update on plasma cell myeloma
TRANSCRIPT
Update On Plasma Cell Myeloma
Chung-Che (Jeff) Chang, M.D., PhD.
Medical Director
Hematopathology and Molecular Pathology
Florida Hospital
Professor of Pathology
University of Central Florida, School of Medicine
Overview
• Brief review of plasma cell myeloma
• Minimal residual disease
• Myeloma stem cells and cancer testis
antigens
Monoclonal Gammopathy of
Undetermined Significance (MGUS)• Incidental (asymptomatic) finding
• M-protein: < 3 g/dL
• < 10% clonal plasma cells in bone marrow
• No myeloma-related organ/tissue impairment
(no CRAB: hypercalcemia (Ca >11 mg/dL) ,
renal insufficiency (creatinine >2 mg/dL),
anemia (<10g/dL), bone lesions)
• No evidence of other B-cell lymphoproliferative disorders
• Seen in 3% of persons > 50 y.o.; 5% of persons > 70 y.o.
• 1% per year risk of progression to overt
PCM, amyloidosis (in non-IgM MGUS), WM
or other LPD (in IgM MGUS)
• Low-risk MGUS: M protein <1.5 g/dL, IgG
type and a normal free light chain ratio.
Clinical Course of MGUS
Leukemia. 2010;24:1121-7
Rajkumar, Lancet Oncol2014;15:e538-48
Pathogenesis of PCM
• NEJM review article picture
NEJM 2011;364:p1046
Myeloma Cancer Genome
• Massively parallel sequencing of 38 myeloma
genomes.
• Unexpected pattern of somatic mutation of
genes involved in protein translation, histone
methylation, and blood coagulation.
• Mutations in 11 members of the NF-κB
pathway.
• Activating mutations of BRAF observed in 4%
of patients.Nature 2011; 471: p467
Plasmablastic
Pleomorphic
(anaplastic)
Immunophenotyping by FCM/IHC
• Normal/neoplastic PC: CD138+, MUM1+,
CD38+++
Hematologic
2008;93:431
Pitfall: Amount of PC under-represented in FCM
% of abnormal PC per total PC is more important
than the % of PC per total cells by flow cytometry
Blood 2007;110:2586
Amounts of plasma cells in aspirate can be under-
representative compared to core biopsy: CD138 IHC
Differential Diagnosis
• Mature plasma cell morphology:
LPL (lymphoplasmacytic lymphoma); MZL
with PC differentiation; CLL with PC
differentiation
• Plasmablastic morphology:
PL (plasmablastic lymphoma); PEL (primary
effusion lymphoma); DLBCL-CI (chronic
inflammation); ALK+ DLBCL
Plasmablastic Lymphoma
• Prototype: HIV, oral cavity
• Immunophenotypically identical to myeloma
CD20-, CD138+, PAX5-, CD56+
(Vega, Chang et al, Mod Pathol 2005)
Mod Pathol,
2005;18:806
PL Extramedullary
plasmablastic
PCM
Ki-67/
MIB1
Plasmablastic
PCM
PL
• Without clinical information, differentiation
of PL and extramedullary plasmablastic
myeloma is very difficult, if not possible,
based on morphology and/or IHC
• Clinically very important: treatment and
prognosis of myeloma and lymphoma (PL
classified as a variant of lymphoma and
treated as such) are very different
• How about the relationship between
DLBCL, PL and PCM at genomic level?
Array-based Comparative Genomic Hybridization
to Investigate the PCM, DLBCL and PL Genome
10.78520.62660.228AIDS-DLBCL
0.785210.63530.1507DLBCL
0.62660.635310.1034PL
0.2280.15070.10341PCM
AIDS -DLBCLDLBCLPLPCM
10.78520.62660.228AIDS-DLBCL
0.785210.63530.1507DLBCL
0.62660.635310.1034PL
0.2280.15070.10341PCM
AIDS -DLBCLDLBCLPLPCM
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
1718
1920
2122
Chromo -
somePCM PL DLBCL AIDS -
DLBCL
0.0
0.2
- 0.4
- 0.2
0.4
0.6
0.8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
1718
1920
2122
Chromo -
somePCM PL DLBCL AIDS -
DLBCL
0.2
0.4
0.6
0.8
Chang,
J Hematol
Oncol,
2009;2:47
• At genomic level, PL is more closed to
DLBCL or DLBCL occurring in HIV+
patients than to PCM.
• Based on the genomic profiling results,
a panel of FISH probes or IHC markers
may be selected to differentiate PL from
PCM.
