Tesi sul tema "Multiple myeloma Chemotherapy"

Le myélome multiple (MM) est une néoplasie B caractérisée par l’accumulation d’un clone plasmocytaire dans la moelle osseuse. Des études ont démontré que les modifications épigénétiques comme la méthylation de l’ADN jouent un rôle dans la régulation d’expression de différents gènes associés au cancer. Dans une étude récente, nous avons pu décrire un score génique de méthylation de l’ADN permettant de prédire la sensibilité des cellules de MM aux inhibiteurs de DNMT (DNA methyltranfexrase) (Moreaux, et al 2012). Parmi les gènes dont l’expression est inhibée par les inhibiteurs de DNMT et associés avec un pronostic péjoratif chez les patients atteints de MM, nous avons identifié RECQ1. RECQ1 est une hélicase de la famille RECQ qui s’associe aux origines de réplication durant la phase S du cycle cellulaire et joue un rôle important dans l’élongation des fourches de réplication. RECQ1 est fortement exprimé dans différents types de tumeurs solides et l’inhibition de RECQ1 conduit à la catastrophe mitotique et inhibe la croissance de tumeurs solides. Le but de notre projet a été de caractériser la fonction de RECQ1 dans la physiopathologie du MM et les mécanismes de résistance aux traitements. Afin d’étudier le rôle biologique de RECQ1 dans les plasmocytes tumoraux, nous avons utilisé des vecteurs lentiviraux pour induire de façon inductible la surexpression ou l'inhibition de RECQ1. La déplétion de RECQ1 dans les cellules de MM entraîne une inhibition de la croissance, une induction significative d’apoptose et la formation de foyers 53BP1 indiquant la présence de cassures d’ADN double brin. Une forte expression de RECQ1 étant associée à un mauvais pronostic et la déplétion de RECQ1 conduisant à une induction de cassures d’ADN double brin, nous nous sommes demandé si l’inhibition de l’expression de RECQ1 pourrait sensibiliser les cellules de MM aux agents génotoxiques utilisés dans le traitement du MM. La déplétion de RECQ1 sensibilise, de façon significative, les cellules de MM au melphalan suggérant que l’association d’un inhibiteur de DNMT pour cibler RECQ1 et du melphalan pourrait avoir un effet synergique chez les patients RECQ1++. La surexpression de RECQ1 protège les lignées cellulaires de myélome contra l'apoptose induite par melphalan et bortézomib. De plus, l'épuisement RECQ1 sensibilise les cellules de myélome de traitement est démontré que RECQ1 interagit avec des protéines impliquées dans différentes voies de réparation des dommages de l’ADN : PARP1 (NHEJ/BER), RAD51 (HR), MSH2 et MSH6 (Mismatch repair). RECQ1 interagit avec PARP1 dans la fraction chromatinienne des cellules de MM mais pas avec RAD51 ni MSH2. Cette interaction est significativement induite en présence de melphalan. Des inhibiteurs de PARP sont actuellement en développement préclinique ou en essai clinique. De façon intéressante, la déplétion de RECQ1 sensibilise significativement les cellules de MM à un inhibiteur de PARP in vitro suggérant que l’association d’un inhibiteur de DNMT pour cibler RECQ1 et d’un inhibiteur de PARP pourrait avoir un intérêt thérapeutique dans le MM. Nous avons également confirmé que des doses sous-létales d’inhibiteur de DNMT sensibilisent les cellules de MM au melphalan in vitro
Multiple myeloma (MM) is a plasma cell cancer with poor survival, characterized by the clonal expansion of multiple myeloma cells (MMCs), primarily in the bone marrow. Using a microarray-based genome-wide screen for genes responding to DNA methyltransferases (DNMT) inhibition in MM cells, we identified RECQ1 among the genes downregulated by DNMT inhibitor. RECQ helicase are DNA unwinding enzymes involved in the maintenance of chromosome stability. RECQ1 silencing in cancer cells results in mitotic catastrophe and prevents tumor growth in murine models. RECQ1 is significantly overexpressed in primary myeloma cells compared to normal plasma cells and in myeloma cell lines compared to primary myeloma cells of patients. High RECQ1 expression is associated with a poor prognosis in two independent cohorts of patients. RECQ1 