Table of contents :

Epidemiology Aetiology Pathogenesis Localizations solitary plasmocytoma of bone extramedullary plasmocytoma / soft tissue myeloma indolent myeloma plasma cell leukemia Symptoms & signs Laboratory examinations Therapy  Prognosis Web resources

Epidemiology (USA) : after age 50; peak at age 60; diagnosed annually in approximately 15,000 new patients in the USA, with a prevalence of approximately 50,000 patients^ref; incidence and mortality rates (per 100,000) 1993-1997 :

	male		female
	African American	white	African American	white
incidence	11.4	5.1	8.6	3.3
mortality	7.4	3.6	5.4	2.4

year of diagnosis/death	1976	1977	1978	1979	1980	1981	1982	1983	1984	1985	1986	1987	1988	1989	1990	1991	1992	1993	1994	1995	1996	1997
SEER incidence	4.2	4.1	3.9	3.9	4.0	4.0	4.3	4.3	4.4	4.2	4.3	4.8	4.4	4.3	4.6	4.9	4.8	4.5	4.5	4.4	4.5	4.4
US mortality	2.5	2.5	2.5	2.6	2.6	2.6	2.7	2.7	2.8	2.8	2.8	2.9	2.9	2.9	3.0	3.0	3.0	3.1	3.1	3.2	3.1	3.1
SEER mortality	2.8	2.6	2.5	2.8	2.5	2.7	2.6	2.8	2.7	3.0	2.6	2.6	2.9	3.1	2.9	3.1	3.2	3.2	3.1	3.1	3.1	3.0
1-yr	65.4	70.2	70.0	69.8	69.8	69.5	73.2	72.6	69.6	72.3	72.0	75.6	73.9	71.8	72.8	75.9	69.1	72.5	72.9	73.4	69.3
2-yr	49.3	52.0	54.8	54.1	54.8	55.6	56.2	56.1	55.6	58.9	57.1	59.4	60.1	58.3	57.1	60.6	56.3	58.2	58.4	56.3
3-yr	36.7	38.7	42.4	43.4	44.4	43.0	44.8	44.1	44.0	46.8	44.7	48.5	47.1	44.8	44.7	48.6	45.2	45.8	47.1
4-yr	31.5	30.7	33.0	33.3	34.2	35.0	37.2	36.4	34.8	36.4	35.5	38.1	39.0	36.1	38.7	38.7	34.3	36.6
5-yr	24.6	25.0	27.3	26.1	27.0	27.8	29.7	28.7	27.6	27.7	29.8	28.8	29.8	27.0	30.7	31.2	26.4
6-yr	19.0	21.1	21.6	20.1	21.2	23.1	21.6	23.2	21.1	22.7	23.9	23.6	24.5	21.8	24.5	24.7
7-yr	15.9	17.7	17.8	18.0	18.8	16.8	17.8	17.6	18.3	19.3	19.2	19.6	18.4	17.0	19.2
8-yr	12.4	15.4	15.1	15.4	15.3	14.4	14.6	14.2	13.8	17.0	17.8	16.5	15.5	13.6
9-yr	10.6	12.7	13.1	12.3	13.8	12.2	12.1	12.2	11.7	13.2	13.1	14.1	12.5
10-yr	9.5	11.4	12.1	10.2	11.5	9.9	11.4	10.5	9.9	11.5	12.5	13.2
11-yr	8.7	9.3	10.9	9.1	10.4	8.8	9.7	9.9	9.7	10.2	10.8
12-yr	8.1	8.7	10.3	8.0	9.4	7.4	8.6	9.0	8.6	9.7
13-yr	6.1	8.2	8.2	6.5	7.8	6.9	8.3	8.0	7.4
14-yr	5.2	7.9	7.9	5.8	6.0	6.6	7.2	7.3
15-yr	5.0	7.6	6.3	4.5	5.8	6.2	7.2
16-yr	5.0	6.6	6.3	3.9	5.3	3.4
17-yr	5.0	5.7	5.5	3.9	4.7
18-yr	4.4.	4.6	5.0	3.7
19-yr	3.6	4.5	4.5
20-yr	2.3	4.4
21-yr	2.3

• SEER (1973-1997) Incidence and Mortality
• Racial and Ethnic patterns of multiple myeloma (SEER 1973-1992)

• benzene
• chronic antigenic stimulation (CAS)
• HHV-8 DNA has been identified in phenotypically normal^ref bone marrow and peripheral blood adherent stromal cells (dendritic cells)^{ref1, ref2} but not in the neoplastic MM plasma cell population. It has been suggested that the cytokines expressed by HHV-8 gene, such as vIRF, vIL-8R and vIL-6, may play a role in the pathogenesis of multiple myeloma. In detection of HHV-8, nested-PCR is more sensitive than fluorescence quantitative PCR^ref. However, the majority of European investigators failed to find evidence to confirm this observation^{ref1, ref2, ref3}. Different explanations have been offered to account for inconsistencies in seroepidemiologic and virologic studies searching for an association of KSHV with MM, including the presence of viral variants. Indeed, Ma et al^ref reported unique KSHV open reading frame (ORF) 65 sequences that were detected exclusively in patients with MM but not in patients without MM who were seropositive for KSHV. Interestingly, in some MM patients, a mutation at the C-terminal end of ORF65 resulted in an extension of the ORF by 33 amino acids. These sequences were found only in samples from patients with MM and were suggested as a possible unique target of KSHV serologic immune responses in such patients, who lack seroreactivity against the "conventional" ORF65 protein : however these possibilities are unlikely, because very sensitive RT-PCR analyses, with a detection limit of 1 viral copy in 10 × 10³ cells, was performed by using primers specific for 3 different KSHV genes^{ref1, ref2}. To avoid detection by this RT-PCR, the virus in patients with MM would have to be changed in all these locations and represent a very distant relative of KSHV. Moreover, if all those KSHV proteins that have been shown to be targeted by humoral or cellular immune responses were either altered or completely absent in the virus associated with MM, the elusive infectious agent would likely be unrelated to the KSHV described by Chang et al in 1994^ref. Nevertheless, when the recently described ORF65 sequence unique to patients with MM was included in the ELISPOT analyses no specific responses were detected in any patient with MM. Although we cannot rule out the possibility that ongoing viral replication was insufficient to maintain detectable memory CTL responses against the lytic ORF65 protein, one would expect to detect at least some responses against the latent gene product of ORF73, which is required for viral genome persistence^{ref1, ref2}. The level of viral replication may be very low and not detectable with the sensitive RT-PCR method used. Such low-level viral replication could also lead to an antigenic load insufficient for induction of humoral and cellular immune responses. It remains unclear whether HHV-8 is consequentially associated with MM or only a regional opportunistic infection. Controversy still focuses on the role of specific HHV-8 strains involved in pathogenesis of MM^ref
• adiposity  : RR= 1.5 for BMI, 1.9 for weight, 2.0 for waist circumference, and 1.8 for hip circumference^ref
• familial MM : RR= 3.23 in first-degree relatives of female sex and also a 2-fold risk for other hematologic malignancies. Although evidence for an increased risk for MGUS was not documented in this series as it has been in other reports, this may be due to the fact that the relatives of MM patients were not systematically screened for the presence of paraproteins. Therefore the inference in this report about the familial risk of MGUS is rather weak. On the other hand, the authors identified 8 families in which the propositus had myelomatosis and at least one relative had MGUS and another gammopathy^{ref1, ref2}.

• translocations of the IgH gene locus, which leads to dysregulation of oncogenes at translocation partner regions (cyclin D1 at 11q13, FGFR3/MMSET at 4p16.3, c-MAF at 16q23, and cyclin D3 at 6p21)
• deletions of 13q14 (assessed with double color FISH), the site of a putative tumour suppressor gene, which is an adverse prognostic indicator (worse EFS and OS, higher relapse rate  patients with deletion 13q had a nearly 2 times higher risk of non surviving (HR: 1.94; 95% CI: 0.95-3.98, p=0.07) after dose-reduced allogeneic stem cell transplantation)
• epigenetic changes and activating mutations of oncogenes are usually associated with disease progression :
• mutations of N-RAS and K-RAS

study	KRAS2 mutations (expecially codon 12)		NRAS mutations (expecially mutations at codon 61 in a subset representing 12-100%ref)
	medullary disease, at diagnosis [at relapse] (%)	extramedullary disease	medullary disease, at diagnosis [at relapse] (%)	extramedullary disease
Neri et alref (1989)	2/43 [2/13]  (7)	NA	11/43 [4/13]  (26)	NA
Paquette et alref (1990)	0/17  (0)	NA	2/17  (11)	NA
Matozaki et alref (1991)	0/15  (0)	NA	4/15  (26)	NA
Tanaka et alref (1992)	0/10  (0)	NA	5/10  (50)	NA
Portier et alref (1992)	2/13  (15)	6/15  (40)	2/13  (15)	6/15  (40)*
Corradini et alref (1993)	0/77  (0)	1/13  (7)	7/77  (9)	3/13  (29)*
Millar et alref (1995)	0/18  (0)	NA	0/18  (0)	NA
Liu et alref (1996)	23/139  (16.5)	NA	29/129  (23)	NA
Bezieau et alref (2001)	35%		25%

• changes in c-MYC
• SHP1 methylation leading to epigenetic activation of the Jak/STAT pathway^ref
• c-MAF is overexpressed in 50% of MM : the expresson of integrin b₇ (which binds E-cadherin on the surface of stromal cells upregulating expresion of VEGF, which is important for MM cell growth and enhances the proliferation through the production of cyclin D1) and the cell-cycle regulator cyclin D2, and the chemokine receptor CCR1 is increased in the presence of c-MAF^ref

circulating ECs (CECs)

a correlation was documented between the level of CECs/EPCs and response to thalidomide treatment

• micromolecular myeloma / light chain myeloma / Bence Jones myeloma (10%) : only monoclonal Ig light (L) chains are produced. Such chains are found minimally in plasma as they can pass glomerular filters, precipitate within renal tubules and be recovered in urine as dimers (Bence Jones (BJ) protein (BJP) (Bence Jones Henry. On a new substance occurring in the urine of a patient with mollities ossium. Phil.Transact.Roy.Soc 138:55-62 (1847))), leading to glomerulonephritis and renal failure. It has unusual solubility properties : on heating it precipitates at 50°-60°C and redissolves at 90°-100°C, and on cooling it again precipitates and redissolves (Bence Jones reaction)
• IgD myeloma
• non-secretory myeloma (0.1-5%) : absence of detectable M-protein in serum and urine. The presenting features of nonsecretory myeloma are similar to those in patients with a detectable M-protein, except for the absence of renal function impairment. The response to therapy and survival of patients with nonsecretory myeloma are similar to those of patients with measurable M-protein. Coexistence of nonsecreting and nonproducing light chain multiple myeloma has been reported^ref
• non-producing myeloma : no cytoplasmic immunoglobulin chains are synthetized

• plasmacytoma (< 5% of patients with a plasma cell dyscrasia) present with a single bone (SBP) or extramedullary plasmacytoma (EMP) without evidence of systemic disease (normocalcemia, absence of anemia, preservation of uninvolved immunoglobulins, or renal disease attributable to myeloma). Diagnosis requires biopsy confirmation of a monoclonal plasma cell infiltrate from a single site. The treatment of choice for both entities is radiotherapy given with curative intent (> 4000 cGy) resulting in long term disease-free survival in approximately 30% of patients with SBP and 65% of patients with EMP.
• solitary plasmacytoma of bone (SPB) / bone localized or solitary myeloma : diagnosis requires
• biopsy-proven monoclonal plasma cell infiltration of a single lytic bone lesion
• no additional lesions on bone survey : the role of MRI of the thoracic and lumbosacral spine in the diagnosis of SBP was prospectively evaluated by Moulopoulos et al in 12 consecutive patients with SBP : MRI detected additional abnormalities in 4 patients who, after radiotherapy for the solitary lesion (of curative intent), had persistent paraprotein (> 50% of the pretreatment value), compared with only 1 of 6 similarly treated patients without an abnormality by pretreatment spinal MRI^ref. In a follow-up report of 23 patients with thoraco-lumbar spine disease from one center, 7 of 8 patients who had SBP by radiographs alone developed MM, compared with only 1 of 7 patients with only 1 lesion confirmed by MRI^ref. Thus, most investigators agree that a negative MRI of the thoraco-lumbar spine is a prerequisite for the diagnosis of SBP
• absence of clonal plasma cells on a random marrow sample : 33% of patients considered to have a SPB according to standard criteria have bone marrow abnormalities consistent with MM on MRI^ref
• no evidence of systemic MM (normocalcemia, absence of anemia or renal disease attributable to MM)
• presence of monoclonal protein (M protein) in the serum or urine has been noted in 24-72% of patients in various series^{ref1, ref2, ref3}. Among 63 consecutive previously untreated patients with SBP, 62% had a serum M protein, 13% had only Bence Jones protein (BJP), and 25% had non-secretory disease^ref. Paraprotein values were usually very low, with only 11 of 37 patients with a serum M protein > l g/dL (high value 2.2 g/dL) and the highest urine BJP was 0.7 g/day
• serum immunoglobulin free light chain (FLC) assays have provided a measurable parameter to follow in approximately 65% of patients previously diagnosed with "non-secretory" MM by standard electrophoretic studies^ref. It is likely that these assays will also be useful in a similar percentage of patients with SBP. Like MRI, this would improve the precision of monitoring SBP and provide more sensitive identification of patients who achieve complete disappearance of paraprotein after radiation therapy and are most likely to be cured. An abnormal FLC ratio at diagnosis may identify risk of progression to MM in patients with solitary bone plasmacytoma (SBP). In the cohort of 116 patients, 43 have progressed to MM; with a median time to progression of 1.8 years. The FLC ratio was determined in all 116 patients on serum collected at time of diagnosis, and was abnormal in 54 patients (47%). An abnormal FLC ratio was associated with a higher risk of progression to myeloma (p=0.039). The risk of progression at 5 years was 44% in patients with an abnormal serum FLC ratio at diagnosis compared to 26% in those with a normal FLC ratio. 1-2 years following diagnosis, a persistent serum M protein 0.5 g/dL was an additional risk factor for progression. Risk stratification^ref :
• patients with a normal FLC ratio at baseline and M protein <0.5 g/dL 1-2 years following diagnosis (low-risk; n=31) => 5-yr PFS = 13%
• either risk factor abnormal (intermediate-risk, n=26) => PFS = 26%
• both an abnormal FLC ratio and M protein 0.5 g/dL (high-risk, n=18) => PFS = 62%
• levels of uninvolved immunoglobulins are usually preserved, and in our series of 63 patients, only 3 had suppressed levels. These 3 patients had disease progression at 12, 18 and 74 months, indicating the presence of systemic disease^ref.
Therapy : radiotherapy with curative intent is the treatment of choice, resulting in local control in > 80% of patients and prolonged cause-specific disease-free survival in approximately 35% of patients with SBP. Strict dosing guidelines are difficult to recommend due to the limited number of patients and the absence of prospective phase I-II and randomized studies. Despite this, some recommendations are reasonable based on multiple single institution studies. Tsang et al report no dose-response above 35 Gy in 32 patients; however, a retrospective review by Mendenhall et al noted that among 81 patients treated with > 40 Gy of radiation, there was only 6% local progression of disease, which was superior to 31% for those who received < 40 Gy^{ref1, ref2}. Similarly, no local failure was seen for doses > 50 Gy^ref. While no dose-response was noted by Tsang et al, size of the tumor appeared predictive for local recurrence. That report indicated that SBP < 5 cm was 100% controlled for local recurrence, while nearly 40% of patients with bulky disease (>= 5 cm) had local progression or recurrence of disease^ref. Outcome after treatment for solitary plasmacytoma (selected studies) :

series	no. of patients	radiotherapy dose (Gy)	10-year DFS (%)	OS (yrs)	10-year OS (%)
Wilderref	60	3-70	38	11	-
Frassicaref	46	< 12-70	25	9.3	-
Tsangref	32	< 30-0	36	10	-
Bolekref	27	28.3-60	46	10	-

