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  • 1
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    American Society of Hematology ; 2014
    In:  Blood Vol. 124, No. 21 ( 2014-12-06), p. 4743-4743
    In: Blood, American Society of Hematology, Vol. 124, No. 21 ( 2014-12-06), p. 4743-4743
    Abstract: Introduction. The spectrum and severity of organ involvement, usually dictate early outcomes in AL amyloidosis. With the advent of novel therapies, higher rates of responses have been noted. The goal of therapy is the prompt, profound and prolonged suppression of the AL clone. Based on the above mentioned, we performed a retrospective review of the use of bortezomib containing regimens to assess the rapidity and quality of response. Methods. Patients with documented AL amyloidosis treated with bortezomib-containing regimens were identified from our Institutional database. Trop-T and NT-proBNP values at baseline, 3, 6 and 12 months were recorded when available. Hematological Response, Cardiac response and OR were assessed according to the more recent validation of the criteria response. Results 31 patients treated with bortezomib-containing regimens from January, 2009 to April, 2014 were identified. Clinical characteristics are seen in Table 1. Median Troponin-T was 78 ng/L and median NT-pro-BNP was 680 ng/L. According to the Mayo Clinic staging criteria (2004): 12 patients were Stage I, 10 Stage II and 6 Stage III. Fourteen-patients received CyBORD (45%) and 15 patients bortezomib and dexamethasone in different combinations (48%). (Table 2) Seven-patients were previously treated and the rest received bortezomib-containing regimens as upfront therapy. ASCT was used in 2 patients and melphalan and dexamethasone in 5 more cases. After a median of 6 cycles (2-22), a HR was seen in 30 cases (96%) including: Complete Response in 10 (32%), Very Good Partial Response in 18 (58%) and Partial Response in 2 (6.45%). At 6 weeks, 29 patients had already achieved ³PR. Organ Response at 6 months was documented in 26 cases (83%). With respect to cardiac response, a ³30% decrease of Troponin-T was seen in 8 of 9 evaluable patients while a decrease of NT-proBNP of ³30% was observed in 7 of 7 evaluable cases (NTproBNP 〉 650ng/L) at a median of 6 months. Only one patient discontinued therapy due to toxicity. At the time of analysis, 4 patients have died and 6 have already progressed. In conclusion, bortezomib is a safe and tolerated therapy for AL patients showing rapid HR and cardiac responses assessed by NT-proBNP and TnT. The use of bortezomib in cardiac advanced disease is feasible but should be carefully monitored and dose adjustement is often required. Table 1. Clinical and Laboratory characteristics of patients with AL Amyloidosis treated with Bortezomib-containing regimens Clinical Characteristics N Median Range % Age (years) 31 64 29-86 Gender Male Female 14 17 45% 55% Kappa Lambda 5 26 16% 84% Renal Involvement 24 77% Cardiac Involvement 25 80% Hepatic involvement 4 12.9% ³3 organs involved by AL 9 29% Hemoglobin (g/L) 31 141 96-155 Creatinine (µmol/L) 31 75.5 38-1042 Albumin g/L 31 30 13-42 Alkaline phosphatase, units/L 31 88 55-311 B2-Microglobulin (mg/L) 31 3.2 1.63-14.7 24 Hr Proteinuria (g/d) 31 2.575 0-17.36 ***BMPC (%) 31 9.5 3-40 Intraventricular Septal thickness (mm) 31 11 10-16 Troponin T ng/L (normal 1-14) 28 78 1-167 **NT-proBNP (ng/L) (normal 〈 300) 29 680 53-4460 **NT-pro Brain Type Natriuretic Peptide *** BMPC: Bone marrow plasma cells Table 2. Treatment combinations and response rates for AL amyloidosis Regimen N % CyBORD 14 45% Bortezomib 1.3mg/m2 + Dexamethasone 15 48% Bortezomib 1.5 mg/m2 + Dexamethasone 1 3.2% Melphalan, Dexamethasone and Bortezomib 1 3.2% Overall Response Rate 30 96.7% Complete Response 10 32% Very good Partial Response 18 58% Partial Response 2 6.45% Less than PR 1 3.2% CyBORD: Cyclophosphamide, bortezomib and dexamethasone Disclosures Jimenez Zepeda: Janssen Ortho: Honoraria. Bahlis:Celgene: Honoraria, Research Funding.