knock down inhibits growth of myeloma cells and induces apoptosis. Given the known role of RECQ1 in replication and DNA repair activation, the effect of RECQ1 depletion in DNA damage response was investigated. RECQ1 depletion induced spontaneous accumulation of DNA double strand breaks (DSBs) evidenced by the phosphorylation of ATM and H2AX histone and detection of 53BP1 foci. Using an alkaline comet assay, a significant increase in DNA strand breaks was confirmed in RECQ1 depleted cell lines compared to control. RECQ1 depletion was associated with CHK1 and CHK2 phosphorylation in MM cells. Since RECQ1 depletion is associated with DNA damage response activation and DNA strand breaks formation, a link between RECQ1 expression and drug sensitivity was hypothesized. RECQ1 overexpression significantly protects myeloma cell lines from melphalan and bortezomib-induced apoptosis. Furthermore, RECQ1 depletion sensitizes myeloma cells to treatment. Using immunoprecipitation, RECQ1 was shown to interact with PARP1 but not RAD51 or MSH2. An increased association of the two proteins was found upon DNA damages induced by melphalan. In agreement, RECQ1 depletion sensitizes myeloma cell lines to PARP inhibitor. We identified RECQ1 as a miR-203 target. Interestingly, aberrant methylation of miR-203 was reported in MM cells and treatment with 5-aza-2’-deoxycitidine led to promoter demethylation and miR-203 re-expression. Furthermore, anti-miR-203 treatment induced a significant increase of RECQ1 mRNA level in MM cells.In conclusion, RECQ1 represent a biomarker of drug resistance in MM, which is targeted by DNMT inhibitors. This suggests association of alkylating agents and/or PARP inhibitors with DNMT inhibitor may represent a therapeutic approach in RECQ1high patients associated with a poor prognosis

Thesis (Ph.D.)--University of Adelaide, Dept. of Medicine and The Hanson Centre, Institute of Medical and Veterinary Science, 2004.
"August 2004" Errata inside front cover. Bibliography: leaves 126-159.

Bibliography: leaves 86-103. Investigates the effect of zoledronic acid on myeloma cells and osteoblast-like cells to establish the molecular and cellular mechanisms responsible for the clinical effectiveness of bisphosphonates in the treatment of patients with myelomatosis. Concludes that zoledronic acid inhibits myelomatosis-induced osteolysis thorugh the mechanisms of myeloma cell death and proliferation and maturation of osteoblasts.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine.
Bone marrow transplants (BMT, also hematopoietic stem cell transplants or HSCT/SCT) are one of the greatest medical achievements of the 20th century. They offer a treatment for a host of malignant and nonmalignant hematopoietic disorders, genetic diseases and solid tumors that could otherwise be fatal. Studies have found that 60% of patients undergoing BMT develop pulmonary complications (PC), and 1/3 of those require intensive care after transplantation. Despite the potential pneumotoxicity of induction agents, to date there have been no longitudinal studies following pulmonary function in this high‐risk patient population. This study reviewed patient who underwent autogeneic bone marrow transplant for multiple myeloma at Banner University Medical Center – Tucson (formerly University of Arizona Health Network) from January 1, 2003 through December 31, 2013. Pretransplant evaluatin and pulmonary function testing data were obtained and stratified between high dose (standard) Melphalan (200 mg/ms2) and reduced dose (140 mg/ms2). Statistically significant differences were present between the 2 groups at baseline for DLCO but disappeared at 6 and 12‐month followup, while a statistically significant difference for FEV1/FVC ratio was seen at baseline and 6 months but disappeared at 12‐month follow‐up. There were no statistically significant differences seen with FEV1 between the two groups. Given there is no difference in mortality and relapse outcomes between the groups, the standard of care dosing for Melphalan is not associated with an increase in pulmonary morbidity.