Thus, in the absence of a large cooperative group study, our practice has been to recommend 45 Gy in 25 fractions over 5 weeks. Recently, evidence-based guidelines of the United Kingdom Myeloma Forum (UKMF) recommend radiotherapy of at least 40 Gy in 20 fractions and ports that encompass the tumor volume plus a margin of at least 2 cm beyond disease detectable by MRI^ref. For bulkier disease (> 5 cm), a higher dose (up to 50 Gy in 25 fractions) was recommended.Surgical resection of SBP is rarely necessary, but occasional patients may require decompressive laminectomy in the presence of cord compression. When possible, an anterior approach is preferred and radiotherapy is generally delayed, but ports may be somewhat compromised due to hardware^ref. Adjuvant chemotherapy has been administered with inconclusive results. Although some studies have found that adjuvant therapy may prevent or delay progression to myeloma, most have noted no benefit with the early administration of chemotherapy^{ref1, ref2, ref3}. More recently, even myeloablative therapy with stem cell support has been evaluated in high-risk patients with solitary bone plasmacytoma, but results are too premature to draw any conclusions given the long natural history of this disease^ref. It is unclear whether the risk of early therapy for SBP may predispose to development of either resistant plasma cell clones or to secondary leukemia. Thus, given the lack of consistent data proving benefit from chemotherapy, we and others believe that there is no current role for adjuvant chemotherapy in the initial treatment of SBP.
Prognosis : while the majority of patients with solitary plasmacytoma of bone develop myeloma after a median of 2-3 years, the overall median survival of 7-12 years is longer than for patients in early phases of symptomatic myeloma. Approximately 15-45% of patients remain disease free at 10 years, and although the majority of these appear to be cured, rare late recurrences have been reported. In our experience, prolonged stability ensued only in patients with complete disappearance of paraprotein by one year, indicating the absence of occult disease outside the radiotherapy port, in contrast to patients with either persistence of paraprotein (after 1 year) or non-secretory disease in whom myeloma usually evolved^ref. Others have reported that neurologic problems associated with SBP, spinal disease, soft tissue masses, bulky disease (>= 5 cm), age > 55 years, radio-therapy dose, and M protein level were important prognostic factors^{ref1, ref2, ref3, ref4, ref5, ref6, ref7, ref8, ref9, ref10, ref11}. In a series of 63 patients researchers were unable to confirm any of these factors, although no patient with a serum M protein > l.0 g/dL had complete disappearance of paraprotein.

Myeloma-free survival (A) and cause-specific survival (B), both in terms of response of myeloma. (M) protein in the blood and/or urine to radiotherapy, for solitary bone plasmacytoma patients.
As further advances in diagnostic testing are evaluated (PET scans, free light chains) occult disease should be more easily recognizable. Consequently, SBP will be diagnosed less, complete disappearance of paraprotein should occur more frequently and the fraction of cured patients should rise.
• solitary extramedullary or extraosseous plasmacytoma (EMP) / soft tissue myeloma is less common than SBP and occurs when there is soft tissue infiltration of clonal plasma cells. There should be no evidence of bone destruction or occult disease elsewhere. EMP must be distinguished from reactive plasmacytoma, plasma cell granuloma and lymphoma (MALT, marginal zone, and immunoblastic)^{ref1, ref2}. This is probably best accomplished by phenotypic studies positive for CD38 and monoclonal cytoplasmic light chain expression of malignant plasma cells obtained by biopsy or fine needle aspiration of the solitary lesion. Similar to SBP, there should be no evidence of clonal marrow plasmacytosis. Approximately 85% of lesions occur in the head and neck mucosa, and underlying bone involvement, particularly in the sinuses, may be noted. Gastrointestinal involvement, although significantly less common, is the next most frequent site and other areas of involvement reported infrequently include lung, bladder, thyroid, testis, ovary, and tonsil among others^{ref1, ref2, ref3}. There are limited data regarding the diagnosis and staging of this disorder, and while CT or MRI is required to document the extent of the solitary lesion, no prospective data exist regarding the role of spinal MRI in staging this entity, but similar to SBP, we find it useful for the accurate staging of EMP. < 25% of patients have evidence of a low level of monoclonal protein in serum or urine by electrophoresis and/or immunofixation, and (similar to our experience with SBP) we require normal levels of uninvolved immunoglobulins to confirm the absence of occult disease elsewhere^ref. Although current experience is minimal, free-light chain assays should also prove useful in monitoring such patients, particularly those classified with non-secretory features. In addition, patients should have no sign of underlying myeloma by bone survey and chemistries should reveal no abnormalities attributable to plasma cell dyscrasia.

Therapy : like SBP, EMP are highly sensitive to radiotherapy with nearly all patients successfully achieving local control (80%-100%) and approximately the 50-65% of patients remaining free of disease longer than 10 years^{ref1, ref2, ref3, ref4, ref5}. Due to small patient numbers and historical retrospective analyses over many decades, no firmly established criteria for treatment exist. Similar to SBP, Tsang et al reported successful local control for nearly all patients (13 of 14) treated with 35 Gy with only 1 failure in a patient with disease > 5 cm; others also confirmed less satisfactory control in sites with bulky disease.8 Median doses of radiation in most studies ranged from 35 to 45 Gy and in our own experience, there appears to be little value for doses beyond 50 Gy (myeloma developed in 1 of 5 patients who received 40-49 Gy versus 4 of 15 patients treated with 50-60 Gy)^ref. The utility of prophylactic irradiation of local lymph nodes is unclear as there have been excellent results with elective inclusion (but with increased morbidity), as well as similar results with inclusion of draining lymph nodes only when clinically involved (or for Waldeyer's ring involvement, which is considered at high risk for local recurrence)^{ref1, ref2, ref3, ref4}.

series	no. of patients	radiotherapy dose (Gy)	10-year DFS (%)	OS (yrs)	10-year OS (%)
Galieniref	46	40-75	78	-	80
Liebrossref	22	40-60	56	-	50
Brinchref	18	28-60	80	-	76
Chaoref	16	40-50.4	75	-	54
Tsangref	14	< 30-50	84	-	65
Hollandref	14	16.11-62	64	-	NA

A group reported 100% local regional control in 5 of 7 patients with tumors in the oral cavity, oral/nasopharynx, larynx, or parotid treated with elective nodal radiotherapy^ref. Because of these excellent results, we currently recommend elective radiation of nodal areas, but not for maxillary sinus or nasal cavity involvement. Current evidence-based recommendations by the United Kingdom Myeloma forum are otherwise similar to our own recommendations and those for SBP^ref. Their recommendations include a radiotherapy dose of 40 Gy in 20 fractions for tumors < 5 cm and up to 50 Gy in 25 fractions for tumors >= 5 cm with at least a 2 cm margin encompassing the primary tumor. If cervical nodes are involved (or in Waldeyer's ring tumors), these should be included in the radiotherapy field. Multiple myeloma-free survival for patients with extramedullary plasmacytoma (EMP) (A) and overall and cause specific survival for all patients (B).

Because EMP is a highly radiosensitive tumor, surgical procedures of the head and neck are not recommended, but surgery may be considered for other sites of disease, such as the gastrointestinal tract. This approach is supported by a literature review by Alexiou et al, in which patients with sites other than the head and neck received either surgery, radiation, or a combined-modality treatment^ref. There was no difference between the 3 arms, suggesting that either surgery or radiotherapy is reasonable for such patients. Considering the high cure rate of EMP with radio-therapy and the lack of published data regarding the use of adjuvant chemotherapy, use of adjuvant chemotherapy is not justified outside a clinical trial.
Prognosis : in most series, < 10% of patients have local recurrence of disease and the 10-year disease free and overall survival ranges from 50-80%, for the 30-50% of patients who develop disease progression to myeloma. This occurs after a median of 1.5-2.5 years and their clinical course at progression is similar to those of patients diagnosed with de novo symptomatic myeloma. Because of the small number of patients in most series, any statistically significant risk factors for development of myeloma are not clear and are further complicated by the inclusion of patients over many decades during which treatment and diagnostic modalities have become more refined and are likely to impact prognosis. In some series, bulky disease > 5 cm may have prognostic significance^ref. In contrast to SBP, because < 25% of patients have a monoclonal protein, any statistically significant analysis of disappearance of paraprotein is precluded for patients with EMP
• indolent myeloma : a variant of MM in which the tumor cells are hypoproliferative; an M component and bone marrow plasmacytosis are present, but significant bone marrow destruction, hypercalcemia, and Bence Jones proteinuria are absent. It is defined as asymptomatic MM with < 4 osteolytic lesions and normal renal function. MRI can detect involvement of the vertebral marrow in 50% of patients^{ref1, ref2}
• plasma cell or plasmacytic leukemia (PCL) (2-4% of all myelomas^{ref1, ref2, ref3}) : a rare form of plasma cell dyscrasia characterized by Kyle's criteria : the presence of > 20% plasma cells in peripheral blood and an absolute plasma cell count > 2,000/ml (Grogan TM, Muller-Hermelink HK, Van CB, Harris NL, Kyle RA. World Health Organization Classification Tumours of Haematopoietic and Lymphoid Tissues. France: IARC Press Lyon; 2001.pp. 142-56)

Epidemiology : in almost all the series median age ranged between 53-57 years (about 10 years younger than median age in MM series). The youngest age reported was 30 years^ref
PCL can be of 2 types :
• primary PCL (PPCL) (60-80%) presents de novo in patients with no previous history of MM and usually features a rapid clinical progression and a short survival. PPCL is a distinct clinicopathological entity, because its clinical features, response to chemotherapy and prognosis are different from those of typical multiple myeloma. PPCL shows higher expression of CD20 as compared to MM^ref.

Epidemiology : incidence < 1 case in 1 million
Symptoms & signs : less lytic bone lesions (60%), hepatosplenomegaly and lymphadenopathy are more common; PPCL has a more aggressive course high frequency of extramedullary involvement (liver, spleen, lymph nodes, extra osseous plasmacytomas etc), thrombocytopenia, anemia, hypercalcemia and impaired renal function
Laboratory examinations : in certain PCL cases, the leukemic cells are more immature than usual and a definitive diagnosis is difficult to obtain (small lymphoid or lymphoplasmacytoid cells with numerous cytoplasmic hairy projections; CD19^-20^-38⁺49e^-79a^-; cytoplasmic and urinary l-type Bence–Jones protein; germinal center B-cells^ref) without electron microscopic^ref or immunohistochemical studies.
Therapy : single alkylating agent with prednisolone is not appropriate for patients with primary PCL. VAD and EDAP with rituximab^ref. Survival is significantly better in PCL patients treated with polychemotherapy as compared to melphalan and prednisolone. Drugs used are vincristine, doxorubicin, dexamethasone and/or cyclophosphamide and etoposide^ref. Alternatively VCMP/VBAP^ref or DMVM^ref is also used. Since the prognosis is so poor, intensification of high dose chemotherapy followed by allogenic/autologous hematopoietic stem cell transplantation should be tried^{ref1, ref2, ref3, ref4, ref5}
Prognosis : median survival is 6 months^ref. The longest survival reported was 28 months^ref. The failure to achieve 50% clearance of blood plasma cells within 10 days after the initiation of treatment is a predictor of no response^ref. Garcia-Sanz et al.^ref identified 10 variables which have unfavorable prognostic value on the survival of PPCL cases, of which serum b₂ microglobulin level > 6 mg/L and S phase bone marrow plasma cells >4.5% retained an independent value on multivariate analysis. Response to treatment of PCL is poor.
• secondary PCL (40%)^ref evolves as a terminal event in 1-2% of MM^ref; it is mostly considered as a complication of the alkylating agents or radiation therapy^{ref1, ref2}

Epidemiology : older than PPCL
Symptoms & signs : hepatosplenomegaly and lymphadenopathy are less common; more lytic bone lesions (100%), lower platelet count, larger M-protein in the serum than did patients with primary plasma cell leukemia
Prognosis : mean survival is 1.3^ref-2.0 months^ref
Therapy : bortezomib^ref
Pathogenesis : deletions of 13q14 were detected in 11 (78%) cases and deletions of 17p13.1(TP53) in 6 (43%) cases. Translocations (11;14), (4;14), and (14;16) were found in 5 (35%), 2 (14%), and 1(7%) cases, respectively. Except for an association between t(4;14) and 13q14 deletions, no association was identified among the genetic abnormalities^ref. Phenotypically they originate from proliferation of plasma cells expressing CD38^ref. Minority of cells expresses CD10, HLA-DR and CD20. The presence of multiple haemopoietic surface antigens on malignant plasma cells suggests its origin from a pluripotent stem cell. Also, plasma cells from both primary and secondary PCL lacks CD56, which is important in anchoring plasma cells to bone marrow stroma. > 80% have a diploid/hypodiploid DNA content^ref. Cytogenetic study shows complex karyotype with multiple numerical and structural abnormalities^ref. Up to 90% may show chromosome 13 monosomy^ref. Among immunoglobulins, IgG is most often increased.
• non-secretory PCL^ref
Laboratory examinations : anaemia with a haemoglobin < 9 g/dl occurs in 80% of cases of PCL versus 35% of cases of MM. Rouleaux formation is usually evident on the peripheral blood smear. Thrombocytopenia with platelets < 100 x 10⁹/L occurs in 50% of patients with PCL versus only 10% of those with MM. Leucocytosis ranges from 20 to > 100 x 10⁹/L with 20% to 100% of plasma cells. An elevated BUN and/or creatinine occur in 75% of cases of PCL versus only 40% cases MM. Most patients with PCL have a monoclonal IgG heavy chain or light chain in the serum and Bence Jones proteinuria occurs in about 80% of cases^ref
Therapy : infection and haemorrhage contribute significantly to morbidity and mortality. DIC has also been reported^ref. SPCL rarely responds to chemotherapy.
Differential diagnosis : acalculous cholecystitis^ref
• ‘hairy-cell’ variant of plasma cell myeloma (Crogan TM, Spier CM. B-cell Immunoproliferative disorders, including multiple myeloma and amyloidosis. In: Knowles DM, editor. Neoplastic hematopathology, 2nd ed. Philadelphia: Lippincot Williams and Wilkins 2001;1564–5)
• lymphoplasmacytoid leukemia producing biclonal IgA but not Bence–Jones protein^ref

• I (approx. cell mass : 0.6 x 10¹²/m²; < 500 cells / mL; low) : all of the following
• hemoglobin > 10 g/dl
• serum calcium < 12 mg/dl (normal)
• on roentgenogram, normal bone structure (scale 0) or solitary bone plasmacytoma only
• low M component production rates
• IgG value < 5 g/dl
• IgA value < 3 g/dl
• urine light chain M-component on electrophoresis < 4 g/24h
• II (approx.cell mass : 0.6-1.2 x 10¹²/m²; 500÷1200 cells / mL; intermediate) : overall data not as minimally abnormal as shown for stage I and no single value as abnormal as defined for stage III
• III (approx.cell mass > 1.2 x 10¹²/m²; > 1200 cells/mL; high) : one or more of the following
• hemoglobin value < 8.5 g/dl
• serum calcium value > 12 mg/dl
• advanced lytic bone lesions (scale 3)
• high M-component production rates
• IgG value > 7 g/dl
• IgA value > 5 g/dl
• urine light chain M-component on electrophoresis > 12 g/24 h