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  • 2
    Online Resource
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    American Society of Hematology ; 2014
    In:  Blood Vol. 124, No. 21 ( 2014-12-06), p. 1202-1202
    In: Blood, American Society of Hematology, Vol. 124, No. 21 ( 2014-12-06), p. 1202-1202
    Abstract: Introduction The treatment of MM patient has improved over the past 10 years, with median PFS approaching 4 years after autologous stem cell transplant (ASCT). Recently, Roussel et al reported a phase 2 trial combining melphalan and bortezomib as conditioning regimen. In this trial, 70% of patients attained VGPR or better with at least 32% of patients in CR after a single course of HDT prepared by the Bortezomib/Melphalan (Bor/MEL) conditioning regimen, regardless of the type of induction therapy. Methods We retrospectively reviewed all cases treated with bortezomib in combination with Melphalan 200 mg/m2 (Bor/MEL) as transplantation conditioning regimen in patients with MM. Bortezomib was administered intravenously at 1 mg/m2 -1.3 mg/m2 on days −5, −2, 1, and 4. Melphalan was administered intravenously at 200 mg/m2 and stem cells were infused on day 0. In an attempt to determine whether this Bor/MEL conditioning regimen was superior to Melphalan alone (MEL), we secondarily compared our cohort with patients treated at the same time where this strategy was not used. Two-sided Fisher exact test was used to test for differences between categorical variables. P value of 〈 0.05 was considered significant. Survival curves were constructed according to the Kaplan-Meier method and compared using the log rank test. Results Fifty-seven patients with documented symptomatic MM undergoing ASCT using Bor/MEL conditioning from July 2010 to February 2014 were identified as well as 57 more in the control arm (MEL only). Clinical characteristics are shown in Table 1. At a median follow-up of 24.2 months in the Bor/MEL group and 20.9 months in the MEL group, 9 and 7 patients have died respectively (p=0.39). Seventeen patients in the Bor/MEL group (29%) and 24 pts in the MEL group (42%) had already progressed. (p=0.121) The CR/nCR rate was higher for the group treated with Bor/MEL and there was a trend of higher VGPR or better rate in this group as well. (p=0.024 and 0.07) (Table 2) Median Overall survival has not been reached in both groups and mean OS for Bor/MEL is 38.7 months versus 44.9 (p=0.66). Median OS was shorter for the group with HR cytogenetics treated with either Bor/MEL or MEL conditioning regimens (20 months vs NR) p=0.0001 while the median progression-free survival (PFS) was 29 months in the Bor/MEL group versus 25.1 in the MEL alone group. (p=0.5653) In addition, Median PFS was shorter in the group of patients with HR disease, 13 months versus 32.8 months in the SR group (p=0.0003) regardless of the use of either Bor/MEL or MEL alone. In conclusion, Bor/MEL conditioning regimen increases the rate of CR/nCR compared to MEL alone for patients with symptomatic MM undergoing ASCT. However, Median OS and PFS are shorter in the group of patients with HR disease even with the use of this strategy. Novel approaches in the HR disease should be considered such as continuous treatment and perhaps lenalidomide/bortezomib combinations in the maintenance setting. Table 1. Clinical Characteristics Characteristic Bor/MEL, N=57 MEL, N=57 p=value Age (median) 58 60 0.429 Gender Male Female 35 (61%) 22 (49%) 35 (61%) 22 (49%) 0.576 Hb (g/L) 114 117 0.288 Calcium (µmol/L) 2.21 2.27 0.227 Creatinine (µmol/L) 73 76 0.399 B2microglobulin (µmol/L) 3.24 2.5 0.415 Albumin (g/L) 31 35 0.098 Stage I Stage II Stage III 11 31 15 19 31 7 0.080 M-spike (g/L) 34 30.2 0.537 LDH (IU/L) 194 168 0.188 BMPC (%) 43 35 0.356 Heavy chain: IgG IgA FLC only 37 12 5 37 8 11 0.506 Light chain: Kappa Lambda Biclonal 37 19 1 42 14 1 0.356 High risk Standard risk 12 45 13 44 0.500 Table 2. Induction chemotherapy and response rate Characteristic Bor/MEL MEL P= value Induction chemotherapy -CyBORD -Velcade and Dexamethasone -RVD Others 19 (33%) 26 (45%) 12 (22%) 10 (17%) 31 (54%) 11 (19%) 5 (10%) 0.142 Induction Response ³VGPR 24 (42%) 22 (38%) 0.394 Day-100 response ³VGPR CR/nCR VGPR PR 〈 PR ³VGPR in HR disease 86% 12/13 (43%) 25 (43%) 6 (10%) 1 (1.8%) 91.6% (11/12) 78% 5/9 (24%) 31 (54%) 11 (19%) 1 (1.8%) 69% (9/13) 0.230 0.024 0.070 Maintenance Lenalidomide None 47 10 45 11 0.580 Consolidation RVD None 14 43 6 51 0.042 CyBORD: Cyclophosphamide, bortezomib and dexamethasone; RVD: Lenalidomide, bortezomib and dexamethasone Disclosures Jimenez Zepeda: Janssen Ortho: Honoraria. Bahlis:Celgene: Honoraria, Research Funding.
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  • 3
    In: Blood, American Society of Hematology, Vol. 124, No. 21 ( 2014-12-06), p. 5747-5747
    Abstract: Introduction Almost all patients with MM eventually relapse, and the remission duration in relapsed MM decreases with each regimen. Pomalidomide is an IMiD with antiproliferative, anti-inflammatory and anti-angiogenic effects that was recently approved for the use of relapsed MM failing lenalidomide and bortezomib. Based on these findings, we aimed to evaluate the efficacy of pomalidomide and dexamethasone (PD) for heavily-pretreated relapsed or refractory MM (RRMM) at our Institution. Methods We retrospectively reviewed the records of all patients with RRMM treated with PD at Tom Baker Cancer Center between 01/10 and 06/14. Eligible patients were age 18 years or older; had RRMM after two or more prior therapies (including lenalidomide, bortezomib or thalidomide); and had an Eastern Cooperative Group performance status of 0 to 2. Patients received oral pomalidomide 2-4 mg/d on days 1-21, and dexamethasone 20 mg or 40 mg on a weekly basis. Definitions of response and progression were used according to the EBMT modified criteria. The primary endpoint of the study was to assess the efficacy and feasibility of PD in this group of patients. All analyses were performed using the SPSS 20.0 software and all p-values were 2-sided and statistically significant if 〈 0.05 Results Between 01/10 and 06/14, 31 patients were identified for the study. Clinical and laboratory characteristics are listed in Table 1.The median age for this cohort of patients was 64 years (46-81). Seventy-one percent of patients had IgG isotype, 19.4% had IgA, and 9.7% had light chain only disease. The median number of therapies prior to PD was 4 (2-11). All patients received lenalidomide and bortezomib prior to PD; 11 patients had bortezomib, 8 had lenalidomide and 7 had both prior to PD. Six patients out of 11 receiving bortezomib prior to PD responded (54%) versus 12.5% (1/8), 14% (1/7), and 20% (1/5) for those receiving lenalidomide, lenalidomide/bortezomib and other regimens respectively prior to PD. (p=0.07) Two patients received pomalidomide at a dose of 3 mg, 1 at 2 mg and 28 at 4 mg. After a median of 5 cycles, the ORR was 29% (9/31) with 1 patient achieving