Multiple myeloma (MM) is a haematological malignancy characterized by terminally differentiated plasma cells and their accumulation in the bone marrow (BM). Despite significant advances in therapeutic strategies it currently remains incurable. The interactions between the BM microenvironment and malignant plasma cells have been pivotal to understanding this disease. Previous reports have shown that patients with a haematological malignancy sustain “damage” to their BM, but how much of this is due to the disease and/or the treatment is currently unknown. Furthermore MM plasma cells have been documented to harness the BM microenvironment to their advantage, improving their growth and survival. However, little is known about the functionality of BM mesenchymal stem cells (MSC) in patients with MM disease which form an essential compartment of the BM microenvironment. It was hypothesised that MSC altruistically protect MM cells from therapy and consequently become phenotypically and genetically compromised. To facilitate the study of the effects of chemotherapeutic agents and MM cells on MSC, a non-contact co-culture model was developed that allowed the investigation of functional and genetic damage. In line with previous studies, U266 cells were found to be protected from drug-induced cell death when in co-culture with the stromal cell line HS5. However, the promoting effects of the BM appear to be at the detriment to their own survival. HS5 cells were found to have lower viability, altered morphology and disrupted differentiation when in a non-contact co-culture with U266 cells. Results from this study have revealed that interactions of MSC with MM cells lead to an altruistic protection of MM cells by the BM. This work demonstrates that U266 cells have an improved viability following exposure to chemotherapy when in a non-contact co-culture with MSC/HS5. Furthermore, genotoxic assays also revealed that HS5/MSC interactions with U266 cells protect U266 from the genotoxic effects of melphalan in co-culture, whilst for the first time HS5 morphology was shown to be severely altered following exposure to chemotherapy and when in co-culture with U266 cells. This work has demonstrated, for the first time, the cytotoxic effects of novel agents bortezomib and carfilzomib on HS5 cells when in co-culture with U266 cells. Results from this study also demonstrate that melphalan severely effects the ability of HS5 cells to differentiate in an osteogenic lineage with a further deficiency in differentiation when in co-culture with U266. Adipogenic differentiation of HS5 was unable to take place when in co-culture with MM cells and was again further impaired by chemotherapy. This is the first study to reveal that primary MSC secrete significantly high concentrations of IL-6 compared to the stromal cell line HS5. A further increase in expression of IL-6 was also shown when in co-culture with U266 cells. Increased multi-nucleation was also identified in both HS5 and U266 cells when exposed to either thalidomide, lenalidomide and bortezomib with abnormalities providing possible explanations for the therapy related malignancies and neurotoxicity that is seen in some patients. Genotoxicity to the MSC/HS5 compartment of the co-culture measured by the micronucleus assay was also found to be reduced suggesting that the BM is protected from the DNA damaging effects of some agents when in co-culture with MM cells. Combined work on the functionality and genotoxicity of the interactions between the BM and MM reveal a tropism of MSC and HS5 towards the MM cell line U266. With this research being conducted in a non-contact co-culture, it has indicated that cell-cell contact is not essential to provide protection of both the BM and MM cells against chemotherapy. This research provides further understanding of the MSC and MM interactions’ impact on the functionality of the BM and their protection from genotoxic damage. Elucidating the consequence of cytotoxic and genotoxic damage to MSC via chemotherapy treatment and/or through haematological disease may allow for the development of effective therapies and improve the quality of life for patients with MM.

Background: Modern treatments extend life expectancy in patients with multiple myeloma (MM) and a high incidence of chemotherapy-induced peripheral neuropathy (CIPN) has evolved. The impact of disease and treatment on health-related quality of life (HRQoL) in MM is poorly characterised. This work aimed to investigate (i) the neuroanatomical functional correlates of pain processing in CIPN and (ii) HRQoL and symptom burden in advanced, intensively-treated myeloma. Methods: First study: twelve neurophysiologically assessed patients with CIPN and 12 healthy volunteers underwent fMRI to determine the brain's haemodynamic response to noxious heat stimuli applied to the extremities. Second study: detailed HRQoL and neuropathy assessments, serum IL-6 and TNF-α levels were measured in 32 patients with MM (median age = 61 yrs, duration of disease = 5.5 yrs) who had previously undergone 3 lines of treatment. Results: First study: Neurophysiological testing in MM patients confirmed peripheral neuropathy in the feet. Significant hypo-activation of the right superior frontal gyrus and hyper-activation in the precuneus were present in response to foot stimulation in the CIPN-myeloma compared to healthy control groups. Significant positive correlation existed between neuropathy score and frontal opercula activation, during foot stimulation in CIPN-myeloma patients. Second study: Thirty-two MM patients (duration of disease = 5.5 yrs) were recruited. Physical functioning was significantly compromised (p < 0.001) and associated with progressive work disability and concerns regarding loss of independence. Fatigue and pain were the predominant symptoms, impacting negatively on physical functioning (p < 0.001). Half of the patients reported neuropathic pain. This sub-group scored lower measures of physical, role and social functioning on EORTC QLQ-C30 and future perspectives from the EORTC MY20 assessments compared to patients without neuropathy. Average pain and pain interference from the BPI-SF were positively correlated (p < 0.05 and p < 0.005, respectively) with serum IL-6 levels. Conclusion: Patients with MM suffer from a high peripheral neuropathy symptomatology burden, leading to a worsening functioning and increased pain. FMRI data indicates that heat-pain stimuli evoke differential activation of distinct cortical regions, suggesting different central pain processing mechanisms in CIPN-myeloma patients. Despite disease control and supportive care, intensively-treated myeloma survivors have significantly compromised HRQoL related to symptom burden.