• A : relatively normal renal function (serum creatinine < 2.0 mg/dl)
• B : abnormal renal function (serum creatinine > 2.0 mg/dl)

• multiple bone marrow tumor foci and secretion of an M component, associated with widespread osteolytic lesions resulting in bone pain, pathologic fractures, height decrease (=> spinal cord compression => paralysis)
• hypercalcemia
• normochromic normocytic anemia
• spread to extraosseous sites occurs frequently in advanced disease
• depression of immunoglobulin levels results in increased susceptibility to opportunistic bacterial infections
• renal failure may also occur from .... :
• calcium nephropathy
• extensive cast formation
• hyperuricemia
• renal amyloidosis (l> k  chains)
• light chain nephropathy (k > l chains)
These features have strong diagnostic value if accompanied by > 10% atypical plasma cells in the bone marrow and either a monoclonal immunoglobulin in the serum or light chains in the urine (Durie BGM, Salmon SE. Multiple myeloma, macroglobulinaemia and monoclonal gammopathies. In: Hoffbrand AV, Brain MC, Hirsh J, eds. Recent advances in haematology. No. 2. Edinburgh, Scotland: Churchill Livingstone, 1977:243-61). Light chains appear in the serum only if the patient has severe renal failure. Bone lesions, hypercalcemia, and anemia correlate directly with the presence of the total mass of myeloma cells^ref and have prognostic value^{ref1, ref2, ref3, ref4}. All these complications, especially infection and renal insufficiency, are also major causes of death^ref. The pathogenesis of these clinical features depends on interactions between myeloma cells and the microenvironment of the bone marrow by means of cell-to-cell contact, adhesion molecules, and cytokines^ref or on the direct effects of circulating monoclonal immunoglobulins or light chains^ref.
• Crow-Fukase syndrome / polyneuropathy, organomegaly, endocrinopathy, monoclonal gammapathy and skin changes (POEMS) syndrome
• sclerosing myeloma : myeloma associated with osteosclerosis, most often manifested by peripheral neuropathy; the myeloma involved may be localized or a part of multiple myeloma; POEMS syndrome may be present

• serum protein electrophoresis (SPE) and immunofixation with % of eventual monoclonal component(s) in g-globulins


• IgG MM (60%)
• IgA MM (20%)^ref
• IgE MM^ref (0.01% in all plasmocytomas^ref) : < 40 cases of IgE myeloma have been described^{ref1, ref2, ref3, ref4, ref5, ref6, ref7, ref8, ref9, ref10, ref11, ref12, ref13, ref14}; more malignant clinical course; a case in which a monoclonal chain was detected in the urine of the patient several years prior to diagnosis^ref; associated with plasma cell leukaemia^ref; in a case an unusual picture was found in the urine where two IgE fragments, namely an incomplete Fc fragment and an IgE specific Fab fragment were excreted^ref
• IgD MM (1-2% of all myelomas) : a small band or no evident M-spike on serum electrophoresis and heavy light-chain proteinuria. Thus, IgD myeloma can be considered a variant of Bence Jones myeloma; the presence of the IgD M-protein and the predominance of the l light chain are the only distinctive features. Predominant occurrence in males and young patients. The median survival of patients with IgD MM is almost 2 years, with 20% of them surviving for > 5 years, frequent renal impairment, hypercalcemia and amyloidosis.
• nonsecretory IgD MM^ref
Outcome remains poor with chemotherapy and appears to be superior with ASCT^ref. Bence Jones myeloma should not be diagnosed without excluding the presence of an IgD paraprotein^ref.
• IgM MM
• biclonal MM (0.1%)
• urine protein immunofixation to detect Bence-Jones proteinuria (70% of MM and 100% of micromolecular myeloma)
• dosage of serum IgA, IgG, IgM
• IgA (n.v : 70-400 mg/dl)
• IgG (n.v. : 700-1600 mg/dl)
• IgM (n.v. : 40-280 mg/dl)
• IgD (n.v. 0.3-14 mg/dl)
• IgE (n.v. : < 0.025 mg/dl or < 150 E/l)
• dosage of l and k L chains in :
• serum :
• k (n.v. 1.7-3.7 g/l)
• l (n.v. 0.9-2.1 g/l)
• k/l ratio (n.v. 1.35-2.65)
• urine :
• k (n.v. : 0.0-7.1 mg/l)
• l (n.v. : 0.0-3.9 mg/l)
• hypogammaglobulinemia (93%) (Kyle RA, Greipp PR, Witzig TE, et al. An analysis of 1027 newly diagnosed cases of multiple myeloma. Blood 1999;94:Suppl 1:537a-537a.abstract)
• hypercalcemia (30%) is uncommon at diagnosis
• hypeuricemia (40%)
• increased plasma viscosity (80%)
• increase in T_reg
• increased [bone marrow AlkP isozyme]_plasma
• increased [b₂m]_plasma
• CBC
• increased ESR (95%), sideremia, transferrin, ferritin, bilirubin, SGOT, SGPT, g-GT, alkaline phosphatase, LDH, fibrinogen, total serum proteins; IL-6, IL-6R, TDK
• at diagnosis : mosaic HAV, HBV, HCV antigens/serology
• skull X-rays : rounded "punched out" lesions


• bone marrow trephine biopsy (BMTB) :
• myeloma cell : found in bone marrow and occasionally in peripheral blood
• in the more anaplastic forms, the cell is large, has abundant blue-staining cytoplasm with no perinuclear pallor, and has one or more moderately large and vesicular nuclei that may be centrally or eccentrically placed and may contain nucleoli
• in better differentiated tumors, the cell is smaller and, except for the finer chromatic structure, greatly resembles a plasmacyte

• Mott cell / berry, grape, or morular cell (an abnormal plasma cell that contains Mott bodies or Russell bodies)
• immunophenotype : CD19^+/-20^9%28⁺33^+/-38⁺⁺43^+/-45^9%52^5%54 / ICAM-1⁺56^72%117^+(18%)138 / syndecan 1⁺227 / EMA^+/-, HM1.24⁺, SP17⁺, MUC1⁺, sIg^-, cIg^hi

• major criteria :
• histological diagnosis of plasmacytoma at bone or soft tissue biopsy
• bone marrow plasma cells > 20%
• M component
• IgG > 3.5 g/dl
• IgA > 2 g/dl
• Bence-Jones proteinuria > 1g/24h
• urinary k or l chain > 1 g/24hr
• minor criteria
• bone marrow plasma cell 10-20%
• M component
• IgG < 3.5 g/dl
• IgA < 2 g/dl
• Bence-Jones proteinuria < 1 g/24h
• osteolytic lesions
• suppression of normal IgG (IgG < 600 mg/dl, IgA < 100 mg/dl, IgM < 50 mg/dl)