• Unfavorable risk:
Gain(1q), del(1p32), t(4;14) FGFR3/MMSET,
t(14;20) MAFB, t(14;16) c-MAF, or del(17p)
• Favorable risk:
Hyperdiploidy, t(11;14) or t(6;14)
Prognosis: FISH
Minimal Residual Disease and
Myeloma Stem (Initiating) Cells
• Many myeloma patients treated with new novel agents with/without stem cell transplant experience a complete clinical response, but the majority eventually relapse.
• The clinical course suggests:
– 1. Minimal residual diseases (MRD) and/or
– 2. the presence of a small population of myeloma cancer stem (initiating) cells that are resistant to therapy and capable of self-renewal and replenish the bulk of mature myeloma cells.
MRD by Flow Cytometry:CD138, CD45, CD38, CD56,
CD27, CD19 at 100 days post PSCT and/or end of induction
MRD+: > 50 aberrant PC/500K events (0.01%)JCO 2013;31:2540-2547
Adverse FISH : gain(1q), del(1p32), t(4;14), t(14;20), t(14;16),
and del(17p)
Favorable FISH: hyperdiploidy, t(11;14), and t(6;14)
T: thalidomide (50 to 100 mg daily)
NM: No maintainance
Faham M et al.
Blood 2012;120:5173-5180
MRD by
Next
Generation
Sequencing
Martinez-Lopez J et al. Blood 2014;123:3073-3079
Myeloma Stem Cells
“Incidental finding”-Myeloma stem (Initiating) cells
Chang et al., Mod Pathol, 2001
Side population (SP)-a surrogate
functional marker for stem cells
• Cells that have high expression of ATP-binding
cassette (ABC) transporter proteins have low
retention of Hoechst 33342 dye and form a
distinct side population (SP) on flow cytometry.
• These cells were originally detected in murine
marrow, where this phenotype identifies
hematopoietic stem cells undergoing
– asymmetric division
– Producing differentiated progeny
Figure 1. Side Population in Myeloma Sample A. from cell line RPMI 8226B. A representative patient sample . C. The SP is negative for CD 138, within
the NSP are CD 138+ cells. D. IGH rearrangement study shows that the size of the highest peak is identical in SP and the CD 138+ NSP cells suggesting
the same clonal origin of both populations on capillary electrophoresis (blue). Markers in red .
Ho
ech
st R
ed
Hoechst Blue
SP
NSP
NSPSP
SP NSP CD138+
Myeloma PatientRPMI 8226
CD
13
8-P
E
A B
C
D
Probability of remission in patients after
autologous SCT with amounts of myeloma stem
cells >1.5% or <1.5% in SC harvests
Conway and Chang, Arch Pathol, 2009
Cancer stem cell model-
considering microenvironment
Rosen, Science, 2009
Morphology of bone marrow
stromal cells (BMSC) in culture
A
B
Myeloma
stem cells on
Myeloma
BMSC
Myeloma
stem cells
on Normal
BMSC
Myeloma stem cells forming larger colonies on
myeloma bone marrow stromal cells (BMSC)
Feng and Chang, Stem Cell and Dev, 2010;19:1289
Bio
lum
inescence (
x10
6
p/s
ec/c
m2/sr)
* **
*
*
P=0.0038 P=0.0029
P=0.027
P=0.0036
P=0.011
SP cells inoculated through tibia with myeloma BMSC
grew faster than control BMSC in NOD/SCID mice
Mayo Clinic MM Expression Array ( 22K)
129 CTA Genes
MM-CTA
Signature
MM CTA High
Throughput Assay
91 NMM
Vs.
14 Normal
23 SMM
Vs.
14 Normal
26 RMM
Vs.
14 Normal
Br J Haematol. 2014;166:711
Cancer Testis Antigen (CTA)
AKAP4
ANKR
D45
AURKA
C4A
CFLA
R
CST3
DDX43
ELOVL4
FANCI
HIS
T1H2B
G
LUZP4
MAG
EA12
MAG
EA3
MAG
EB2
MAG
EB3
PRAM
E
RRM
2
SSX2
TEX14
0
2
4
6
8N
orm
aliz
ed
ge
ne
s e
xp
ressio
n le
ve
l
in p
rim
ary
MM
bo
ne
ma
rrow
Primary MM MPC
Primary MM SP
Conclusion
• The long term cure of myeloma likely
relies on eliminating MRD and /or
myeloma stem cells.
• This may be achieved by 1) targeting
myeloma BMSCs and 2) novel
immunotherapy specifically against
myeloma stem cells, such as CTA.
AcknowledgementChang’s Lab
Albert Mo, BS
Joe Conway, MD
Wan-Ting Huang, MD
Jianguo Wen, PhD
Yongdong Feng, MD, PhD
David Choi, PhD
Collaborators
Lawrence Rice, MD
Kyriacos A. Athanasiou, PhD
Helen Heslop, MD
Jessica Shafer, MD
Funding Agency
NIH/NCI