Multiple myeloma

Multiple myeloma in detail

1. MULTIPLE MYELOMA Dr. Ayush Garg

2. Multiple Myeloma Introduction Epidemiology Etiology Pathophysiology Clinical features Diagnostic Work Up Classification and staging Prognostic Factors Treatment Follow Up

3. Sarah Newbury, the first reported patient with Multiple M yeloma . Bone destruction in the sternum. The patient with fractured femurs and right humerus . Bone destruction involving the femur.

4. Timeline depicting the history of Multiple Myeloma The term Multiple Myeloma was coined by Rustizky .

5. Introduction Multiple myeloma (MM) is characterized by the neoplastic proliferation of a single clone of plasma cells producing a monoclonal immunoglobulin. The Spectrum of Myeloma-

6. Epidemiology The incidence rises with advancing age, with a median age at diagnosis of 70 years , and <1% of cases are diagnosed in those younger than 35 . Incidence : 0.7M/0.5 F per 100,000 population. 1/10 as common as Leukemias

7. Etiology Radiation : Association with prior exposure to radiation (e.g., atomic bomb survivors in Hiroshima ). Environmental or occupational causes : Farmers (DDT exposure) Wood workers Leather workers Sheet metal workers Nuclear industry workers Exposure to petroleum products

8. Genetic causes: Chromosomal alterations identified: Recurrent Chromosomal Aberrations Chromosome Frequency % Patients Gene(s) Function 11q13 30 Cyclin D1 Induces growth 4p16 25 FGFR3, MMSET Growth factor 8q24 5 C- myc Growth/ apoptosis 16q23 1 C- maf Transcription factor 6p25 <1 IRF4 transcription factor Differentiation and growth 9p13 1 PAX-5 Transcription factor 20q12 1 MAFB Transcription factor 18q21 1 Bcl-2 Antiapoptosis Structural Chromosomal Aberrations Del 17p13 15 P53 Del 13 40-55 ? Hypodiploidy 20-30 - Hyperdiploidy 45-50 -

9. Pathophysiology Multiple myeloma arises from malignant transformation of a late-state B cell . Cytogenetic hyperploidy and up-regulation of cell cycle control genes. Mutations of kinases, deletions of chromosomes, and up-regulation of enzymes such as c- myc The malignant plasma cells proliferate in the bone marrow Producing monoclonal proteins and causing osteolytic bone disease. Cytokines IL-6 and ILGF-1 Rank ligand/ osteprotegrin and the WNT signaling antagonist Dickkopf1

10. Clinical Features

11. Monoclonal Gammopathy of Unknown Significance MGUS is a benign or a premalignant condition. In MGUS, the monoclonal protein is <3 g/ dL and the bone marrow clonal plasma cells are <10 %. The risk of transformation to Myeloma and related diseases (such as amyloidosis or Waldenstrom’s macroglobulinemia ) has been estimated at 1% per year.

12. Asymptomatic Multiple Myeloma ( Smoldering Myeloma) The risk of transformation to Multiple Myeloma is much higher than in MGUS (20% per year ). These patients generally do not require therapy but should be followed closely to monitor for progression.

13. Solitary Plasmacytomas The median age at diagnosis of solitary plasmacytoma (SP) is 55 to 65 years. Male-to-female ratio 2:1. A histologically confirmed single lesion with negative skeletal imaging outside the primary site, normal bone marrow biopsy (<10% monoclonal plasma cells), and no myeloma-related organ dysfunction. The disease more commonly presents in bone (80%). Such cases are considered stage I multiple myeloma according to the Durie Salmon staging system . The most common location is the vertebra . Patients with bone involvement present with pain, neurologic compromise, and occasionally pathologic fracture.

14. Multiple Myeloma Common tetrad of multiple myeloma is CRAB C = HyperCalcemia (Calcium) R = Renal failure A = Anemia B = Bone disease Osteopenia Multiple Lytic Bone Lesions

15. Myeloma bone disease -- >proliferation of tumor cells and release of IL-6 <osteoclast activating factor :OAF>-- >stimulates osteoclasts to break down bone-- > leading to hypercalcemia . These bone lesions in plain radiographs-- > "punched-out" / lytic bone lesion Bone pain Myeloma bone pain -- > Involves the rib, sternum , spine, clavicle, skull, humerus & femur. The lumbar vertebrae are one of the most common sites of pain -- > may lead to spinal cord compression . Persistent localized pain may indicate pathological fracture .