• induction therapy :
• first line :
• IFN-a_2b has been shown to be effective in about 20% of patients
• chemotherapy : in most patients, the fraction of proliferating cells is < 1% until late in the disease^ref.
• melphalan + prednisone (MP) was the standard first-line treatment for elderly MM patients ineligible for stem cell transplant since 1960. However, complete responses (CRs) are rare
• cyclophosphamide + prednisone
• thalidomide
• alone or thalidomide + dexamethasone : 28 patients with previously untreated asymptomatic MM were treated with thalidomide 100 to 200 mg orally (PO) at bedtime (qhs) with serial increments of 50 to 100 mg at weekly intervals, as tolerated to a maximum of 600 mg PO qhs. 40 consecutive previously untreated patients with symptomatic MM were also treated as above (maximum dose 400 mg) and received dexamethasone 20 mg/m² for 4 days beginning on days 1, 9, and 17; the second and third cycles of repeated dexamethasone were begun on day 30. Both groups of patients were treated for at least 3 months. The response rate was 36% for patients treated with thalidomide alone and 72% for patients treated with Thal-Dex, the latter including complete remission in 16% of patients. The median time to remission was 4.2 months with thalidomide alone and 0.7 months with thalidomide-dexamethasone. Grade 3 toxicity included infections (9 patients) and thrombotic/embolic events (7 patients). 5 deaths have occurred as a result of MM (2 patients), infection (1 patient), unknown cause (1 patient), and a possible thromboembolic event (1 patient)^ref
• thalidomide + dexamethasone (Thal-Dex) : administered for 75 days (200 mg/day) and 3 months, respectively. The monthly dose of dexamethasone was 20 mg/m²/day for 4 days, with cycles repeated on days 9 to 12 and 17 to 20 on the first and the third month of therapy.
• is better than dexamethasone alone : the response rate with thalidomide 200 mg per day + dexamethasone 40 mg was significantly higher than with dexamethasone 40 mg alone (63% v 41%, respectively) in patients with newly diagnosed myeloma for 4 cycles (28 days per cycle), followed by stem cell collection in patients eligible for high-dose chemotherapy (ECOG-EA100). A recent interim analysis of 109 patients showed an overall response rate of 80% ( 50% reduction in serum and urine M-protein) in the Thal/Dex arm, significantly higher than 53% for patients on Dex alone (P = .0023; one-sided Fisher's exact test). The most important side effect reported was deep vein thrombosis (including pulmonary embolus), occurring in 16% of patients receiving the Dex/Thal combination, compared with 3% receiving Dex alone (Rajkumar SV, Blood E, Vesole DH, Shepard R, Greipp PR. A randomised phase III trial of thalidomide plus dexamethasone versus dexamethasone in newly diagnosed multiple myeloma (E1A00): a trial coordinated by the Eastern Cooperative Oncology Group. Proc Am Soc Clin Oncol; 2004:558). The response rate allowing for use of serum monoclonal protein levels when a measurable urine monoclonal protein was unavailable at follow-up was 72% v 50%, respectively. The incidence rates of grade 3 or higher deep vein thrombosis (DVT), rash, bradycardia, neuropathy, and any grade 4 to 5 toxicity in the first 4 months were significantly higher with thalidomide plus dexamethasone compared with dexamethasone alone (45% v 21%, respectively; P < .001). DVT was more frequent in arm A than in arm B (17% v 3%); grade 3 or higher peripheral neuropathy was also more frequent (7% v 4%, respectively)^ref
• is better than VAD, Thal-Dex resulted in a significantly higher response rate (52% versus 76%, respectively; P < .001) and effected more profound reduction in myeloma cell mass of both IgG and IgA type. More frequent toxicities included nonfatal deep vein thrombosis with Thal-Dex (15%) and granulocytopenia with VAD (12%). In each of the 2 treatment groups, 91% of patients proceeded to PBSC mobilization. The median number of collected CD34⁺ cells was 7.85 x 10⁶/kg in the Thal-Dex group and 10.5 x 10⁶/kg in the control group. Thal-Dex may be considered an effective and relatively well-tolerated oral alternative to the more complex VAD regimen as front-line therapy for MM patients who are candidates for subsequent autologous transplantation^ref
• in young patients (< 61 years) with symptomatic MM, on an ITT basis, the overall response (> or = PR) rate was 74%, including 24% of patients who obtained a complete remission. Grade 3-4 toxicities consisted of infections (12%), deep-vein thrombosis (3%), constipation (5%), and neuropathy (5%). A total of 58 patients (96%) proceeded to PBSC mobilisation and yielded a median number of 8 x 10⁶ CD34⁺ cells/kg.^ref.
• In the Mayo Clinic Phase II trial, patients received Thal 200 mg per day and Dex 40 mg on days 1-4, 9-12, and 17-20 (odd cycles) and 40 mg/d on days 1-4 (even cycles); a 64% rate of major response, defined as  50% reduction in serum and urine M-protein, was reported. The most common grade 3/4 toxicities were deep vein thrombosis (12%), constipation (8%), rash (6%), and dyspnea (4%)^ref.
• The MD Anderson Cancer Center (MDACC) Phase II trial enrolled patients with previously untreated symptomatic disease to receive Thal 100 mg per day, escalated to 400 mg per day, plus Dex 20 mg. Partial and complete responses were observed in 63% of patients, and grade 3 toxicities included infection (23%), thrombotic/embolic events (15%), constipation (3%), and fatigue (3%)^ref.
• thalidomide was given at the fixed dose of 200 mg/day; dexamethasone was administered at the dose of 40 mg/day on days 1-4, 9-12 and 17- 20 in odd cycles and 40 mg/day on days 1-4 in even cycles, repeated monthly for 4 months. 71 patients with symptomatic MM were evaluated for response and toxicity. On an ITT basis, the overall response (>or= partial remission) rate was 66%, including 17% of patients who attained a complete remission or a very good partial remission. In addition to common toxicity of thalidomide, deep-vein thrombosis was a troublesome adverse event (16%). 9 patients (13%) required thalidomide discontinuation because of toxicity, including 3 patients who died during the study treatment. 59 patients proceeded to PBSC mobilization and yielded a median number of 7.1x10⁶ CD 34⁺ cells/kg^ref.
• pegylated liposomal doxorubicin (Caelyx) 40 mg/m² on day 1 every 28 days, dexamethasone 40 mg p.o. on days 1-4 and 9-12 and thalidomide 100 mg daily (TAD / ThaDD)
• in advanced MM achieved CR in 26%, nCR in 6%, VGPR in 6%, PR in 38%, minor response in 16% and PD in 8% (ORR = 92%). The median EFS was 17 months and the median OS was not reached. Grade 3 non-hematologic toxicity occurred in 12% of patients, thromboembolic disease in 12% and severe infection in 16%^ref
• phase II study in the treatment of 50 newly diagnosed MM patients > 65 years. Thalidomide was administered orally 100 mg at bedtime continuously, dexamethasone orally 40 mg days 1-4 and 9-12 and pegylated liposomal doxorubicin intravenously 40 mg/m² on day 1 over the 28-days cycle. Response was assessed according to the EBMT criteria. Seventeen (34%) patients achieved CR, 7 (14%) nCR, 5 (10%) VGPR, 15 (30%) PR and 5 (10%) MR resulting in an ORR of 98%. Only one patient (2%) presented progressive disease. TTP, EFS and OS projected at 3 years were 60%, 57% and 74% respectively, and these parameters were significantly higher in those patients achieving a response VGPR versus those who did not. Grade 3-4 nonhematologic adverse events were constipation (10%), fatigue (6%), tremors (4%), mucositis (4%) and palmar-plantar erythro-dysesthesia (2%). Grade 3-4 neutropenia occurred in 12% of patients. Grade 3-4 infections and thrombo-embolic accidents were observed in 22% and 14% of patients, respectively^ref.
• doxorubicin and dexamethasone were given for 2 or 3 months followed by thalidomide and dexamethasone for 2 months (AD-TD regimen) with prophylactic antibiotics and daily aspirin (81 mg/d). Among the 42 patients whose response could be assessed, 38 responded to therapy (90.5%). The ITT response rate was 84.4% with 7 complete responses (CR 15.5%), 9 near complete responses (nCR 20.0%), and 22 partial responses (PR 48.9%). 2 patients had stable disease (4.4%), and 2 progression of disease (4.4%). Normalization of the free light chain ratio after 1 or 2 cycles of treatment was highly predictive of achievement of CR or nCR. Patients tolerated the treatment well although 5 patients developed thromboembolic complications (11%)^ref
• melphalan + prednisone + thalidomide (MPT) : a multicentre randomised trial compared MP for 6 4-week cycles plus thalidomide (100 mg per day continuously until any sign of relapse or progressive disease) with MP alone in patients aged 60–85 years with newly diagnosed MM. Patients treated with thalidomide had higher response rates and longer event-free survival (primary endpoints) than patients who were not. Combined CR or PR rates were 76.0% for MPT and 47.6% for MP alone (absolute difference 28.3%), and the nCR or CR rates were 27.9% and 7.2%, respectively. 2-year EFS rates were 54% for MPT and 27% for MP (hazard ratio [HR] for MPT 0.51). 3-year OS rates were 80% for MPT and 64% for MP (HR for MPT 0.68). Rates of grade 3 or 4 adverse events were 48% in MPT patients and 25% in MP patients (p=0·.002). Introduction of enoxaparin prophylaxis reduced rate of thromboembolism from 20% to 3% (p=0·005)^ref
The impact of thalidomide given in addition to chemotherapy throughout the whole program is currently being tested in the Arkansas Total Therapy II. When incorporated into high-dose, melphalan-based therapy for MM during primary remission-induction therapy, between the 2 autologous HSCT, with consolidation therapy, and as maintenance treatment, patients who received thalidomide had a significantly higher rate of both complete response (62% vs. 43%) and 5-year event-free survival (56% vs. 44%). Nevertheless, overall survival curves in the 2 groups were nearly identical, owing in part to the poorer outcome after relapse in the thalidomide group. In particular, thalidomide-treated patients had a lower rate of response to salvage therapy and shorter OS after relapse than the control patients^ref. These results indicate that contrary to a widely held belief, a CR is not a valid surrogate for OS in clinical trials. The higher rate of failure to respond to salvage therapy in the thalidomide group needs to be investigated further, especially with respect to the salvage potential of new drugs in patients who had received thalidomide as initial treatment.
• lenalidomide :
• Revlimid + dexamethasone (Rev-Dex) : 34 patients were enrolled. Lenalidomide was given orally 25 mg daily on days 1 to 21 of a 28-day cycle. Dexamethasone was given orally 40 mg daily on days 1 to 4, 9 to 12, and 17 to 20 of each cycle. Objective response was defined as a decrease in serum monoclonal protein level by 50% or greater and a decrease in urine M protein level by at least 90% or to a level less than 200 mg/24 hours, confirmed by 2 consecutive determinations at least 4 weeks apart. 21 of 34 patients achieved an objective response, including 2 (6%) achieving complete response (CR) and 11 (32%) meeting criteria for both very good partial response and near complete response, resulting in an overall objective response rate of 91%. Of the 3 remaining patients not achieving an objective response, 2 had minor response (MR) and one had stable disease. Fortyseven percent of patients experienced grade III or higher nonhematologic toxicity, most commonly fatigue (15%), muscle weakness (6%), anxiety (6%), pneumonitis (6%), and rash (6%). Rev/Dex is a highly active regimen with manageable side effects in the treatment of newly diagnosed MM^ref. Rev-Dex is associated with an increased risk of venous thrombosis and concomitant administration of erythropoietic agents may further increase the risk of thrombosis (Dimopoulos M, Weber D, Chen C, et al. Evaluating oral lenalidomide (Revlimid) and dexamethasone versus placebo and dexamethasone in patients with relapsed or refractory multiple myeloma. Haematologica 2005;90:Suppl 2:160-160)^ref. Erythropoietin or other agents that may increase the risk of thrombosis should be used with caution in patients receiving lenalidomide and high-dose dexamethasone. Antithrombotic medications, including aspirin, should be considered for such patients, especially in those with additional risk factors^ref.
• VAD (vincristine, adriamycin, dexamethasone)^ref followed by high-dose melphalan with stem cell rescue^{ref1, ref2}
• vincristine, doxorubicin, and reduced-dose induction (VAd)
• pegylated liposomal doxorubicin + vincristine intravenous injection + oral dexamethasone (DVD) is at least as effective as VAD/VAd for the treatment of MM, but DVd is associated with less neutropenia and alopecia in addition to requiring fewer days in the hospital or clinic for drug administration. DVd therapy has also been reported to be associated with an antiangiogenic effect not observed with VAD.
• pegylated liposomal doxorubicin + vincristine intravenous injection + reduced-dose oral dexamethasone (DVd)
• cyclophosphamide, vincristine, doxorubicin and dexamethasone (C-VAD)^ref
• bortezomibis currently being evaluated as part of induction treatment prior to ASCT, alone or in combination with dexamethasone or with chemotherapy. It is probably more attractive to test the impact of these new agents given in addition to HDT rather than to again compare HDT with standard dose chemotherapy including these drugs.
• bortezomib + melphalan + prednisone (VMP) : in a phase I/II trial in 60 untreated MM patients aged > 65 years (half >75 years), response rate was 89%, including 32% immunofixation-negative CR, of whom half of those analyzed achieved immunophenotypic remission (no detectable plasma cells at 10^-4-10^-5 sensitivity). VMP appeared to overcome the poor prognosis conferred by Rb gene deletion and IgH translocations. Results compare favorably with historical control data for MP, notably response rate (89% vs 42%), EFS at 16 months (83% vs 51%), and survival at 16 months (90% vs 62%). Side effects were predictable and manageable; principal toxicities were hematologic, gastrointestinal, and peripheral neuropathy, and were more evident during early cycles and in patients aged  75 years. In conclusion, in elderly patients ineligible for transplant, the combination of bortezomib plus MP appears significantly superior to MP, producing very high CR rates, including immunophenotypic CR, even in patients with poor prognostic features^ref
• as second-line in relapsed, refractory MM :
• high-dose dexamethasone (40 mg orally on days 1 through 4, 9 through 12, and 17 through 20 for 4 5-week cycles)
• thalidomide
• alone (100-600 mg per day) : using response criteria defined as >= 25% reduction in serum M-protein concentration, response rates are 30/70%, with a median time to response ranging from 3 to 8 weeks^{ref1, ref2}.
• Thal + melphalan and Thal + melphalan + dexamethasone yielded response rates of 82% (> 25% reduction in M-protein) but significant rates of myelotoxicity, with 87% and 62% of patients experiencing leukopenia and neutropenia, respectively^{ref1, ref2}
• Thal + liposomal doxorubicin + vincristine + dexamethasone (DVd-T) : an encouraging overall response rate of 74% was seen, but an increased incidence of neutropenia, bacterial and viral infection, and deep vein thrombosis was observed, prompting a protocol amendment to allow concomitant treatments, which proved largely successful in abrogating these toxicities^ref.
• Thal + cyclophosphamide + dexamethasone (ThaCyDex) is effective in patients with b₂-microglobulin </=4 mg/dL and </=65 years^ref
• melphalan 50 mg/m² and bortezomib 1.3 mg/m² on days -6 and -3 in association with thalidomide 200 mg and dexamethasone 20 mg on days -6 through -3, followed by hematopoietic cell support on day 0. Nonhematologic toxicities included pneumonia, febrile neutropenia, and peripheral neuropathy. All patients had undergone autologous transplantation at diagnosis, and 13 patients (50%) underwent an additional transplantation at relapse. Responses occurred in 17 of 26 patients (65%), including 1 complete remission, 3 near complete remissions (12%), and 2 very good partial remissions (8%). Response rate was higher than that induced by the previous line of treatment in 12 patients (46%)^ref
• lenalidomide^ref
• Rev alone :
• phase I studies :
• IMiD CC-5013 dose escalation (5 mg/day, 10 mg/day, 25 mg/day and 50 mg/day) study in 27 patients (median age 57, range 40-71 years) who had received a median of 3 (range 2-6) prior regimens, including autologous stem cell transplantation and Thal in 15 and 16 patients, respectively. In 24 evaluable patients, no dose-limiting toxicity was observed in patients treated at any dose level within the first 28 days; however, grade 3 myelosuppression developed after day 28 in all 13 patients treated with 50 mg/day CC-5013. In 12 patients, dose reduction to 25 mg/day was well tolerated and therefore considered the maximal tolerated dose. Importantly, no significant somnolence, constipation, or neuropathy has been seen in any cohort. Best responses of  25% reduction in paraprotein occurred in 17 of 24 (71%) patients (90% confidence interval [CI]: 52%, 85%), including 11 (46%) patients who had received prior Thal. Stable disease (< 25% reduction in paraprotein) was observed in an additional 2 (8%) patients. Therefore, 17 of 24 (71%) patients (90% CI: 52%, 85%) demonstrated benefit from treatment^ref
• Zangari M, Tricot G, Zeldis J, et al. Results of a phase I study of CC-5013 for the treatment of multiple myeloma (MM) patients who relapse after high dose chemotherapy (HDCT) [abstract]. Blood. 2001:3226a
• Revlimid + dexamethasone (Rev-Dex) : Dimopoulos MA, Spencer A, Attal M, et al. Study of lenalidomide plus dexamethasone versus dexamethasone alone in relapsed or refractory multiple myeloma (MM): results of a phase 3 study (MM-010). Blood 2005;106:6a-6a
• CC-4047, has been tested in a Phase I study of patients with relapsed MM, and results have shown a favorable toxicity profile (although deep vein thrombosis occurred in approximately 10% of patients) and high response rates^ref
• proteasome inhibitors : are a novel class of therapeutics targeting the MM cell in its BM microenvironment by blocking NF-kB-mediated IL-6 production. Bortezomib has been shown to induce apoptosis of MM cells resistant to known conventional therapies. It overcomes the protective effects of IL-6, and adds to the anti-MM effects of Dex^ref. It acts in the BM microenvironment to inhibit the binding of MM cells to BMSCs, the transcription and secretion of IL-6 triggered by MM to BMSC adhesion, and BM angiogenesis. Gene microarray profiling studies demonstrate that bortezomib induces transcriptional downregulation of growth/survival signaling pathways and upregulates apoptotic cascades, ubiquitin/proteasome pathways, and heat-shock proteins^ref.
• alone (1.3 mg/m²_BSA) on days 1, 4, 8, and 11 for 8 3-week cycles, followed by treatment on days 1, 8, 15, and 22 for 3 5-week cycles) : in a multicenter Phase II trial of bortezomib in patients with advanced and heavily pretreated MM, CR was seen by Blade criteria in 10% of patients, with 4% immunofixation negative and 6% with residual MM paraprotein detected only by immunofixation^ref. The overall response rate (MR + PR + CR) was 35% with an additional 24% experiencing stable disease. In a recently updated analysis of time-to-event parameters, median TTP was 7 months and median duration of survival was 17 months, with the median duration of response 12.7 months in those patients with PR and CR^ref. Responses were associated with improved hemoglobin levels, decreased blood transfusion requirements, improvement in renal function and normalization of uninvolved immunoglobulins. Drug-related gastrointestinal toxicity and fatigue were in most cases manageable; significant thrombocytopenia and neuropathy occurred primarily in patients in whom these conditions were pre-existent, with treatment-emergent neuropathy seen in about a third of patients, and serious adverse events were relatively uncommon^ref.
• is superior to high-dose dexamethasone (40 mg orally on days 1 through 4, 9 through 12, and 17 through 20 for 4 5-week cycles) for the treatment of patients with MM who have had a relapse after 1 to 3 previous therapies^ref. Response rates were superior to those observed with dexamethasone regardless of the type of first-line therapy, with the exception of prior thalidomide treatment (Sonneveld P, Richardson PG, Schuster MW, et al. Bortezomib at first relapse is superior to high-dose dexamethasone and more effective than when given later in relapsed multiple myeloma. Haematologica 2005;90:Suppl 1:146-146). Based upon preclinical studies showing an additive anti-MM activity of Dex and bortezomib^ref, Dex was added in those patients who either progressed or achieved only stabilization of disease on bortezomib alone, with additional responses seen in 18% of those evaluable^ref. As a result of these encouraging data, US Food and Drug Administration (FDA) approval for bortezomib in the treatment of relapsed and refractory MM was given in 2003. An interim analysis of a Phase III international, randomized trial of bortezomib versus high-dose Dex in relapsed MM showed significant benefit in the bortezomib arm as assessed by time to progression and OS, resulting in the closure of the Dex arm and permitting all patients to cross over to bortezomib (Richardson PG, Sonneveld P, Schuster MW, et al. Bortezomib vs. dexamethasone in relapsed multiple myeloma: a phase 3 randomized study. Proc Am Soc Clin Oncol. 2004;23:558).
According to Trippoli et al.^ref and Sonneveld et al.^ref, life expectancy for patients with myeloma who are alive at 1 year after treatment is about 1.5 additional years (range, 0.253 to 2.472). Bortezomib costs € 49,077 ($59,991 in the USA at the current exchange rates) per patient on the basis of the schedule outlined in the article and current Italian prices. Considering that some treatment cycles are discontinued early because of side effects or death, the incremental cost of bortezomib as compared with dexamethasone is about € 40,000 ($48,942) per patient. Improving survival by 14% at 1 year gives a lifetime gain of at least 21 years (14 x 1.5) for every 100 patients. On the basis of these data, the cost per life-year gained for bortezomib as compared with dexamethasone is € 190,476 ($232,924). This analysis suggests that the benefit of bortezomib has a cost that exceeds current international benchmarks^ref. Anyway the critic was partially faulty, since the mean number of treatment cycles in the study was 6 rather than 11. The mean body-surface area of patients was 1.89 m² rather than 2 m². Furthermore, it is premature to use survival data to model cost-effectiveness on the basis of data from the Assessment of Proteasome Inhibition for Extending Remissions (APEX) trial, since fewer than one third of the events had occurred at the cutoff point for data collection. In a comprehensive, published analysis that was performed on the basis of data from patients with relapsed and refractory myeloma and that accounted for the costs of therapy, disease complications, and management of adverse events, bortezomib, as compared with best supportive care, had an incremental cost-effectiveness ratio of $45,356 per life-year gained^ref. In another analysis, bortezomib had an incremental cost-effectiveness ratio as low as € 25,271 ($30,910) per life-year gained (Bagust A, Haycox AR, Boland A, et al. Economic evaluation of bortezomib (VELCADE) for relapsed and refractory multiple myeloma. Blood 2004;104:80a-80a. abstract), suggesting that the ratio fell below the international benchmark^{ref1, ref2}. These findings suggest that bortezomib is a cost-effective option for patients with relapsed multiple myeloma^ref
• combination trials in which bortezomib has been administered with other agents in patients otherwise resistant to each agent alone :
• bortezomib + thalidomide^ref
• bortezomib + thalidomide + dexamethasone (VTD)^{ref1, ref2, ref3}
• Velcade (bortezomib), Doxil (pegylated liposomal doxorubicin) and thalidomide (VDT)^ref
• bortezomib + melphalan (Yang H, Swift R, Sadler K, et al. A phase I/II trial of Velcade and melphalan combination therapy (Vc+M) for patients with relapsed or refractory multiple myeloma (MM) [abstract]. Blood. 2003;102:235a)
• bortezomib + dexamethasone^ref
• bortezomib + pegylated liposomal doxorubicin^{ref1, ref2}
• bortezomib + dexamethasone + doxorubicin (Cavenagh JD, Curry N, Stec J, et al. PAD therapy (bortezomib, doxorubicin and dexamethasone) for untreated multiple myeloma (MM) [abstract]. Proc ASCO. 2004;23:568)
• bortezomib + non-myeloablative ¹⁵³Sm-EDTMP skeletally targeted radiotherapy in an orthotopic model of MM^ref
• arsenic trioxide (ATO)^ref has been identified as a third agent targeting the MM cell interacting with its BM microenvironment. As₂O₃ at clinically achievable levels induces apoptosis of drug-resistant MM cell lines and patient cells via caspase-9 activation, adds to Dex, and can overcome the anti-apoptotic effects of IL-6^ref. It also decreases MM cell binding to BMSCs, inhibits IL-6 and VEGF secretion in BMSCs induced by MM cell adhesion, and blocks proliferation even of those MM cells adherent to BMSCs. Clinical trials of As₂O₃ are ongoing.
• VEGFR inhibitors (including PTK787/ZK222584) have been identified as a promising therapy in MM as VEGF is expressed and secreted by MM cells and BM stromal cells with VEGF secretion by MM cells augmenting IL-6 secretion in BM stromal cells^ref. VEGF receptor tyrosine kinase inhibitor PTK787/ZK222584 blocks VEGF-induced tyrosine phosphorylation of Flt-1, MEK/MAPK activation, and proliferation as well as PKC activation-dependent migration^ref. These studies both define VEGF as a novel therapeutic target and provide the basis for a current Phase II clinical trial of the oral agent PTK787/ZK222584 in patients with relapsed MM.
• farnesyl transferase inhibitors (FTI) inhibit tumor cell growth both in vitro and in vivo. Cytokine (IL-6, VEGF, IGF-1)-induced proliferation of MM cells is mediated, at least in part, via the Ras/Raf/MAPK signaling, which provides the basis for both ongoing and recently reported Phase I/II clinical trials of two promising FTIs, SCH-66336 and R115777, in relapsed and refractory MM^ref
• histone deacetylases (HDACs) inhibitors^ref : novel hydroxamic acid-based hybrid polar compounds, such as suberoylanilide hydroxamic acid (SAHA), are histone deacetylase inhibitors that induce differentiation and/or apoptosis selectively in transformed and neoplastic cells. SAHA is an orally bioavailable HDAC inhibitor, which induces in vitro growth arrest and apoptosis of primary tumor cells from MM patients and cell lines, irrespective of their status of resistance to other agents^{ref1, ref2}
• + bortezomib^ref. Phase I studies in other malignancies have documented that SAHA is well tolerated, and a Phase I trial of this promising novel agent for the treatment of relapsed MM is underway. LBH589 is a novel hydroxamic acid derivative that at low nanomolar concentrations induces apoptosis in MM cells resistant to conventional therapies via caspase activation and poly (ADP-ribose) polymerase (PARP) cleavage. Significant synergistic cytotoxicity was observed with LBH589 in combination with bortezomib against MM cells which were sensitive and resistant to Dexamethasone (Dex), as well as primary patient MM cells. LBH589 at low nanomolar concentrations also induced -tubulin hyperacetylation. Aggresome formation was observed in the presence of bortezomib, and the combination of LBH589 plus bortezomib induced the formation of abnormal bundles of hyeracetylated a-tubulin but with diminished aggresome size and apoptotic nuclei. These data confirm the potential clinical benefit of combining HDAC inhibitors with proteasome inhibitors, and provide insight into the mechanisms of synergistic anti-MM activity of bortezomib in combination with LBH589^ref.
• heat shock protein 90 (hsp90) inhibitors is a molecular chaperone that facilitates the intracellular trafficking, conformational maturation, and proper 3-dimensional folding of a broad range of intracellular proteins required for cell proliferation, survival and drug resistance. Selective inhibitors of hsp90, such as ansamycin antibiotic geldanamycin (GA) and its analogs (e.g., 17-allylamino-17-demethoxy-geldanamycin or 17-AAG) have profound pro-apoptotic consequences on MM cells, regardless of their resistance to other agents. Gene microarray profiling has shown that bortezomib treatment induces a stress response in MM cells, which includes the compensatory upregulation of hsp90, in an effort of the tumor cells to escape the effect of proteasome inhibition; conversely, blocking this protective stress response with GA or 17AAG enhances bortezomib-triggered MM cell apoptosis^ref. A Phase I study of single agent 17-AAG in relapsed and relapsed, refractory MM patients is now ongoing (Mitsiades CS, Mitsiades N, Poulaki V, et al. Hsp90 inhibitors prolong survival in a SCID/NOD mice model of diffuse multiple myeloma: therapeutic implications. Blood. 2002;100:106a).
• P38a MAPK inhibitors mediates the production of various pro-inflammatory cytokines such as IL-1B, IL-6 and TNFa, which play a critical role in MM, and the targeting of P38a MAPK has been shown to inhibit MM cell growth and survival in the BM milieu^ref. An orally bioavailable P38a MAPK inhibitor (SCIO-469) is now entering Phase II study in relapsed, refractory MM in combination with bortezomib.
• IGF-1R / CD221 inhibitors (NVP-ADW742)^{ref1, ref2}
• PKB / Akt inhibitorsinduces in vitro and in vivo cytotoxicity in human MM cells^ref
• 2-methoxyestradiol (2ME₂), a natural endogenous product of estradiol metabolism, has demonstrated activity against tumor cell lines and can inhibit angiogenesis^ref
• radiotherapy : MM cells are highly radiosensitive, and local radiotherapy provides effective palliation for painful bone lesions^ref. However, the disseminated nature of MM precludes curative external beam radiation therapy due to unacceptable end organ toxicity^ref. Bone-seeking radioisotopes that bind to bone mineral are being tested in MM^ref, but their appeal and efficacy are limited by their inability to penetrate into the centers of myelomatous bone marrow deposits.
• (remission) maintenance therapy :
• thalidomide : preliminary results of the IFM99-02 trial show that, in patients with standard prognosis, maintenance treatment with thalidomide significantly prolongs EFS, as compared with no maintenance therapy^ref. It will be important to assess whether relapses of aggressive myeloma, such as those reported by Barlogie et al., also occur when thalidomide is reserved for maintenance therapy^ref or combined initially with chemotherapy at conventional doses (Palumbo A, Bringhen S, Musto P, et al. Oral melphalan, prednisone and thalidomide for multiple myeloma. Blood 2005;106:230a-230a). Another matter of importance concerns the dose- and duration-related toxicity of thalidomide, a complication that led to its discontinuation in 30% of patients within the first 2 years and in > 60% within 4 years in the study by Barlogie and colleagues. As in previous reports, deep-vein thrombosis and peripheral neuropathy were the chief adverse effects of thalidomide therapy
• prednisone 50 mg a.d.^ref
• IFN-a_2b 3 MIU 2 times a week for (delays relapse or up to 10 years)
• responding to conventional induction chemotherapy^ref
• in first plateau phase^{ref1, ref2}
• following high-dose chemotherapy^ref
• after high-dose treatment and autologous HSCT^ref
• IFN-a_2b + prednisone is more effective than IFN-a_2b alone^ref :
• hematopoietic stem cell transplantation (HSCT)^{ref1, ref2, ref3} :
• autologous HSCT : for patients responding to initial chemotherapy, ASCT is a safe (< 5% toxic deaths) and effective consolidation therapy. 30-50% complete remissions (CR) could be achieved with this approach in newly diagnosed MM and this more important tumor burden reduction can be converted into a prolongation of remission and of survival. Thanks to autologous transplantation of peripheral blood progenitor cells (PBPC) and to hematopoietic growth factors, the sequential use of 2 courses of HDT has become more feasible and appears to increase the CR rate and even to induce molecular remission), CD34⁺ selection, as well as modifications in the conditioning regimen to improve outcomes. Sensitive PCR techniques using patient-specific oligonucleotide primers show the persistence of up to 10% myeloma cells in the CD34⁺ cell fractions while highly purified CD34⁺lin^-90 / THY1⁺ stem cells do no apparently contain clonal myeloma cells^{ref1, ref2}, but substantial delay of neutrophil and platelet engraftment compared to unmanipulated PBPC grafts let the latter appear as the best source of stem cell for ASCT in MM.
• superiority of high-dose therapy (HDT) supported by autologous bone marrow transplantation (BMT) compared to conventional chemotherapy (CC) (alternating cycles of VMCP and of BVAP) aministered at 3-week intervals for 12 months for a total of 18 cycles) was first demonstrated by the Intergroupe Francophone du Myelome (IFM) 8 years ago^ref. In this randomized IFM90 trial HDT significantly increased the complete remission (CR) rate, the EFS and the OS in patients with newly diagnosed MM up to the age of 65. Following this publication, the number of ASCT performed worldwide as part of front-line therapy in younger patients increased dramatically. However some concerns remained until last year when the IFM90 results were fully confirmed by a larger trial published by the British Medical Research Council (MRC)^ref. Other randomized trials have been presented in meetings but not yet published (Fermand JP, Ravaud P, Katsahian S, et al. High dose therapy and autologous blood stem cell transplantation versus conventional treatment in multiple myeloma: results of a randomized trial in 190 patients 55 to 65 years of age [abstract]. Blood. 1999;94 (suppl 1):396a; Blade J, Sureda A, Ribera JM, et al. High-dose therapy/autotransplantation/intensification versus continued conventional chemotherapy in multiple myeloma patients responding to initial chemotherapy. Definitive results from Pethema after a median follow-up of 66 months [abstract]. Blood. 2003;102:42a; Palumbo A, Bringhen S, Petrucci MT, et al. A prospective randomized trial of intermediate dose melphalan (100 mg/m²) vs oral melphalan/prednisone [abstract]. Blood. 2003;102:984a; Barlogie B, Kyle R, Anderson K, et al. Comparable survival in multiple myeloma with high dose therapy employing Mel 140mg/m2 + TBI 12 Gy autotransplants versus standard dose therapy with VBMCP and no benefit from interferon maintenance: results of Intergroup trial S9321 [abstract]. Blood. 2003;102:42a). Although the details of CC and of HDT varied, the general outline of these studies were the same, except for the Spanish group trial where only patients responding to their initial CC were randomized.