"August 2004"
Errata inside front cover.
Bibliography: leaves 126-159.
xi, 159, [12] leaves : ill., plates ; 30 cm.
Thesis (Ph.D.)--University of Adelaide, Dept. of Medicine and The Hanson Centre, Institute of Medical and Veterinary Science, 2004

Das multiple Myelom muss trotz aller Therapierfolge in den letzten drei Jahrzehnten seit Einführung der Melphalan-basierten Hochdosistherapie mit autologer Stammzell-Transplantation als eine unheilbare maligne hämatologische Systemerkrankung angesehen werden. Trotz einer großen Anzahl vielversprechender neuer Therapieoptionen im Bereich von IMiDs, PIs und gänzlich neuer immuntherapeutischer Behandlungsansätze stellt dabei die Behandlung eines Myelom-Patienten im späten Krankheitsrezidiv nach Versagen von Lenalidomid und Bortezomib eine therapeutische Herausforderung dar. Daneben erweisen sich dabei im klinischen Alltag mit zunehmender Zahl an Vortherapien insbesondere auch Behandlungs-assoziierte Toxizitäten als den Behandlungserfolg limitierende Faktoren. Diese retrospektive Analyse zeigt, dass eine dritte Melphalan-Hochdosistherapie mit anschließender autologer Stammzelltransplantation in dieser Situation eine wirkungsvolle Therapieoption darstellt, die zum einen ein überzeugendes Ansprechen (ORR 59 %) bewirkt, und über diese unmittelbare Wirksamkeit hinaus zu einem Zugewinn Progressions-freier Überlebenszeit von im Mittel 9 Monaten führt. Zudem kann insbesondere auch die neuerliche autologe Transplantation durch eine Verbesserung der häufig Therapie-assoziiert erschöpften hämatopoetischen Funktion dazu beitragen, dass Patienten im nahezu unweigerlich auftretenden neuerlichen Rezidiv durch bessere Therapieadhärenz und höhere Therapieintensität maximal von Folgetherapien profitieren. Dieser Effekt spiegelt sich in einem gemessen an einem trotz intensiv vortherapierter Patienten langen mittleren Überlebens von 26 Monaten wider. Trotz hoher Therapieeffektivität zeigt sich dabei ein günstiges Sicherheitsprofil mit einer Therapie-assoziierten Mortalität von 4,9 %. Daneben konnte diese Arbeit in einer großen Kohorte bestätigen, dass eine lange Kryokonservierung autologer Stammzellen nicht nur in vitro sondern auch in vivo nicht zu einem Qualitätsverlust und somit beeinträchtigtem Stammzell-Engraftment führt. Insgesamt kann sich die ASCT3 im späten Krankheitsrezidiv in ihrer Wirksamkeit und Sicherheit in refraktären/relabierten Fällen mit Proteasomen-Inhibitoren sowie immunmodulatorischen Substanzen der zweiten bzw. dritten Generation messen lassen, ist jedoch ebenso wenig wie diese im alleinigen Einsatz in der Lage, den negativ-prognostischen Einfluss einer Doppel-Refraktärität bzw. einer Hochrisiko-Zytogenetik vollständig zu überwinden. Hieraus ergeben sich neue Ansätze für Therapiekonzepte, die beispielsweise immunmodulatorische Substanzen sowie Proteasomen-Inhibitoren der neueren und neuesten Generation ebenso wie Antikörper-basierte Therapien im Rahmen einer prospektiven Studie mit einer dritten Hochdosistherapie und anschließender autologer Stammzelltransplantation kombinieren könnten, um das Gesamtüberleben von Myelom-Patienten weiter zu verlängern
This analysis demonstrates that a third autologous stem cell transplant after high-dose Melphalan-based chemotherapy contributes to an improved PFS of 9 months. Furthermore, a median OS of 26 months in heavily pre-treated patients could indicate that a third transplant’s improvement of haematopoietic function contributes to better tolerability and thus viability of additional lines of therapy. Moreover, this paper provides scarce in vivo data about the unimpaired durability of long-term cryopreserved stem cells. In summary, a third autologous stem cell transplant is able to compete with next generation novel agent based treatment in multiple myeloma regarding safety and efficacy, but as a monotherapy neither overcomes adverse prognosis of high risk cytogenetics and IMiD and PI-refractory patients. Given these facts, the inclusion of ASCT3 into new, next generation IMiD-, PI- or even antibody-based therapeutic concepts could be a promising new approach in the treatment of relapsed and refractory multiple myeloma. A third autologous stem cell transplant as an effective treatment in relapsed multiple myeloma