16. Skeletal Complications ~ 80% of patients with multiple myeloma will have evidence of skeletal involvement on skeletal survey Vertebrae: 65% Ribs: 45% Skull: 40% Shoulders: 40% Pelvis: 30% Long bones: 25%

17. Plasma Cell Leukemia This is a very rare variant of multiple myeloma, where the proliferation of plasma cells is not confined to the bone marrow but may be detected in the peripheral blood. It carries a very poor prognosis, with median survival <1 year.

18. Diagnostic Work UP

19. Diagnosis Serum protein electrophoresis is used to determine the type of each protein present and may indicate a characteristic curve ( ie , where the spike is observed ). The M protein should be measured with serum protein electrophoresis. If no M protein is detectable, assays for free light chains should be performed in the serum and in the urine ( Bence -Jones proteinuria). Urine protein electrophoresis is used to identify the presence of the Bence Jones protein in urine. Immunofixation is used to identify the subtype of protein ( ie , IgA lambda).

20. Imaging Studies Skeletal series Skull (a very common site ), the long bones ( for impending fractures), and the spine. Diffuse osteopenia may suggest myelomatous involvement before discrete lytic lesions are apparent. Do not use bone scans to evaluate myeloma MRI scan MRI to obtain a clear view of the spinal column and to assess the integrity of the spinal cord.

21. Skeletal Survey

22. PET-CT Scan

23. Major Criteria and 1 Minor Criteria Diagnostic :   0 Major Criteria and 3 Minor Criteria   Major Diagnostic Criteria Plasmacytoma on tissue biopsy Bone marrow plasmacytosis of > 30% M Protein: IgG > 3.5 g/L; IgA > 2.0 g/L Urinary kappa or lambda chain excretion of > 1g / 24 hours in absence of amyloidosis Minor Diagnostic Criteria Marrow plasmacytosis of 10-30% Lytic bone lesions Evidence of a monoclonal protein but lessor amounts than above Hypoglobulinemia of normal proteins: IgM < 500 mg/L, IgA < 1 g/L or IgG < 6g/L Diagnostic Criteria : Confirmation of 1 major and 1 minor criterion or 3 minor criteria in symptomatic patients Major Diagnostic Criteria Minor Diagnostic Criteria

24. Staging

25. Prognostic Factors Performance status 3 or 4 Serum albumin < 3 g/dl Serum Cr ≥ 2.0 mg/dl Platelet count <150,000 Age ≥ 70 years Beta-2-Microglobulin >4 mg/L Serum Calcium ≥ 11 mg/dl Haemoglobin <10 g/dl Bone marrow plasma cell percentage ≥50% Deletion of chromosome 13 Presence of the t(4;14) translocation P53 deletion.

26. MM Treatment Options Conventional chemotherapy: Melphalan Doxorubicin Cyclophosphamide Radiation therapy Stem cell transplantation: Autologous Allogenic Novel therapeutics: Thalidomide Lenalidomide Bortezomib Steroid therapy: Dexamethasone Prednisolone

27. The changes in the treatment of M ultiple M yeloma Melphalan From 1980s Myeloablation + ASCT 2000s Tandem ASCT 1999 First report on thalidomide 1962 Prednisone + melphalan Bortezomib US licence 2003, EU licence 2004 1990s Supportive care March/April 2005 Bortezomib approved for second-line in USA & Europe 2006 Lenalidomide + Dexa improved OS in relapsed Myeloma

28. Bortezomib /cyclophosphamide/dexamethasone This combination may be used in any of the following regimens: Bortezomib 1.3 mg/m 2 IVP on days 1, 4, 8, and 11 plus cyclophosphamide 300 mg/m 2 /day PO on days 1 , 8, 15, and 22 plus dexamethasone 40 mg PO daily on days 1-4, 9-12, and 17-20; 28-d cycle for 3 or 4 cycles. Bortezomib 1.3 mg/m 2 IVP on days 1, 4, 8, and 11 plus cyclophosphamide 500 mg/m 2 /day PO on days 1 , 8, and 15 plus dexamethasone 40 mg PO daily on days 1, 8, and 15; 21-d cycle for 3 or 4 cycles Bortezomib 1.3 mg/m 2 IVP on days 1, 4, 8, and 11 plus cyclophosphamide 900 mg/m 2 IV over 1 h on day 1 plus dexamethasone 40 mg PO daily on days 1 2, 4, 5, 8, 9, 11, and 12; 21-d cycle for 3 or 4 cycles