study	no. of patients	age	CR Rate  (%)  (CC vs ASCT)	p value	median EFS  (months)  (CC vs ASCT)	p value	median OS  (months)  (CC vs ASCT)	p value
Intergroupe Francophone du Myelome (IFM90)ref	200	< 65	5 vs 22	< 0.001	18 vs 28	0.01	44 vs 57	0.03
Medical Research Council (MRC7)ref	401	< 64	8 vs 44	< 0.001	19 vs 31	< 0.001	42 vs 54	< 0.001
Myelome Auto Greffe (MAG91) (Fermand JP, Ravaud P, Katsahian S, et al. High dose therapy and autologous blood stem cell transplantation versus conventional treatment in multiple myeloma: results of a randomized trial in 190 patients 55 to 65 years of age [abstract]. Blood. 1999;94 (suppl 1):396a)	190	55-65			19 vs 25	0.05	45 vs 42	NS
PETHEMA, Spanish Cooperative Group (Blade J, Sureda A, Ribera JM, et al. High-dose therapy/autotransplantation/intensification versus continued conventional chemotherapy in multiple myeloma patients responding to initial chemotherapy. Definitive results from Pethema after a median follow-up of 66 months [abstract]. Blood. 2003;102:42a)	164	< 65	11 vs 30	0.002	34 vs 42	NS	67 vs 65	NS
US Inter Group (USIG) (Barlogie B, Kyle R, Anderson K, et al. Comparable survival in multiple myeloma with high dose therapy employing Mel 140mg/m2 + TBI 12 Gy autotransplants versus standard dose therapy with VBMCP and no benefit from interferon maintenance: results of Intergroup trial S9321 [abstract]. Blood. 2003;102:42a)	50		15 vs 17	NS	21 vs 25	0.05	53 vs 58	NS
Italian Multiple Myeloma Study Group (IMMSG) (Palumbo A, Bringhen S, Petrucci MT, et al. A prospective randomized trial of intermediate dose melphalan (100 mg/m2) vs oral melphalan/prednisone [abstract]. Blood. 2003;102:984a)	195	50-70	7 vs 26	< 0.0001	16 vs 28	0.0036	43 vs 58+	0.0008

CR defined either by a negative immunofixation (true CR) or by a negative electrophoresis (near CR) was significantly more frequent after HDT, except in the US Intergroup Study where the CR rate obtained with CC was higher than expected (15%). Median EFS was always longer with HDT compared to CC (4-12 months). The difference was significant in 5/6 trials (except in the Spanish trial, where patients refractory to initial CC were excluded). The median EFS is remarkably constant (25-31 months). It is more difficult to analyze OS results since OS partly depends on salvage therapy. However, median OS was significantly longer in the three studies where differences in EFS were more marked. In all studies procedure-related death rate was < 5% and not greater than that observed with CC. From this large experience one can now conclude that HDT supported by ASCT is the standard of care of patients with newly diagnosed MM, at least up to the age of 65. High-dose methotrexate (HDM) 200 mg/m² should be preferred to HDM 140 mg/m² plus TBI 8-12 Gy delivered in 4 fractions as the conditioning regimen for ASCT in MM; total marrow irradiation (9 Gy), busulfan (12 mg/kg) and cyclophosphamide (120 mg/kg) is another possibility^ref
• consolidation chemotherapy (CC) after single autologous peripheral blood stem cell transplant (auto-PBSCT) in 103 mostly newly diagnosed myeloma patients (67 patients were < or =6 months from the initial treatment). Patients received conditioning with BCNU, melphalan+/-gemcitabine and auto-PBSCT followed by 2 cycles of the DCEP+/-G regimen (dexamethasone, cyclophosphamide, etoposide, cisplatin+/-gemcitabine) at 3 and 9 months post-transplant and alternating with two cycles of DPP regimen (dexamethasone, cisplatin, paclitaxel) at 6 and 12 months post-transplant. With a median follow-up of 61.2 months, the median event-free survival (EFS) and overall survival (OS) are 26 and 54.1 months, respectively. The 5-year EFS and OS are 23.1 and 42.5%, respectively. Overall, 51 (49.5%) patients finished all CC, suggesting that a major limitation of this approach is an inability to deliver all planned treatments. In order to improve results following autotransplantation, novel agents or immunologic approaches should be studied in the post-transplant setting^ref
• tandem autologous transplantation : in the IFM90 trial, achievement of a least a very good partial remission (> 90% reduction of the M-component) was significantly correlated with longer survival. The impact of achieving CR on the duration of disease control and survival was confirmed by several investigators^ref. Thus, in MM as in other hematological malignancies, the primary objective of therapy should be to achieve CR. One way to increase the CR rate is to repeat intensive treatments. To this end, Barlogie and colleagues in Arkansas used a strategy with tandem ASCT^ref that appeared to increase the CR rate to approximately 40%. In newly diagnosed patients this better tumor cell reduction was translated into encouraging EFS and OS of 43 months and 68 months, respectively^ref. However, comparison with less aggressive strategies is needed to evaluate the actual impact of tandem ASCT on EFS and OS. The IFM was again the first to conduct a randomized trial (IFM94) comparing single and double ASCT^ref. In this study, 399 previously untreated patients under the age of 60 years were randomly assigned to receive either a single ASCT prepared by melphalan 140 mg/m² (Mel 140) plus total body irradiation (TBI) or a double ASCT, the first being prepared by Mel 140 and the second by Mel 140 plus TBI. On an intention-to- treat basis, CR or very good partial remission was achieved by 42% of patients in the single ASCT group versus 50% in the double ASCT group (P = 0.10). The probability of 7-year EFS was 10% versus 20% (P = 0.03) and the probability of 7-year OS was 21% versus 42%, respectively. These results are confirmed by a preliminary analysis of a comparable study conducted by the Bologna Group (Cavo M, Zamagni E, Cellini C, et al. Single versus tandem autologous transplants in multiple myeloma: Italian experience (abstract). The Hematol J. 2003;4:supp 1:560). The preliminary analysis of a Dutch trial reported by Segeren and colleagues yielded negative results, in that there was no improvement in outcome with more intensive therapy^ref. However, the updated results showed a significant advantage in term of EFS in the more intensive treatment group (Sonneveld P, Van Der Holt B, Segeren CM, et al. Intensive versus double intensive therapy in untreated multiple myeloma. Updated analysis of the prospective phase III study Hovon 24-MM [abstract]. The Hematol J. 2003;4, suppl 1:559-560). 2 other studies have been presented in part in meetings (Fermand JP, Alberti C, Marolleau JP. Single versus double high dose therapy supported with autologous blood stem cell transplantation using unselected or CD34 enriched ABSC: results of a two by two designed randomized trial in 230 young patients with multiple myeloma [abstract]. The Hematol J. 2003;4, suppl 1:S59; Goldschmidt H. Single versus double high dose therapy in multiple myeloma: second analysis of the trial GMMG-HD2 [abstract]. Proc Multiple Myeloma 2004 Meeting. Torino, Italy; 22-24 April 2004: 119). Although the CR rate is significantly higher in only 1 trial, the median EFS is significantly longer in 4/5 trials. A significant difference in OS was found only in the IFM94 trial but, since divergence of the OS curves occurred only after 4 years, longer follow-up is probably needed before drawing definite conclusions from other trials. The available data are in favor of tandem autotransplants. Results of randomized studies of single versus double autologous stem cell transplantation (ASCT) :