In dieser Arbeit wurden die Daten von 90 konsekutiven Patienten mit Multiplem Myelom, welche im Zeitraum vom 11.04.2005 bis zum 08.11.2010 mit einer Hochdosischemotherapie und autologer Stammzelltransplantation in den Kliniken Essen Süd behandelt wurden, retrospektiv untersucht und statistisch ausgewertet. Es konnte gezeigt werden, dass ein gutes Ansprechen nach den Induktionstherapien mit einem guten Ansprechen sechzig Tage nach der Transplantation korreliert. Einen Zusammenhang zwischen dem initialen Ausmaß der Endorganschäden und dem Verlauf oder dem Ansprechen der Hochdosischemotherapie mit autologer Stammzelltransplantation konnte nicht gefunden werden. Das kalendarische Alter spielt im Gegensatz zum Allgemeinzustand und den Vorerkrankungen bei der Einschätzung der zu erwartenden Toxizität eine untergeordnete Rolle. Die beiden Hauptfaktoren, die den Verlauf einer Hochdosischemotherapie mit anschließender peripherer Stammzelltransplantation beeinflussten, waren die Dauer der G-CSF Therapie und die Anzahl der übertragenen Stammzellen. Während die unterschiedlich lange G-CSF Gabe (ab Tag „+3“ vs. Tag „+7“) nur zu einer schnelleren Regeneration der Leukozyten führt und keinen relevanten Effekt auf die untersuchten klinischen Parameter Fieber, Dauer der intravenösen Antibiotikatage, Ausmaß der Mukositis und die Aufenthaltsdauer der Patienten hatte, führte die Steigerung der Anzahl der übertragenen Stammzellen zu einer signifikant schnelleren Regeneration von Thrombozyten und Leukozyten, einem Rückgang der Transfusionshäufigkeit an Erythrozyten und einem geringeren Verbrauch an intravenösen Antibiotika. Zusammenfassend ist die G-CSF Gabe ab Tag „+7“ nach Hochdosistherapie ausreichend, eine längere Gabe erbringt keinen relevanten klinischen Vorteil. Zudem sollte auf eine ausreichende Menge an übertragenen Stammzellen geachtet werden. Zur Beurteilung der zu erwartenden Toxizität ist die Anwendung des HCT-CI-Score einfach und praktikabel
In this study the data of 90 consecutive patients with multiple myeloma were analyzed retrospectively. There is a correlation between a good response after the induction therapy and sixty days after high-dose chemotherapy with autologous stem cell transplantation. There is no correlation between organ damages (CRAB) and the progression or the response of the high-dose chemotherapy with autologous stem cell transplantation. The chronological age is not as important as the general condition and medical history of the patient to expect the toxicity of the high-dose chemotherapy. The two main factors that influenced the process of high dose chemotherapy followed by peripheral stem cell transplantation were the duration of G-CSF therapy and the number of transplanted stem cells. The different duration of G-CSF leads only to a faster recovery of leukocytes with no relevant effect on the investigated clinical parameters temperature, duration of intravenous antibiotic days and the extent of mucositis. The increase of transplanted stem cells results in a significant faster recovery of platelets and leukocytes, a decrease in frequency of transfusion of red blood cells and a reduced use of intravenous antibiotics. In summary, the G-CSF administration from the 7th day after transplantation is sufficient for high-dose therapy, a longer administration provides no relevant clinical advantage. One should take care for having got sufficient quantity of transplanted stem cells