29. Bortezomib /dexamethasone Bortezomib 1.3 mg/m 2 IVP on days 1, 4, 8, and 11 plus dexamethasone 40 mg PO on days 1-4 and days 9-12 (cycles 1 and 2), then 40 mg PO on days 1-4 (cycles 3 and 4); 21-d cycle for 3 or 4 cycles Either of the following two regimens may be used: Bortezomib 1.3 mg/m 2 IVP on days 1, 4, 8, and 11 plus doxorubicin 9 mg/m 2 IV push on days 1-4 plus dexamethasone 40 mg PO daily on days 1-4, 8-11, and 15-18 (cycle 1), then days 1-4 (cycles two-four); 21-d cycle for 3 or 4 cycles Bortezomib 1.3 mg/m 2 IVP on days 1, 4, 8, and 11 plus doxorubicin 9 mg/m 2 continuous IV infusion over 24 h daily on days 1-4 plus dexamethasone 40 mg PO daily on days 1-4, 9-12, and 17-10; 28-d cycle for 3 or 4 cycles

30. Bortezomib / lenalidomide /dexamethasone Bortezomib 1.3 mg/m 2 IVP on days 1, 4, 8, and 11 plus lenalidomide 25 mg PO daily on days 1-14 plus dexamethasone 20 mg PO daily on days 1, 2, 4, 5, 8, 9, 11, and 12 or 40 mg PO daily on days 1, 8, and 15; 21d cycle for 3 or 4 cycles Bortezomib /thalidomide/dexamethasone Bortezomib 1-1.3 mg/m 2 IVP on days 1, 4, 8, and 11 plus thalidomide 50-200 mg (titrate to tolerance) PO daily at bedtime on days 1-21 plus dexamethasone 40 mg PO daily on days 1, 2, 4, 5, 8, 9, 11, and 12 or 40 mg on days 1-4 and 9-12 or 40 mg on days 1-4 and 8-11; 21d cycle for 3 or 4 cycles

31. Lenalidomide /dexamethasone Either of the following two regimens may be used: Lenalidomide 25 mg PO daily on days 1-21 plus dexamethasone 40 mg PO daily on days 1, 8, 15, and 22 or 40 mg PO daily on days 1-4, 9-12, and 17-20; 28-d cycle for 3 or 4 cycles Lenalidomide 25 mg PO daily on days 1-28 plus dexamethasone 40 mg PO daily on days 1-4, 9-12, and 17-20 ; 28-d cycle for 3 or 4 cycles

32. Alternative regimens Any of the following four regimens may be used: Dexamethasone 40 mg/day for 4 d beginning on days 1, 9, and 17 for the first two cycles and 40 mg/day for 4 d beginning on day 1 for the next 10 cycles; every 6 wk for 12 cycles Pegylated liposomal doxorubicin 40 mg/m 2 plus vincristine 1.4 mg/m 2 (maximum, 2.0 mg) as an IV infusion on day 1 plus reduced-dose dexamethasone 40 mg PO on days 1-4 Lenalidomide 25 mg PO on days 1-21 plus dexamethasone 40 mg daily on days 1-4, 9-12, and 17-20; every 28 d Thalidomide 200 mg PO daily plus dexamethasone 40 mg PO on days 1-4 and 15-18 on even cycles and on days 1-4 on odd cycles; every 28 d