study	no. of pts	preparative regimen				CR rate (%)		EFS (months)		OS (months)
		age	single	double	difference	single vs  double	p  value	single vs  double	p  value	single vs  double	p  value
Intergroupe Francophone du Myelome (IFM94)ref	339	< 61	Mel140+TBI	Mel280+TBI	Mel140	42 vs 50	0.10	25 vs 30	0.03	48 vs 58	0.01
Myelome Auto Greffe (MAG) 95 (Fermand JP, Alberti C, Marolleau JP. Single versus double high dose therapy supported with autologous blood stem cell transplantation using unselected or CD34 enriched ABSC: results of a two by two designed randomized trial in 230 young patients with multiple myeloma [abstract]. The Hematol J. 2003;4, suppl 1:S59)	227	< 56	Mel140+ multidrug  + TBI	Mel280+ VP16+TBI	< Mel140	39 vs 37	NS	31 vs 33	NS	49 vs 73	0.14
Bologna (Cavo M, Zamagni E, Cellini C, et al. Single versus tandem autologous transplants in multiple myeloma: Italian experience (abstract). The Hematol J. 2003;4:supp 1:560)	220	< 61	Mel200	Mel320+  BU12	Mel120+  BU12	31 vs 43	NS	21 vs 31	0.02	56 vs 60	NS
German Multiple Myeloma Group (GMMG) (Goldschmidt H. Single versus double high dose therapy in multiple myeloma: second analysis of the trial GMMG-HD2 [abstract]. Proc Multiple Myeloma 2004 Meeting. Torino, Italy; 22-24 April 2004: 119)	261	< 66	Mel200	Mel400	Mel200	-	-	23 vs NR	0.03	-	-
Hovon (Sonneveld P, Van Der Holt B, Segeren CM, et al. Intensive versus double intensive therapy in untreated multiple myeloma. Updated analysis of the prospective phase III study Hovon 24-MM [abstract]. The Hematol J. 2003;4, suppl 1:559-560)	303	< 66	Mel140	Mel140+  Cy120+TBI	Cy120+TBI	13 vs 28	0.002	20 vs 22	0.01	55 vs 50	NS

As compared with a single infusion of stem cells, 2 infusions significantly prolonged both OS and EFS, particularly among patients who did not enter remission after receiving the first transplant^{ref1, ref2}. The benefit of melphalan-based double autologous transplantations was greatest in patients whose myeloma cells had a normal karyotype: these patients had an estimated probability of remaining in remission at 10 years of nearly 20%, suggesting that long-term control and even cure of MM are possible with double autologous stem-cell transplantation^ref
After 7 years, 42% of patients who got 2 rounds of HDT followed each time by a SCT were still alive, compared with 21% of those who received the standard single round of chemo plus a transplant. In addition to increasing life span, the second round of treatment doubled the chance of surviving 7 years without a recurrence of cancer (20% versus 10%). The difference was most striking for people who had not had a good response to the first transplant. Only 11% of those patients lived 7 years without a second transplant. With a second transplant, 43% survived that long. The combination of high levels of b₂m and chromosome 13 deletion allows identification of a high-risk subgroup of patients with de novo MM. In this population of patients, we have evaluated the impact of a murine anti-IL-6 mAb (BE-8) as part of the second conditioning regimen in a multicenter prospective randomized trial of tandem autologous stem cell transplantation (ASCT). Conditioning for the first ASCT was accomplished with melphalan 200 mg/m² and for the second one with melphalan 220 mg/m² + dexamethasone with or without BE-8 infusion. This trial included 219 patients, of whom 166 were randomized, 85 without BE-8 (arm A) and 81 with BE-8 (arm B). The median OS and EFS times of the whole group of patients were 41 and 30 months, respectively. Response rates, OS, and EFS were not different between the 2 arms of the trial. OS at 54 months was 46% in arm A and 51% in arm B (P = .90); median EFS was 35 months in arm A and 31 in arm B (P = .39). In high-risk patients the dose intensity of melphalan at 420 mg/m² led to encouraging results, but the addition of anti-IL-6 mAb to the second conditioning regimen did not improve either OS nor EFS^ref.
Between August 1993 and March 2003, 130 consecutive MM patients eligible for high-dose treatment were offered a program including up-front autologous HSCT after conditioning with 200 mg/m² melphalan followed by a second ASCT in case of relapse or progression. A total of 107 (82%) patients completed the first ASCT. The best response obtained after ASCT was CR 23%, VGPR 28%, PR 42%, and minimal response (MR) 7%. Median OS and EFS were 65.4 and 27.7 months, respectively. Relapse or progression occurred in 70 patients; 26 received a second autologous HSCT (with a median time of 20.4 months from first ASCT). A major response (> or =PR) was obtained in 69% of these patients. Median OS and EFS after the second ASCT were 38.1 and 14.8 months. TRM was 1.9% after the first autologous HSCT but no deaths occurred after the second. Elective up-front single ASCT followed by second ASCT after relapse or progression is a safe and effective global strategy to treat MM patients^ref.
• prognostic factors in the context of autologous HSCT : as with CC, a number of parameters have been shown to significantly influence the outcome after ASCT in newly diagnosed patients^{ref1, ref2}.
• standard biological markers that are important predictors of outcome after CC has also been demonstrated for ASCT.
• high levels of ß₂M^ref
• high levels of C-reactive protein
• high levels of LDH
• low levels of albumin
• age
• response to therapy^ref
• high bone marrow plasma-cell labeling index (PCLI)
• genetic abnormalities as evaluated by conventional cytogenetics or by molecular biology techniques appear to be powerful prognostic markers as well. Based on a large experience with tandem ASCT, statistical analysis performed by the Arkansas group has shown that hypodiploidy and cytogenetic abnormalities such as chromosome 13 deletions^{ref1, ref2} or myelodysplastic-like abnormalities^ref are associated with a poor prognosis^{ref1, ref2}
• del13q^ref either by conventional cytogenetics^{ref1, ref2} or by FISH^ref is an adverse prognostic factor. While metaphase-defined chromosome 13q deletion is found in only 15% of karyotypes, FISH detects this abnormality in approximately 45% of patients. However, when the deletion is found by conventional cytogenetics, the prognosis appears to be even poorer^ref.
• translocations involving 14q32 has also been studied retrospectively
• t(4;14)(p16.3;q32) : by FISH analysis,  is present in approximately 13% of patients and is associated with a short EFS and OS^{ref1, ref2}.
• t(4;14)(p16.3; q32) identified by elevated cyclin D1 levels as evaluated by real-time RT-PCR appear to enjoy longer remissions and to have longer survival^{ref1, ref2}
• -17p13
• presence of circulating myeloma cells (CMCs) does not predict for chemosensitivity but rather for short time to progression perhaps in part due to a higher proliferation rate as reflected by the higher PCLI. The poor outcome with CMCs should not be interpreted as justification for purging of the apheresis product since there is no evidence that purging of the hematopoietic stem-cell prior to transplantation confers any benefit^ref. CMCs may not be involved in posttransplantation relapse but may reflect loss of adhesion indicative of unfavorable biology. CMCs can be detected by :
• slide-based immunofluorescence method has been shown to predict early relapse of the disease after HDT/ASCT^{ref1, ref2}. However, this test is time-consuming, technically difficult, and not widely available.
• flow cytometry is widely available and can detect CMCs^ref. Detection of circulating myeloma cells at the time of diagnosis of multiple myeloma is associated with a shortened survival^{ref1, ref2}. The presence of CMCs is not a consequence of disease burden but suggests biologically aggressive disease^ref. Thus, we hypothesized that detection of CMCs by flow cytometry prior to hematopoietic stem-cell collection would be a predictor of biologically aggressive disease leading to early relapse regardless of initial response to HDT/ASCT therapy.
• achieving a CR is considered an important goal of HDT/ASCT, since various studies have shown that achieving a CR is associated with an improved TTP and OS^{ref1, ref2, ref3, ref4}. However, achieving a CR is not the only factor associated with an improved survival, since CR rates with single and tandem transplantations were not significantly different in the IFM 94 trial, yet patients who underwent tandem transplantation had an improved survival^ref. The lack of correlation between CR and OS and TTP has been reported in a smaller cohort of patients^ref
For instance, Barlogie and colleagues in Arkansas have shown that patients with low ß₂M (or low LDH) and no cytogenetic abnormalities have a good prognosis when treated with tandem ASCT^{ref1, ref2}. Patients with high ß₂M and cytogenetic abnormalities (especially hypodiploidy and/or chromosome 13 deletion) have a poor prognosis even with tandem ASCT, and for these patients new treatments are clearly needed^{ref1, ref2}. The IFM group has shown similar prognostic implications for the combination of ß₂M and chromosome 13 deletions detected by FISH analysis. Patients with low ß₂M and no chromosome 13 abnormality by FISH had a median OS of 111 months, while patients with high ß₂M levels and chromosome 13 deletions had a median OS of only 25 months. These findings led to the risk-adapted IFM99, with 2 different strategies for standard-risk patients (0 or 1 adverse prognostic factor) and for high-risk patients (2 adverse prognostic factors). The use of initial prognostic factors could also help in determining which patients benefit more from HDT. Unfortunately, in most randomized trials, the number of patients is too small to evaluate the impact of HDT in each prognostic subgroup. In the MRC7 trial comparing CC and HDT, there was a trend toward a greater survival benefit with HDT for the group of patients with a poor prognosis defined by a high ß₂M level (> 8 mg/L)^ref. In the IFM94 trial, double ASCT was superior to single ASCT in prognostic subgroups defined by ß₂M or LDH but, due to a small number of patients in each group, the difference was not statistically significant. The superiority of double ASCT was only significant in patients failing to achieve at least 90% reduction of the M-component within 3 months after one ASCT^ref. Therefore, according to available data HDT could be proposed to all patients and could be even more beneficial for patients with adverse prognostic factors. Blade and colleagues reported that there was no significant difference between CC and HDT in patients responding to initial CC in the Spanish Cooperative Group PETHEMA randomized trial (Blade J, Sureda A, Ribera JM, et al. High-dose therapy/autotransplantation/intensification versus continued conventional chemotherapy in multiple myeloma patients responding to initial chemotherapy. Definitive results from Pethema after a median follow-up of 66 months [abstract]. Blood. 2003;102:42a), suggesting that patients who fail to respond to their first treatment should undergo ASCT as well.
211 MM patients received autologous PBSCT at Hammersmith Hospital between 1994 and 2004 after conditioning with melphalan alone (183 patients), or melphalan and total blood irradiation (28 patients). The influence of age, type of MM, status prior and post ASCT, previous treatment regimens, time of ASCT from diagnosis, year of autograft, dose of re-infused CD34⁺ cells, plasma cell infiltration and b₂-microglobulin at diagnosis on overall survival (OS) and event-free survival (EFS) were evaluated to define patients with better prognosis. Median OS and EFS from transplantation were 50.9 and 20.1 months, respectively. Median OS from diagnosis was 68.8 months. TRM was 1.4%. Lower b₂-microglobulin levels, achievement of CR post transplant and lower plasma cell infiltration at diagnosis and transplant correlated with longer EFS and OS, whereas CR at transplant and low IPI at transplant correlated with better EFS. Higher CD34⁺ cell dose correlated with improved OS^ref.
• how to further improve the outcome of ASCT : in the IFM94 trial, the 7-year EFS following ASCT is only 20%
• improve pretransplant chemotherapy regimens :
• induction :
• improve conditioning :
• melphalan 200 mg/m² (Mel 200) is considered as the standard preparation regimen prior to ASCT^ref. In the absence of randomized trials, the benefit of other regimens using higher doses of melphalan, combinations of drugs, or melphalan coupled with bone-seeking radioisotopes remains unknown. It is clear, however, that in the context of tandem ASCT, the dose intensity of the preparative regimen is crucial. In the IFM94 trial^ref the CR rate was not significantly higher in the double ASCT arm, but the preparative regimen prior to the first ASCT was only Mel 140, while in the Arkansas experience the CR rate appears higher with 2 ASCT prepared by Mel 200 (Barlogie B, Kyle R, Anderson K, et al. Comparable survival in multiple myeloma with high dose therapy employing Mel 140 mg/m² + TBI 12 Gy autotransplants versus standard dose therapy with VBMCP and no benefit from interferon maintenance: results of Intergroup trial S9321 [abstract]. Blood. 2003;102:42a).
• "Total Therapy II" (Barlogie B, Jacobson J, Sawyer J, et al. Increasing CR frequency as a strategy toward extending event-free survival and overall survival in multiple myeloma: 4-year results of Total Therapy II versus Total Therapy I (abstract). Blood. 2003;102:42a). This is an aggressive protocol with 4 consecutive phases: increased intensity induction treatment (including combination chemotherapy with dexamethasone + cyclophosphamide + etoposide + platinum), tandem ASCT, consolidation chemotherapy and maintenance therapy with interferon + dexamethasone. This trial also addressed the possible contribution of thalidomide in a randomized trial design from initiation of treatment, but the thalidomide arm is still blinded. Current analysis of 462 patients included into Total Therapy II program compared to 231 patients treated with the previous "Total Therapy I" protocol shows a higher CR rate (66% versus 43%) and an increased 4-year EFS rate. This improvement was more marked for patients without cytogenetic abnormalities (4-year EFS 70% versus 37%)
• high-dose idarubicin 42 mg/m² + melphalan 200 mg/m² + cyclophosphamide 120 mg/kg as conditioning for autologous stem cell transplantation increases treatment-related mortality compared to melphalan 200 mg/m²  in patients with multiple myeloma^ref
• ¹⁵³Sm-EDTMP in myeloablative dosage followed by a second autotransplantation in patients with relapsed MM^ref
• 2 courses of pulsed-VAD (vincristine, adriamycin, dexamethasone) followed by 2 courses of DCEP (dexamethasone, cyclophosphamide, etoposide and cis-platinum) has an adequate mobilizing capacity, without significant toxicity, and a good anti-myeloma activity (a higher percentage of responses (CR+VGPR+PR) than VAD alone), and therefore represents a safe and effective therapeutic approach for multiple myeloma patients at the onset of their disease^ref
• allogeneic HSCT appear to offer a better chance for a possible cure of myeloma thanks to GVT effect (here renamed graft-versus-myeloma (GVM) effect) : if given early in the course of the disease, allogeneic BMT yields molecular remissions and about 33% of the patients remain free of disease 6 years later) but ...
• it is available only for a small minority of MM patients under 50 years of age and having a HLA identical sibling
• it has been associated with an unusually high transplantation-related mortality (TRM) mainly as a consequence of
• bacterial and fungal infections => advent of less toxic non-myeloablative BMT (miniallo-transplant) (conditioning regimen =
• low-dose TBI
• melphalan :
• MEL100 (100 mg/m²) : CR = 35%, EFS = 32 months; significantly reduced haematological and extra-haematological toxicity; tandem MEL100 was less toxic than tandem MEL200
• MEL200 : CR = 48%; EFS = 42 months; OS and TRM were not different
... combined with donor leukocyte infusion (DLI) has provided an 81% short-term survival in a trial combining this approach with an initial conventional autologous BMT to reduce tumor burden (as results are related to diseases status and relapse rate is high in patients with advanced disease). Level of chimerism did not correlate with either the quality of response or aGVHD. No significant differences were found between bone marrow and peripheral blood samples. Analogously, even if donor DNA percentage often resulted higher in the PMN fraction than in the mononuclear one, these differences were not significant after statistical analysis. On the other hand, cGVHD was associated with increased rates of FDC^ref
• GvHD => advent of CD6 T-cell depleted (TCD) allogeneic BMT reduces the incidence of GvHD but is associated to a higher relapse rate due to abrogation of GVT effect, which can ayway be maintained with prophylactic CD4⁺ donor leukocyte infusion (DLI) administered 6 to 9 months after BMT^ref.
Between 1989 and 2000, 71 patients received a myeloablative unrelated transplant for multiple myeloma; 70 patients consented for this analysis. The median recipient age was 44 years. A total of 31% of patients had received a prior autologous transplant. In all, 91% of patients engrafted. The 3-year cumulative incidence estimate of relapse was 34+/-10%. The incidence of grade II-IV GVHD was 47%. The Kaplan-Meier estimate for overall survival at 5 years was 9+/-7%. The 100-day treatment-related mortality was 42%^ref.
• high relapse rates
The use of allogeneic peripheral blood precursor cell (PBPC) trasplant (PBSCT) instead of BMT is associated with earlier engraftment but yields no significant survival benefits.
• standard (myeloablative) conditioning regimen still has a limited role in MM. Because of its toxicity, it can be proposed only to a small number of patients with MM (patients aged < 55 years with an HLA-identical sibling). Even in younger patients TRM is very high with standard regimens, mainly as a consequence of infection and GVHD. However, there are several arguments in favor of pursuing allogeneic SCT in MM:
• analysis of the European Blood and Marrow Transplantation Registry showed improved results in the late 1990s, mostly due to a higher frequency of early transplantation^ref
• comparison of autologous and allogeneic transplantations show that short-term survival is superior with autologous SCT, mainly due to a higher transplant-related mortality in the first year with allogeneic SCT. However, while patients treated with autologous SCT can experience late relapses, there is a plateau of the EFS and OS curves after 5 years for patients receiving allogeneic transplantation. Long-term survival could be superior with allogeneic HSCT^ref.
• the so-called GvM effect has been demonstrated by the efficacy of donor lymphocyte infusions in patients relapsing after allogeneic BMT^ref.
Therefore, recent clinical studies on allogeneic SCT in MM have focused on frontline therapy with the goal of reducing transplant-related mortality while harnessing the graft-versus-myeloma effect. One way to influence transplant-related mortality is to reduce the incidence and severity of GVHD by T cell depletion. While attempts to reduce GVHD have frequently been associated with a higher incidence of relapse, preliminary results of prophylactic CD4⁺ donor lymphocyte infusions after CD6 T cell depletion appeared promising^ref. But it has been recently shown that response to donor lymphocyte infusions is statistically related to the occurence of GVHD, suggesting that in MM, like in other hematological malignancies, targets for graft versus host and graft versus myeloma are identical or that antitumor activity is related to GVHD^ref. Finally, results of a Dutch prospective evaluation of T cell-depleted allogeneic SCT as part of frontline therapy were very disapointing^ref. In this series of 53 patients up to the age of 55 with an HLA-identical sibling, the CR rate was only 19% and median OS from transplantation was only 25 months. The cause of death was either disease progression or transplant-related toxicity.
Plasma cell chimerism after allogeneic HSCT is delayed in comparison to T-cell chimerism : increasing and stable chimerism were associated with ongoing remission in 15 out of 16 samples (93%), and decreases in chimerism predicted relapse in 5 out of 6 patients^ref
• reduced-intensity allogeneic transplantation : nonmyeloablative or reduced-intensity allogeneic SCT (so-called miniallogeneic transplantation) represents a new hope and a new way of taking advantage of the graft-versus-myeloma effect related to the donor immune system while reducing transplant-related toxicity. However, it has been shown that relapses are frequent when reduced-intensity regimens are used in patients with relapsed/refractory disease^{ref1, ref2}. In the past few years, reduced-intensity regimens have been widely used after tumor burden reduction with HDT + ASCT. The feasibility of reduced-intensity allogeneic transplantation after one or two ASCT has been shown^ref. HDT with melphalan 200 mg/m² supported by ASCT yields a high response rate with a low toxicity and a low transplant-related mortality. Allogeneic SCT with nonmyeloablative conditioning regimens provides a tumor-free stem cell source and reduces transplant-related mortality while harnessing the graft-versus-myeloma effect. Although the risk of acute GVHD and of infections related to chronic GVHD and its treatment remains, this approach appears to be safer than allogeneic BMT and can be proposed to older patients (up to 65 years of age). 2 groups have published their preliminary experience^{ref1, ref2} :

