropic cytokine IL-6 has also been shown to mediate drug resistance in both solid and hematopoietic tumors [1]. The influence of these two effectors on drug resistance has primarily been studied separately; however, within the context of the bone marrow, myeloma cells are influenced by both soluble and physical effectors simultaneously. Using a reductionist model of the multivariate microenvironment, we demonstrated that unique collaborative signaling between FN-adhered cells and IL-6 leads to increased proliferation of protected tumor cells and a more malignant phenotype [2]. Our results demonstrate the FN-adhesion mediated cell-cycle arrest of myeloma cells was reversed following stimulation of adhered cells with IL-6 and drug resistance was maintained. This phenotype was associated with a novel amplification of IL-6-induced STAT3 activation in adhered cells [2]. We have since validated the FN-adhesion-dependent amplification of IL-6-induced STAT3 phosphorylation in myeloma patient specimens by flow cytometry. To further characterize post-translational events induced by beta1 integrin mediated adhesion and under multivariate conditions, we performed immune-affinity phosphotyrosine proteomic screening in RMPI8226 myeloma cells maintained in suspension or adhered to FN with or without IL-6 stimulation. Screening identified 179 differentially tyrosine phosphorylated peptides among four conditions (Suspension or FN, +/- IL-6). Among these were proteins involved in signal transduction, cytoskeleton assembly, survival, and metabolic pathways. Among 67 peptides upregulated by adhesion to FN alone, proline-rich tYrosine Kinase 2 (PYK2/FAK2) was highly phosphorylated at Y580 in RPMI8226 myeloma cells, and focal adhesion formation in adhered cells was validated by phosphorylation of paxillin at pY118 and p130CAS at pY128/pY249. PYK2 is a downstream intermediate of integrin signaling and has been demonstrated to amplify EGFR and cSrc-induced STAT3 activation [3]. PYK2 has also been linked to downstream signaling events of JAK-dependent cytokine receptors, but not to a STAT3 amplification mechanism within the Type I or Type II cytokine receptor families [4-7]. As such, we hypothesized that PYK2 may be an important modulator of the enhanced STAT3 activation following multivariate signaling between beta1 integrin and the IL-6 signal transducer, gp130. In addition to enhanced phosphorylation of PYK2 at Y580 identified by proteomic screening, western blot analysis demonstrated PYK2 autophosphorylation of Y402 following myeloma cell adhesion to FN correlating with the amplification of IL-6-induced STAT3 and JAK1. Targeting PYK2 with RNA interference attenuated the adhesion-associated amplification of STAT3 and JAK1 phosphorylation, but did not influence the limited STAT3 activation in cells grown in suspension. PYK2 siRNA did not inhibit myeloma cell adhesion (n=4, p-value >0.05). We have also demonstrated that STAT3 activation is markedly enhanced in myeloma cell lines adhered to patient bone marrow stroma (BMS), but not cells grown in transwell coculture (no myeloma cell-BMS contact). The protective advantage afforded myeloma cells in coculture was attenuated knockdown of PYK2 or STAT3 expression in myeloma cell lines and patient specimens using novel antisense oligonucleotides (ISIS Pharmaceuticals, n=4, p-value < 0.05). Critically, inhibition of PYK2 with nanomolar amounts of the focal adhesion kinase inhibitor PF562.271 had a similar impact only on myeloma cells directly adhered to BMS, but did not impact BMS viability. These data demonstrate a novel PYK2-mediated JAK1/STAT3 signaling cascade within the context of multivariate stimulation. Moreover these data identify a novel PYK2-mediated survival pathway activated only within the context of multivariate stimulation in the bone marrow microenvironment, and suggests that PYK2 represents a MRD-specific target. Disclosures: No relevant conflicts of interest to declare.