33. Non Transplant Candidates Bortezomib 1-1.3 mg/m 2 on days 1, 4, 8, 11, 22, 25, 29, and 32, followed by a 10-d rest period plus Melphalan 9 mg/m 2 PO plus prednisolone 60 mg/m 2 PO, both on days 1-4; every 6 wk for four cycles then a maintenance phase consisting of bortezomib 1-1.3 mg/m 2 on days 1, 8, 22, and 29, followed by a 13-d rest period plus Melphalan 9 mg/m 2 PO plus prednisolone PO 60 mg/m 2 ; every 5 wk for five cycles Melphalan 0.25 mg/kg PO plus prednisolone 2 mg/kg plus thalidomide 200 mg PO daily (escalating to 400 mg as tolerated) on days 1-4; every 6 wk Lenalidomide 25 mg PO on days 1-21 plus dexamethasone 40 mg PO daily on days 1-4, 9-12, and 17-20; every 28 d Bortezomib 1.3 mg/m 2 IV on days 1, 4, 8, and 11 every 3 wk plus dexamethasone 20 mg on the day of and the day after bortezomib Twelve 6-wk cycles of chemotherapy, including melphalan 0.25 mg/kg PO plus prednisolone 2 mg/kg PO for 4 d Lenalidomide 10 mg PO on days 1-21 plus melphalan 0.18 mg/kg PO on days 1-4 plus dexamethasone 40 mg PO weekly; every 28 d

34. Alternative treatment recommendations One of the following may be used: Pegylated liposomal doxorubicin 40 mg/m 2 plus vincristine 1.4 mg/m 2 (maximum, 2.0 mg) as an IV infusion on day 1 plus reduced-dose dexamethasone 40 mg PO on days 1-4 Vincristine 0.4 mg/day plus doxorubicin 9 mg/m 2 /day by continuous infusion on days 1-4 plus dexamethasone 40 mg/day on days 1-4, 9-12, and 17-20 (odd cycles) and 40 mg/day for 4 d on even cycles ; every month Thalidomide may be added to standard regimens in patients with myeloma who are not transplant candidates ; a meta-analysis of trials demonstrated improved survival with this approach

35. Treatment recommendations for maintenance therapy Lenalidomide 10 mg/day on days 1-21 every 28d or Thalidomide 50 mg/day to start, escalated to 200 mg/day, titrated to tolerance

36. Salvage therapy regimens Panobinostat  20 mg PO once every other day for three doses/week (on days 1, 3, 5, 8, 10, and 12) of weeks 1 and 2 of each 21-day cycle for eight cycles   plus  bortezomib and dexamethasone; consider continuing treatment for an additional eight cycles for patients with clinical benefit . Lenalidomide 25 mg/day PO on days 1-21  plus  dexamethasone 40 mg/day PO on days 1-4, 9-12, and 17-20 of each 28-d cycle for the first four cycles of therapy and then 40 mg/day PO on days 1-4 thereafter, every 28 d, who have received at least one prior treatment Pomalidomide  is a thalidomide analogue indicated for patients who have received at least two prior therapies (including lenalidomide and bortezomib ) and have disease progression on or within 60 days of completion of the last therapy  ; Dosage is 4 mg PO QD on days 1-21 of repeated 28-day cycles until disease progression; may be given in combination with dexamethasone

37. Carfilzomib   : A proteasome inhibitor, is indicated as monotherapy, in combination with dexamethasone, or in combination with lenalidomide plus dexamethasone for relapsed or refractory multiple myeloma in patients who have received at least 1 prior line of therapy Lenalidomide or thalidomide can be used as single agents in salvage therapy Daratumumab is an anti-CD38 monoclonal antibody for patients who have received at least three prior treatments, including a proteasome inhibitor (PI) and an immunomodulatory agent ( IMiD ), or whose disease is refractory to both a PI and an IMiD ; dosage is 16 mg/kg IV infusion once weekly (weeks 1 to 8); reduce frequency to q2 wk (weeks 9-24) and ultimately q4 wk (week 24 and thereafter) until disease progression

38. Ixazomib  is a reversible proteasome inhibitor indicated in combination with lenalidomide and dexamethasone for patients who have received at least 1 prior therapy; starting dose is 4 mg PO on days 1, 8, and 15 of a 28-day cycle until disease progression  [41] Elotuzumab  is a humanized IgG1 monoclonal antibody targeting SLAMF7 indicated in combination with lenalidomide and dexamethasone for patients who have received 1-3 prior therapies; the dose is 10 mg/kg IV weekly for the first two 28-day cycles, and then 10 mg/kg IV q2wk (on days 1 and 15) Bisphosphonates The second- and third-generation bisphosphonates, pamidronate and zoledronate , reduce skeletal complications and bone pain.