author	patients	age (median)	autologous SCT	RIC	GVHD	TRM	CR rate	median follow-up	survival
Maloneyref	54 (48% relapsed or refractory MM)	29-71 (52)	Mel 200	low-dose*  TBI (2 Gy )	38.5% aGVHD  II  46% cGVHD	100 days 2%  1-yr 15%	52%	18 m	2-yr EFS 55%  2-yr OS 78%
Krogerref	47 (23 unrelated donors)	31-64 (52)	Mel 200	Flu/Mel/ATG	32% aGVHD  II  32% cGVHD	100 days 6%	55%	15 m	3-yr EFS 54%  3-yr OS 70%
Gerullref	52 patients with relapsed MM or high-risk features at diagnosis received . Regimen-related toxicity was low. .	patients were heavily pretreated with a median of 8 cycles of conventional chemotherapy and one or more autologous transplants for all but one patient		2 Gy TBI alone (n=3) or with fludarabine (n=49) as conditioning	aGvHD II-IV occurred in 37% of patients, and 70% experienced cGvHD	567 days 17%			Estimated PFS and OS at 18 months was 29.4 and 41.1%, respectively. Patients with cGvHD had a significantly higher PFS, as did patients with up to 8 cycles of pretreatment chemotherapy vs those with >= 9. In this highly pretreated patient group, disease control was unsatisfactory and a potential strategy might be to perform allogeneic transplant earlier in the course of the disease.
Carellaref	16 with stage III MM	51							9 patients are alive in remission at a median of 30 months after their transplants, 1 patient is alive in relapse and 6 patients died of progressive disease (5) or extensive chronic GvHD, infections and progressive disease (1).

In both studies, all patients had sustained allogeneic engraftment, and at 100 days transplant-related mortality was low. However, due to acute or or chronic GVHD complications, 1-year nonrelapse mortality was 15% and 11%, respectively. Allogeneic transplantation with reduced-intensity regimens can be safety proposed to patients older than 50 years. This approach is highly effective, with a CR rate over 50%. Progression free survival and OS rates are encouraging, but the follow-up time is still short. Compared to allogeneic transplantation with a myeloablative conditioning regimen, miniallotransplantation is obviously associated with a much lower transplant-related mortality. The incidence of acute GVHD remains relatively high and is probably influenced by the conditioning regimen itself. Transplantation from unrelated donors is feasible^ref and could yield results comparable to those achieved with HLA-identical siblings. Conditioning regimens with high doses of antithymocyte globulin or with Campath 1-H could reduce the incidence of severe acute GVHD. The optimal procedure (conditioning regimen, type and duration of posttransplant immunosuppression, interval between auto- and allogeneic transplantation, and the role of donor lymphocyte infusions) remains to be determined. Longer follow-up is needed to evaluate the impact of this strategy on EFS and OS. Prospective multicenter trials comparing tandem autologous transplantation and tandem autologous/allogeneic transplantation are ongoing in the US and in Europe. Preliminary results of the IFM 9903-04 trial were presented at the 2003 ASH meeting^ref. This trial recruited patients with newly diagnosed MM up to the age of 65 and with 2 adverse prognostic factors (ß₂M level > 3 mg/L, presence of chromosome 13 deletion by FISH analysis). After four courses of VAD (vincristine, doxorubicin, dexamethasone), these patients received Mel 200 with ASCT. Then, according to the availibility of an HLA-identical sibling, they received either an autograft with reduced-intensity conditoning or a second allograft prepared by Mel 220 mg/m² (± anti-IL-6 antibody). There was no significant difference between the two strategies in terms of EFS or OS (both on an ITT analysis and when comparing actually received treatments). Although the follow-up is still short (median follow-up time 18 months), these results can be interpreted since the outcome in this subgroup of patients is usually poor even with tandem ASCT.20 Moreover it has been recently shown that deletion 13q detected by FISH remains a negative prognostic factor after allograft with reduced-intensity conditioning^ref. In this retrospective multicenter study, patients with 13q deletion (n = 31) had a lower 2-year EFS rate (18% vs 42%) and a lower 2-year OS rate (18% vs 47%). The major question regarding the use of allotransplantation in patients with newly diagnosed MM remains: Should it be proposed to all patients with an HLA-identical sibling (or even an HLA-identical unrelated donor) or should it be proposed to selected patients? For instance, considering the very good results obtained with tandem ASCT in patients with no adverse prognostic factors, is it justified to propose a therapy that carries a high risk of chronic GVHD and a 10%-15% incidence of toxic death? This question remains to be answered by ongoing prospective multicenter trials.
Different g/d T clones sustain GVM (MRD eradication) and aGVHD effects in MM patients after non-myeloablative transplantation^ref.
Sustained molecular remission by RIC allogeneic HSCT after autologous HSCT in a patient with MM^ref.
Associated with a high incidence of extramedullary relapses^ref.
• immunotherapy :
• vaccines :
• TSAs : idiotype
• idiotypic or DNA vaccination
• subcutaneous (s.c.) injections of autologous Id, conjugated to keyhole limpet hemocyanin (KLH) and in association with low doses of GM-CSF induced anti-KLH IgM and IgG (90% of patients), anti-KLH IgE (30%), anti-GM-CSF IgG (20%), anti-Id IgG (20%), and anti-Id IgE (30%) for almost 2 years after the end of treatment. Id-specific delayed type hypersensitivity skin tests were positive in 85% of tested patients^ref
• idiotype pulsed dendritic cells cancer vaccine (Mylovenge^©) appears now to be a feasible way to enhance innate or acquired immunity to help eliminate minimal residual disease (MRD) following autologous peripheral blood stem cell transplantation (ASCT)
• TAA : known genes, including ring finger protein 167, KLF10, TPT1 / p02 protein, cDNA FLJ46859 fis, and DNMT1, were related to the development of different tumors. Bioinformatics was performed to predict 12 novel multiple myeloma special antigen (MMSA) genes^ref
• monoclonal antibodies : there are relatively few surface antigens on the plasma cells that are suitable for antibody-directed treatment. Possible molecules include^ref ...
• anti-CD20 mAbs : rituximab administration following autologous SCT for MM is associated with severe IgM deficiency^ref
• anti-CD38 mAbs :
• anti-CD40 mAbs :
• anti-CD45 mAbs :
• anti-CD54 / ICAM-1 mAbs :
• HM1.24 :
• syndecan 1 :
• immuno-gene therapy
• plasma exchange
• bisphosphonates to diminish the painful skeletal complications
• combined kidney transplantation and HSCT in patients with end-stage renal disease (ESRD) to achieve donor-specific allotolerance through the induction of mixed lymphohematopoietic chimerism.
• conditionally replicating measles virus

• complete remission (CR) : absence of paraprotein on serum and urine electrophoresis (negative immunofixation) and < 5% plasma cells in the marrow
• very good partial response (VGPR) : decrease of 90% in the serum paraprotein level
• partial remission (PR) : decrease of 50% in the serum paraprotein level and/or a decrease of 90% in the urine BJ protein
• minimal response : decrease of 25% in the serum paraprotein level.

• 1950-54 : 6%
• 1960-63 : 12%
• 1970-73 : 19%
• 1974-76 : 24.1%
• 1977-79 : 26.3%
• 1980-82 : 28.1%
• 1983-85 : 28.0%
• 1986-88 : 29.3%
• 1989-91 : 29.6%
• 1992-97 : 28.7%