Abstract 4021 Multiple myeloma remains an incurable bone marrow resident malignancy, in part, due to the eventual development of drug resistance linked to both acquired genetic changes and the dynamic influences of the microenvironment. We and others have shown that adhesion of tumor cells to the extracellular matrix component fibronectin (FN) via integrins leads to cell cycle arrest and protection from chemotherapy or Cell Adhesion-Mediated Drug Resistance (CAM-DR). The pleiotropic cytokine IL-6 has also been shown to mediate drug resistance in both solid and hematopoietic tumors [1]. The influence of these two effectors on drug resistance has primarily been studied separately; however, within the context of the bone marrow myeloma cells are influenced by both soluble and physical effectors simultaneously. Using a reductionist model of the multivariant microenvironment, we demonstrated that unique collaborative signaling between FN-adhered cells and IL-6 leads to increased proliferation of protected tumor cells and a more malignant phenotype [2]. Our results demonstrate the FN-adhesion mediated cell-cycle arrest of myeloma cells was reversed following stimulation of adhered cells with IL-6 and drug resistance was maintained. This phenotype was associated with a novel amplification of IL-6-induced STAT3 activation in adhered cells [2]. We have since validated the FN-adhesion-dependent amplification of IL-6-induced STAT3 phosphorylation in myeloma patient specimens by flow cytometry. To further characterize post-translational events induced under multivariant conditions, we performed immune-affinity phosphotyrosine proteomic screening in RMPI8226 myeloma cells maintained in suspension or adhered to FN with or without IL-6 stimulation. Screening identified 338 differentially tyrosine phosphorylated peptides. Among these were proteins involved in signal transduction, cytoskeleton assembly, survival, and metabolic pathways. Proline-rich tYrosine Kinase 2 (Pyk2/FAK2) was highly phosphorylated at Y597 in FN-adhered RPMI8226 myeloma cells. Eighty-three phosphorylation events were up-regulated by adhesion, including paxillin at pY118 and p130CAS at pY249 indicating focal adhesion formation. Pyk2 is a downstream intermediate of integrin signaling and has been demonstrated to amplify EGFR and cSrc-induced STAT3 activation. As such, we hypothesized that Pyk2 may be an important modulator of the enhanced STAT3 activation following multivariant signaling between beta1 integrins and gp130 [3]. In addition to enhanced phosphorylation of Pyk2 at Y579 identified by proteomic screening, western blot analysis demonstrated Pyk2 autophosphorylation of Y402 following myeloma cell adhesion to FN correlating with the amplification of IL-6-induced STAT3 and JAK1. Targeting Pyk2 with RNA interference attenuated the adhesion-associated amplification of STAT3 and JAK1 phosphorylation, but did not influence the limited STAT3 activation in cells grown in suspension. Pyk2 siRNA did not inhibit myeloma cell adhesion (n=4, p-value >0.05). Our previous results demonstrated that that the enhanced STAT3 signaling involved a FN-adhesion specific binding of unphosphorylated STAT3 with gp130 (independent of IL-6 stimulation). To determine if Pyk2 was similarly recruited to gp130 under co-stimulatory conditions we have used proximal ligation assay (PLA). Confocal imaging of the PLA reaction with antisera to Pyk2 and gp130 demonstrated colocalization of the two effectors upon adhesion of patient myeloma cells to FN, but not in those grown in suspension. We have also demonstrated that STAT3 activation is markedly enhanced in myeloma cell lines adhered to patient bone marrow stroma (BMS), but not cells grown in transwell coculture (no myeloma cell-BMS contact). Critically, the protective advantage afforded myeloma cells in coculture was attenuated only by dual knockdown of STAT3 and Pyk2 using novel antisense oligonucleotides (ISIS Pharmaceuticals, n=4, p-value 0.027). These data demonstrate a novel Pyk2-mediated JAK1/STAT3 signaling cascade within the context of multivariant stimulation. Moreover, these data suggest that strategies targeting of both lateral and vertical signaling (Pyk2 & STAT3) may be required to overcome therapy resistance conferred to tumor cells by the multivariant bone marrow niche. Disclosures: No relevant conflicts of interest to declare.