39. Renal I mpairment In patients with renal impairment, the combination of bortezomib and highdose dexamethasone is the preferred therapy Autologous transplantation should be reserved for younger patients with chemosensitive disease. Because of the common occurrence of renal involvement in myeloma, the use of nephrotoxic agents—most notably, nonsteroidal anti inflammatory drugs (NSAIDs) and IV contrast agents —should be minimized or avoided

40. Panobinostat On February 23, 2015, FDA gave approval to Panobinostat in combination with bortezomib and dexamethasone for the treatment of patients with multiple myeloma who have received at least two prior regimens, including bortezomib and an immunomodulatory agent . Panobinostat is a histone deacetylase inhibitor. A randomized trial was done evaluating panobinostat (or placebo) in combination with bortezomib and dexamethasone. The primary efficacy endpoint was PFS determined by investigators. The median PFS values were 10.6 and 5.8 months in the panobinostat -containing  arm ( panobinostat - bortezomib -dexamethasone) and control (placebo- bortezomib -dexamethasone), respectively.   Overall response rates were 58.5% vs 41.4%.

41. The most common adverse reactions (>20%) are diarrhea , fatigue, nausea, peripheral edema , decreased appetite, pyrexia, and vomiting. Serious adverse reactions included pneumonia, diarrhea , thrombocytopenia, fatigue, and sepsis.  The most common hematologic abnormalities included thrombocytopenia and neutropenia; the most common chemistry abnormalities were hypophosphatemia and hypokalemia .   ECG changes, including new T-wave changes and ST-segment depressions and Arrhythmias. 

42. Recommended Treatment Regimen for Panobinostat Treatment Phase 1: Cycles 1-8, 3 week cycles (Total time 24 weeks): Panobinostat 20 mg orally once daily 3 times a week for 2 weeks per 3 week cycle Bortezomib 1.3mg/m 2  intravenously twice weekly for 2 weeks per 3 week cycle Dexamethasone 20 mg orally per day of bortezomib and the day after each dose   Treatment Phase 2: Cycles 9-16, 3 week cycles (Total time 24 additional weeks): Patients achieving clinical benefit without unresolved severe or medically significant toxicity may be considered for another 8 cycles of therapy at modified dosing. Panobinostat 20 mg orally once daily 3 times a week for 2 weeks per 3 week cycle Bortezomib 1.3mg/m 2  intravenously once weekly for 2 weeks per 3 week cycle Dexamethasone 20 mg orally per day of bortezomib and the day after each dose

43. DETERMINING TRANSPLANT ELIGIBILITY Autologous hematopoietic cell transplantation (HCT) results in superior event-free and overall survival rates when compared with combination chemotherapy All patients should be evaluated at diagnosis for transplant eligibility so that the risks and benefits of autologous HCT can be reviewed with those eligible A minority of patients will be eligible for allogeneic HCT, but the value of allogeneic approaches in myeloma remain investigational

44. NOT Eligible for Autologous HCT Age >77 years Direct bilirubin>2.0 mg/ dL (34.2 µ mol /liter) Serum creatinine>2.5 mg/ dL (221 µ mol /liter ) ECOG performance status 3 or 4 unless due to bone pain New York Heart Association functional status Class III or IV

45. Autologous transplantation Patients < 65-70 years Treatment related mortality 10-20% Response rate 80% Long term survival 40-50% Conventional allogeneic transplantation Patients < 45-50 years with HLA-Identical donor Treatment related mortality 40-50% Long term survival 20-30%

46. Sources of Hematopoietic stem cells Bone marrow (BM) Peripheral blood (PBSC) Umbilical cord blood (UCB )

47. Transplant process: 1-Stem cells collection Bone marrow harvesting. Marrow aspirated from pelvis. Peripheral blood harvesting. Stem cells mobilised – G-CSF On day 5 : stem cell collection is done( apheresis ) by machine

48. Transplant process: 2-Processing & Cryopreservation Processing BM /PBSC processed and stem cells concentrated and purify and prepared for freezing process. Cryopreservation. Stem cells are preserved by freezing to keep stem cells alive until day of infusion into the patient.

49. Transplant process: 3-Conditioning ( Chemotherapy Regimen) By delivery of chemotherapy and/or radiation To eliminate any existing malignant cell. To suppress the patient’s immune system from rejecting the new stem cells To create space for the new cells.