• traditional prognostic factors account for only 15-20% of outcome heterogeneity :
• [b₂-microglobulin]_serum > 4 mg/L at diagnosis
• high [CRP]_serum
• albumin
• abnormal metaphase karyotypes, present in 33% of newly diagnosed patients and reflecting stroma independence, have been consistently associated with a rapidly fatal outcome, and < 10% of patients with these abnormalities survive > 5 years
• primary translocations involving the immunoglobulin heavy chain locus at 14q32 in 40% of patients^ref. According to a consensus report of a recent Paris workshop on myeloma genetics, hyperdiploid and t(11;14)(q13,q32)⁺ myeloma are associated with a good prognosis, whereas non-hyperdiploidy, often associated with translocations other than t(11;14) and chromosome 13 deletion, imparts a strikingly dismal prognosis^ref.
• gene expression profiling (GEP) has become a routine method for the detailed analysis of gene activity in normal cell development and the disease process. Comparative GEP has been used with a limited number of genes (~6800) from CD138-enriched plasma cell RNA, obtained from patients with newly diagnosed myeloma, patients with MGUS, and normal healthy subjects, to identify genes that might play a role in the initiation and progression of myeloma^{ref1, ref2}.7,8 These studies revealed that newly diagnosed myeloma could be classified into four subgroups, with the two extremes being similar to either MGUS or myeloma cell lines. The myelomas with a myeloma cell line-like GEP signature also tended to have poor-risk features at presentation, such as elevated serum ß₂M (> 4 mg/mL) and cytogenetic abnormalities. These studies also revealed that, whereas MGUS and myeloma could be distinguished from normal plasma cells, these two conditions were difficult, if not impossible, to differentiate from each other. It is curious that MGUS appears to harbor all the hallmarks of overt malignancy, yet this condition rarely converts to overt myeloma requiring systemic therapy^ref. These data suggest that changes in the bone marrow microenvironment or failure of immune surveillance, rather than a genetic change in the tumor cell, may account for the malignant conversion of this benign plasma cell dyscrasia. Although myeloma manifests itself at the terminal differentiated stage of the B cell lineage, there is much speculation about the actual origins of the disease. Thus, to place myeloma in the context of plasma cell differentiation, we determined the molecular signatures of cells representing the late stages of human B cell development and showed that the GEP-defined high-risk form of myeloma has a tonsil B cell-like signature, whereas cells with low-risk features tend to be either bone marrow or tonsil plasma cell-like^ref. GEP profiling of CD138-selected plasma cells and CD19-selected B cells from the bone marrow of patients with Waldenström's macroglobulinemia revealed that both compartments exhibit signs of malignancy, with the plasma cells having either a tonsil plasma cell-like or a myeloma-like GEP signature (Shaughnessy J, Zhan F, Tian E, et al. Gene expression profiling of CD19 and CD138-enriched cells from Waldenstrom's macroglobulinemia (WM) reveals distinct classes and novel WM-specific genes [abstract]. Blood. 2002;100:1227abstract). Taken together, these data support the concept that Waldenström's macroglobulinemia, and possibly myeloma, may be derived from either terminally differentiated cells with various degrees of plasticity or from cells transformed at distinct stages of late-stage B-cell differentiation, with the ability to self-renew and produce progeny with partially differentiated phenotypes and transcriptome profiles. Nearly 40% of myelomas harbor 1 of 5 recurrent chromosomal translocations involving the immunoglobulin heavy (IGH) chain locus^ref. Given the transcription-activating nature of IGH translocations, GEP represents a valuable tool for identifying all myeloma-specific IGH translocations^{ref1, ref2, ref3}. Furthermore, genes that exhibit highly correlated expression patterns with these activated oncogenes may point to downstream targets of the deregulated genetic pathways resulting from their hyperactivation. Approximately 50% of myelomas harbor deletion of chromosome 13, and this abnormality is linked to poor survival^ref. We have mapped a putative myeloma tumor suppressor gene to a minimal region of deletion at 13q14, and we have recently used a combination of triple-color-interphase fluorescence in situ hybridization (FISH) and GEP to predict, with a high degree of accuracy, chromosome 13 deletion by GEP alone^ref (Zhan F, Hardin J, Bumm KH, et al. Global GEP can be used to accurately predict chromosome 13 deletion in MM [abstract]. Blood. 2001;98:1553). Finally, we have used GEP to investigate the mechanisms by which myeloma plasma cells contribute to the development of osteolytic bone lesions. Comparative GEP between myeloma patients with and without bone lesions demonstrated that elevated expression of the Wnt signaling inhibitor DKK1 by myeloma plasma cells is highly correlated with bone disease and that treatment of osteoblast precursors with serum from myeloma patients with high serum DKK1 could block BMP2/Wnt-induced differentiation of these cells into osteoblasts, suggesting a mechanism by which myeloma cells directly contribute to the development of osteolytic bone lesions in this disease^ref
• gene expression profiling to model the effectiveness of tandem autotransplantation for the treatment of Myeloma : GEP has been used to develop risk-adapted prognostic models for leukemias and lymphomas^{ref1, ref2, ref3, ref4, ref5, ref6, ref7}. The highly variable outcome in patients with MM, with very little of this variability being accounted for by current laboratory tests, prompted us to investigate if GEP could better model event-free (EFS) and overall (OS) survival in this disease as well. The GEP studies to be described are on CD138-enriched (> 90% CD38⁺/CD45^-) plasma cells from bone marrow aspirates taken from newly diagnosed myeloma patients entering the National Cancer Institute-sponsored Phase III clinical trial (Total Therapy II), which enrolled 660 patients from 1998 to 2003. In addition to tandem transplants with melphalan (200 mg/m²), Total Therapy II also randomized patients upfront to thalidomide or no thalidomide and provided one year of intensive consolidation therapy and an additional year of dexamethasone maintenance. Since 2000, we have performed GEP on pretreatment plasma cells from 351 consecutive patients entering the Total Therapy II trial with a median follow up of 25 months.
• Unsupervised Hierarchical Clustering of Global Gene Expression Patterns of Pretreatment Myeloma Plasma Cells Defines Biological and Clinical Subgroups : unsupervised hierarchical cluster analysis, based on a set of 4580 highly variable genes from ~10,000 tested (SD = 0.6) genes, segregated 221 myelomas into four discrete subgroups. These groups were characterized by significant differences in genetic features, such as chromosome ploidy (P < 0.01), trisomy 11 (P < 0.001), and 14q32 IGH translocations (P < 0.01), as well as by clinical parameters, such as IgA isotype, albumin (< 3.5 g/dL), ß2M (> 4 mg/L), creatinine (> 2 mg/d), MRI lesions (P < 0.05), and EFS (P = 0.002) and OS (P = 0.06). In the current unsupervised hierarchical cluster analysis, we noted a nonrandom distribution of spiked expression of recurrent translocation partners within the dendrogram-defined subgroups (Figure 2; see Color Figures, page 511). The data revealed that 26 of 30 CCND1 spikes were clustered in one subgroup whereas 28 of 32 MMSET/FGFR3, 4 of 5 MAF, and 3 of 4 MAFB spikes were all located in the same cluster branch. CCND1 expression, either low-level expression associated with chromosome 11 trisomy and hyperdiploid karyotypes or spiked expression linked to the t(11;14)(p13;q32) translocation and presence of normal karyotypes, defined two distinct subgroups with relatively low risk for relapse. Elevated expression of proliferation-associated genes, whether in a hyperdiploid or hypodiploid karyotype or MMSET/MAF/MAFB, defined 2 poor-prognosis subgroups. The MMSET/MAF/MAFB groups was more frequently associated with hypodiploid karyotypes, an IgA isotype, increased incidence of 14q32 translocations by FISH, and reduced incidence of MRI lesions, whereas the CCND1 spike group was significantly associated with normal cytogenetics. Taken together, our results highlight the relationship between the transcriptome, cytogenetics, and the biological and clinical features of myeloma. These findings extend and refine our previous gene expression classification system and provide further evidence that distinct molecular entities of myeloma exist.

Outcome in gene expression profiling (GEP)-defined myeloma subgroups.
Kaplan-Meier plots of overall survival (OS) (left panel) and event-free survival (EFS) (right panel), dated from initiation of Total Therapy II, according to the GEP subgroups. Numbers in brackets indicate 95% confidence interval. Note that risk of relapse is significantly different between the groups. As expected, Group IV has the shortest EFS, Group III exhibits an intermediate risk, and Groups I and II, which are essentially the same, have the best prognosis. Although the OS is not currently significant, a trend similar to the EFS is evident. Groups I-IV are defined as above. The cumulative number of patients does not equal 221 due to removal of patients who had a diagnostic gene array but failed to start the protocol.
• Cox Regression Modeling of Gene Expression Patterns in Pretreatment Plasma Cells Identifies Three Genes Associated with Rapid Relapse : because microarrays are not likely to become routine clinical tests, comprehensive global GEP studies will probably be used to identify a small subset of genes whose expression can be applied in the development of gene-based risk-adapted patient stratification, as has been recently done in lymphoma^ref. We used Cox regression modeling of gene expression on EFS in 212 newly diagnosed myeloma patients using data from U95Av2 microarray (~10,000 genes). The median follow-up at the time of this analysis was 20 months. There were 34 events representing either disease-specific death or progression/relapse. EFS was modeled by using standard prognostic values as well as by GEP using the Affymetrix signal. A generalized estimate of R2 was obtained by using the approach suggested by Cox and Snell (Cox DR, Snell EJ. The analysis of binary data (ed Second). London: Chapman & Hall; 1989). Gene expression values considered were based on significance of univariate association with EFS. The median signal call was used as a cut point prior to modeling inclusion. The 100 genes most significantly associated with EFS based on the score test were potential variables in multivariate modeling. Using standard prognostic variables only, the model that best fit disease-specific EFS was FISH13 (chromosome 13 deletion detected by FISH) and the presence of chromosomal abnormalities (CA).
Adjusting for CA and FISH13, three genes-RAN, ZHX-2, and CHC1L-were simultaneously significant, each at the P < 0.005 level. After adjustment for other model variables, patients with high RAN expression had increased risk of event while patients with high ZHX-2 or high CHC1L had decreased risk of event. After adjusting for these three genes and each other, FISH13 patients had an increased risk of event but those with CA did not. R2 for the FISH13 and CA model was 30%. The R2 value for the RAN, ZHX-2, and CHC1L model was 66%. It is important to note that each of these genes has independent prognostic influence, so the combination of RAN overexpression and loss of expression of ZXH-2 and CHC1L represents a much more powerful model than any other combination
High-risk myeloma defined by expression of 3 genes.
Cumulative incidence of event-free survival defined by the various combinations of expression of 3 genes. Note that only high RAN/low ZHX-2/low CHC1L shows dismal prognosis. It is important to note that the three-gene combination accounts for 66% of patient outcome variability. The best current models are near 30%.
We next compared the EFS between a high-risk entity (patients whose plasma cells express RAN above the median and ZHX-2 and CHC1L below the median; n = 45) and a low-risk entity (all remaining cases; n = 165). In this population, there were 30 events in the 45 high-risk patients (66%) and 30 events in the 165 low-risk patients (18%) (P < 0.0001). We next calculated the EFS based on the combination of GEP risk groups and CA. EFS rates were not significantly different between high-risk and low-risk disease with and without CA. However, high-risk and low-risk disease groups were significantly different irrespective of the presence of CA (P < 0.0001).
Gene expression profiling (GEP) model defines a high-risk disease and is not affected by presence of abnormal cytogenetics.
Left panel presents Kaplan-Meier curves for high-risk myeloma (high RAN/low ZHX-2/low CHC1L) and low-risk myeloma (all others). The right panel shows Kaplan-Meier curves for high-risk and low-risk disease with respect to the presence or absence of any cytogenetic abnormalities (CA). Note that the model is not influenced by CA, implying that GEP high-risk myeloma is a more robust indicator of poor prognosis than the current best prognostic variable.
• RAN, ZHX-2, and CHC1L Function Provides Insight into How These Genes Might Impart a High-Risk Phenotype
• RAN, which maps to 6p21, is a member of the Ras family of GTPase proteins that has a role in many aspects of cell biology, including shuttling protein and RNA in and out of the nucleus as well as regulating chromosome condensation, spindle formation, nuclear assembly, and cell-cycle progression^{ref1, ref2}. During interphase, RAN promotes nuclear localization signal-mediated protein import through the association and dissociation of transport complexes. A complex containing aster-promoting activities, importin /importin ß, forms in the cytosol and translocates across the nuclear pore. In the nucleus, Ran-GTP binds to importin ß and dissociates the transport complex. Ran-GTP and importin ß shuttle back to the cytosol, where Ran-GTP is hydrolyzed by cytosolic RanGAP1 and RanBP1, to form Ran-GDP. The polarized distribution of Ran-GTP across the nuclear envelope is maintained by the compartmentalization of RCC1 (RanGEF), RanGAP1, and RanBP1. The localization of RCC1 on chromatin promotes microtubule assembly in mitosis. During mitosis, importin  and importin ß sequester APA in an inactive form in regions where Ran-GTP is low. Increased levels of Ran-GTP near the chromosome promote local disassembly of APA components from complexes containing importin  and importin ß. In high Ran-GTP regions, importin ß associates with Ran-GTP, maintaining it in an inactive state until RanGAP1 and RanBP1 catalyze Ran-GTP hydrolysis. After dissociation from importin complexes, APA becomes active in promoting microtubule assembly^ref.
• The CHC1L gene (CHromosome Condensation 1-Like, also called E4.5)^ref maps to 13q14.3 in a region suspected to harbor a tumor suppressor gene for myeloma^{ref1, ref2, ref3}. Although we have evidence that the chromosome 13 tumor suppressor gene may be RB1^ref, this has not been proven. Reduced CHC1L expression has emerged as an integral component of a three-gene model for high-risk disease, and, consequently, it must be considered as a potential candidate tumor suppressor gene. Although the function of the product of CHC1L has not been completely described, it is a homologue of RCC1, which, as pointed out above, is the GTP exchange factor (GEF) for RAN^ref. CHC1L has been proposed to be a candidate tumor suppressor gene in both B-CLL30 and prostate cancer^ref. Thus, a loss of function of CHC1L may somehow influence the function of RAN and, together with the increased expression of RAN and loss of ZHX-2, may impart the aggressive phenotype on myeloma with this particular gene expression pattern. The poor MSK phenotype is conferred only by genetic interaction, in that gain of RAN or loss of CHC1L alone does not confer the aggressive phenotype. We are currently investigating whether CHC1L may have a RanGEF function in myeloma, if myeloma with activated RAN and loss of CHC1L has an altered ratio of nuclear and cytoplasmic RAN, and whether levels of Ran-GTP in the nucleus are altered in cases or/altered CHCTL.
• ZHX-2, the third gene in the model, has recently been cloned and has been shown to be a negative regulator of the NF-Y transcription factor^ref. This has important implications as the NF-Y complex is a master transcriptional regulator of many genes involved in cell-cycle control and proliferation, including CCNB1, CCNB2, CCND2, CDC2, CDC25, TOP2A, TK1, and others. There is a negative correlation between ZHX-2 expression and the expression of a panel of 30 proliferation-associated genes, including genes known to be positively regulated by NF-Y). The gene ZHX-2 maps to 8q24.3, very near the MYC oncogene. The loss of chromosome 8 by cytogenetic analysis imparts a very high risk of relapse, but not to death when patients are treated with high-dose therapy and peripheral blood stem cell transplants^ref. Reduced expression of ZHX-2 was linked to poor survival in Total Therapy II, which, based on its chromosomal locus, may provide a mechanistic explanation for why loss of chromosome 8 by conventional cytogenetics imparted such a high risk in Total Therapy I^ref. As would be expected from the results of the ZHX-2 correlation studies, overexpression of proliferation-associated genes is also linked to poor survival. Given the link between ZHX-2 loss and rapid development of resistance in myeloma to combination chemotherapy, it is noteworthy that NF-Y-mediated transactivation of the human ribonucleotide reductase subunit M2 is related to Gemcitabine resistance^ref. The transcription factor homeobox B4 (HOXB4) gene is preferentially expressed in immature hematopoietic cells and implicated in the transition from primitive hematopoiesis to definitive hematopoiesis as well as in immature hematopoietic cell proliferation and differentiation. Recent studies have shown that NF-Y cooperates with USF1/2 to induce the hematopoietic expression of HOXB4^ref. Thus, it is possible that myeloma cells that lose ZXH-2 upregulate HOXB4, and these cells acquire a stem cell-like phenotype and resistance to chemotherapy. The mechanism by which ZXH-2 expression is reduced and its potential function in multiple myeloma are currently under investigation. Elevated expression of cell cycle- and proliferation-associated genes is associated with poor event-free survival (EFS) (left) and overall survival (OS) (right).
Kaplan-Meier curves based on the 4 quartiles of CCNB1 (top), PCNA (middle), and BUB1B (bottom) gene expression. Q1 is the lowest quartile and Q4 is the highest. Note that all Q4 patients tend to do poorly.
Unsupervised hierarchical cluster analysis of gene expression patterns in CD138-enriched plasma cells from untreated myeloma patients allowed the identification of four subgroups of patients whose GEP signatures are highly correlated with distinct cytogenetic abnormalities, clinical parameters, and survival after high-dose therapy with peripheral blood stem cell transplant. These data lend credence to the concept that multiple myeloma consists of multiple disease entities with distinct mechanisms of transformation, as evidenced by the highly coordinated gene expression changes seen in each subtype. It is currently not clear whether this coordinated subgroup-specific expression occurs through the deregulation of distinct molecular pathways. However, if confirmed, these data could provide a framework for the development of novel therapeutic interventions based on the molecular biology of disease subtypes. Our experience over the last five years with the prospective application of genomic analysis of tumor cells from a uniformly treated population at diagnosis and follow-up suggests that myeloma is amenable to genomic classification. We firmly believe that a molecular classification of myeloma will prove useful in promoting the more effective application of current therapies and provide the framework for the development of novel therapeutic strategies based on common molecular features of each distinct subtype.
Please note that data described here are preliminary and based on the use of microarrays containing ~12,000 genes in a population of 221 patients. These models represent the most current iterations in our attempts to create a genomic classification of myeloma and have not been validated.

• Multiple myeloma
• Multiple myeloma : evolving genetic events and host interactions
• Current clinical and laboratory strategies to augment the efficacy of immunotherapy in multiple myeloma
• Chromosome translocations in multiple myeloma
• Benzene and multiple myeloma: appraisal of the scientific evidence

International Myeloma Foundation (IMF) Myeloma Institute for Research and Therapy in the Arkansas Cancer Research Center at University of Arkansas for Medical Sciences (UAMS) Multiple Myeloma Research Center at the Cleveland Clinic Multiple Myeloma Research Foundation (MMRF) Multiple Myeloma Research Web Server by Prof. Leif Bergsagel, MD, FRCP(C), Division of Hematology-Oncology, Weill Medical College of Cornell University Multiple Myeloma Discussion Area Myeloma Chat Room [registration required] Multiple Myeloma : how far have we come ? in Mayo Clinic Proceedings Myeloma mailing list at ACOR Amyloidosis mailing list at ACOR Multiple Myeloma Association (MMA) : MyelomaExchange Multiple Myeloma Multiple Myeloma Treatment

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