50. I. Chemotherapy regimen Chemotherapy agents used in conjunction with TBI include cyclophosphamide, etoposide, and cytosine, arabinoside , with cyclophosphamide at 120 mg/kg over 2 days being the most common.

51. II. TBI IN STEM CELL TRANSPLANT Successful hematopoietic stem cell engraftment requires ( a) eradication of the recipient bone marrow (b)immunosuppression to prevent rejection of donor marrow in the case of an allotransplant ( c) relative sparing of the recipient’s bone marrow stromal cells . Immunosuppression in the setting of allogeneic bone marrow transplantation is necessary to avoid rejection of donor marrow, and TBI is a very efficient immunosuppressant

52. II. TBI IN STEM CELL TRANSPLANT The conditioning regimen for hematopoietic stem cell transplantation has several functions. One is cytotoxicity: to contribute to the eradication of any residual cancer. Another important function of the conditioning regimen is immunosuppression so that the host does not reject the allogeneic donor stem cells. TBI in the broad range of 2 to 15 Gy in conjunction with chemotherapy serves these functions well

53. Transplant process: 4- Stem cells infusion Infusion - 20 minutes to an hour, varies depending on the volume infused. Infused through a central venous line ( CVL), much like a blood transfusion. Premedication with acetaminophen and diphenhydramine to prevent reaction.

54. Transplant process: 5-Recovery Neutropenic phase D uring this period the patient essentially has no effective immune system Supportive care (GCSF) and antibiotic therapy are the mainstays of successful passage through this phase.

55. ENGRAFTMENT PHASE Recovery of normal levels cells is called engraftment Bone Marrow (2-6 weeks) PBSC ( 8-10 days for neutrophil & 10-12 days for platelets ) Cord blood (Neutrophil is 4 weeks) Platelets are the next to return with red cells last (Commonly patients require transfusion of red cells and platelets).

56. Radiation Therapy Total Body Irradiation A phase III French study (IFM [ Intergroupe Francophone du Mye’lome ] trial 9502) examined melphalan , 200 mg/m 2 alone (M200) versus melphalan 140 mg/m 2 with TBI, 8 Gy in 4 fractions (M140/TBI ), and found that patients in the TBI-containing arm suffered more grade 3 or 4 mucosal toxicity, heavier transfusion requirement, and longer hospitalization stay. There was a higher toxic death rate in the M140/TBI arm (3.6% vs. 0% for the M200 arm). The event-free survival was no different between the two treatments, but the 45-month overall survival favoured the M200 arm (M200: 65.8%; M140/TBI: 45.5%; P = .05).

57. Hemibody Radiation Half-body radiation with single doses of 5 to 8 Gy. The bone marrow in the unirradiated half-body serves as a stem cell reserve and will slowly repopulate the irradiated marrow after treatment. The dose for upper half-body should not exceed 8 Gy due to lung tolerance. The main toxicity is myelosuppression . It is not used now a days.

58. Radioimmunotherapy Approaches β - emitting isotope is conjugated to a phosphonate complex, such as Samarium-153-ethylene diamine tetramethylene phosphonate ( 153 Sm-EDTMP). Holmium-166-DOTMP ( 166 Ho-1,4,7,10-tetraazacyclododecane-1,4,7,10-tetramethylene-phosphonic acid), with a higher energy β emission (maximum energy 1.85 MeV) than 153 Sm and a shorter T 1/2 of 26.8 hours. It also has a γ emission (81 KeV ) suitable for imaging.

59. Assessment of Response

60. TREATMENT OPTIONS FOR RELAPSED MULTIPLE MYELOMA

61. Future Direction A nti-CS1 antibody Elotuzumab , A nti-CD38 antibody Daratumumab , HDAC6 inhibitor Ricolinostat , H eat shock protein 90 inhibitor (AUY 922) Telomerase inhibitor (GRN 163L)

62. Conclusions Care should be taken with IMiD -based therapy to include aspirin prophylaxis for DVT/PE. Care should be taken with bortezomib -based regimens to include herpes zoster prophylaxis.

63. Thalidomide: Proposed mechanisms Inhibition of TNF-  Suppression of angiogenesis Increase in cell-mediated cytotoxic effects Modulation of adhesion molecule expression

64. Lenalidomide Immunomodulatory derivative of thalidomide More potent than thalidomide in preclinical models Dose-dependent decrease in TNF- α and interleukin-6 Directly induces apoptosis, G1 growth arrest Enhances activity of dexamethasone More favorable toxicity profile than thalidomide Richardson P, et al. Blood. 2003;100:3063. Hideshima T, et al. Blood. 2000;96:2943-2950.

65. Bortezomib: A Reversible Proteasome Inhibitor Chymo- tryptic Site Post- Glutamyl Site Tryptic Site b1 b2 b 3 b 4 b5 b 6 b 7 Cross section of  ring Bortezomib Adams J, et al. Invest New Drugs. 2000;18:109-121. Adams J, et al. Bioorg Med Chem Lett. 1998;8:333-338. H N B N H O O OH N N OH

66. Summary: Mechanism of Action of Bortezomib (VELCADE  ) The 26S proteasome is a large protein complex that degrades tagged proteins Bortezomib is a reversible inhibitor of the chymotrypsin-like activity of the 26S proteasome Inhibition of the 26S proteasome prevents proteolysis of tagged proteins which can affect multiple signaling cascades with the cell Nonclinical studies showed bortezomib to be cytotoxic to a variety of cancer cell types 1 2 3 4 Millennium Pharmaceuticals, Inc., 2003. Adams J. Drug Discov Today . 2003;8:307-315.

67. Bortezomib (VELCADE  ) Ik B/NF k B  Apoptosis Inhibitors (IAP, FLICE) Caspases 8,3  FAS MAPK PI 3 K Decreased Proliferation antiapoptotic Intracellular level X X proliferation Increased Apoptosis IL-6, VEGF Block activation Inhibition DNA-repair effectors  Adhesion  Cytokine  Angiogenesis BMSC MM cells VEGF IGF-I TNF a IL-6 BM Vessels X     Disruption of unfolded protein response San Miguel J. Hematol J . 2003;4(suppl 3):201-207.

68. Chromosomal Alterations 13q14 deletions 17p13 deletions 11q abnormalities Common translocations t(11;14)(q13;q32) and t(4;14)(p16;q32) Overexpression of myc or ras genes has been noted in some cases Mutations in p53 and Rb1 have also been described

69. Complete Response No M-protein detected in serum or urine. Fewer than 5% plasma cells in bone marrow, no hypercalcemia Partial Response > 50% reduction in serum paraprotein level and/or 90% reduction in urine free light chain excretion. In non-secretory disease at least 75% reduction in bone marrow plasma cells number Minimal R esponse 25-49% reduction in serum M-protein or < 90% reduction in urinary light chain excretion. Stable Disease No evidence of continuing myeloma-related organ damage, less than 25% change in serum M-protein levels for 3 months Progressive D isease Organ damage continuing despite therapy or its re-appearance in plateau-phase Relapse Reappearance of disease in patients previously in CR

70. Mechanism of Bone Destruction

71. Graft Verses Host Disease (GVHD) GVHD results from the activation and proliferation of mature donor T cells that recognize recipient alloantigen presented as peptide molecules by antigen-presenting cells (APCs). In the setting of allogeneic transplantation, despite HLA matching, a repertoire of peptides displayed on recipient cells can be recognized as minor histocompatibility antigens by donor T cells due to the polymorphisms in genes outside the HLA system

72. Graft Verses Host Disease (GVHD) The activation of donor T cells after contact with specialized APCs leads to differentiation to effector cells that produce cytokines such as interferon-gamma and tumor necrosis factor, as well as mediate cytotoxicity against normal recipient organs. Acute GVHD includes clinical damage to skin, gastrointestinal tract, and liver, but other organs can also be involved. Later GVHD may present as a chronic form with more varied clinical symptoms similar to rheumatologic or connective tissue diseases.

73. Graft Verses Host Disease (GVHD) More than half of the recipients undergoing HLA matched sibling hematopoietic transplants develop some degree of GVHD

74. monitoring of the engraftment Chimerism test / Engraftment Analysis The test performed by the analysis of genomic polymorphisms short tandem repeat (STR) sequences in multiple chromosome STR test is done 1,2,3,6 months and 1 year