nCR and 8 patients (25.8%) PR. (Table 2 ) The median time to first response was 8 weeks with majority of cases achieving at least PR after 2 cycles of therapy. Stable disease was seen in 22.6% and progression in 29% of cases. FISH cytogenetics at relapse were available in 24 patients with 6 cases exhibiting high risk disease (25%). At a median follow-up of 20 months, 16 patients (51.6%) are alive and 21 (67.7%) had already progressed. Median OS was 19.1 months and median PFS 5.6 months. Median PFS was 6.5 months in the group with SR cytogenetics compared to 3.1 months for the HR group. (p0.2) Median OS was similar between SR and HR (19.4 vs 23 months) (p=0.14) With regards to toxicity, 9 patients experienced grade 3/4 hematological toxicity. Eight patients required blood transfusion and one patient discontinued therapy due to grade 4 thrombocytopenia. In conclusion, Pomalidomide is an efficacious drug for the treatment of RRMM. The current report confirms the ORR seen in previous studies and the benefit in HR disease. Further combinations with pomalidomide in the setting of HR disease and for those patients who immediately progressed on IMiD therapies should be considered. Table 1. Clinical and Laboratory characteristics for RRMM patients treated with Pomalidomide and Dexamethasone Characteristic N Median Range % Age (years) 31 64 46-81 Gender -Male -Female 14 17 45.2% 54.8% ISS Stage I II III 5 14 12 16.1% 45.2% 38.7% Heavy chain IgG IgA Free light chain only Light chainKappa Lambda 22 6 3 25 6 71% 19.4% 9.7% 〈 ![if !supportEmptyParas] 〉 〈 ![endif] 〉 80.6% 19.4% Hemoglobin (g/L) 31 113 75-142 Creatinine (µmol/L) 31 86 50-290 Calcium (µmol/L) 31 2.3 2.06-2.64 LDH (IU/L) 31 189 84-489 B2-microglobulin (mg/L) 31 4.2 1.36-16.3 Albumin (g/L) 31 33 21-42 BMPC (%) 31 30 8-98 FISH Cytogenetics Standard risk High risk 24 18 6 75% 25% Prior Therapies ASCT Thalidomide Lenalidomide Bortezomib Carfilzomib 21 13 31 31 6 67.7% 41.9% 100% 100% 19.4% Table 2. Response rates for RRMM patients treated with Pomalidomide and Dexamethasone Characteristic Median (Range) N % Number of cycles 5 (1-31) Overall Response rate 9/31 29% Near Complete Response Complete Response 1 0 3.2% 0% Very Good Partial Response 0 0% Partial Response 8 25.8% Stable Disease 7 22.6% Minimal Response 6 19.4% Progression 9 29% Alive 16 51.6% Disclosures Jimenez Zepeda: Janssen Ortho: Honoraria. Bahlis:Celgene: Honoraria, Research Funding.
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  • 4
    In: Blood, American Society of Hematology, Vol. 124, No. 21 ( 2014-12-06), p. 170-170
    Abstract: Background: Immunomodulatory (IMiDs) drugs are now recognized as modifiers of the degrons targeted by the CLR4-CRBN E3 ligase. Lenalidomide binding to CRBN promotes the proteasomal degradation to the B cell specific zinc finger transcription factors Ikaros (IKZF1) and Aiolos (IKZF3) and the transcriptional repression of IRF4 and MYC. Loss of CRBN thalidomide binding domain as well as the expression of mutants IKZF1Q146H or IKZF3Q147H confer resistance to IMiDs in vitro; however these events are rare in primary MM cells. In addition over-expression of IRF4 only partially protects MM cells from the anti-proliferative effects of IMiDs suggesting that a yet unidentified Aiolos dependent mechanism(s) regulate IMiDs sensitivity. Methods and Results: In order to identify novel mechanisms of resistance to IMiDs we profiled the transcriptome of IMiDs treated patients (sensitive and resistant), MM cell line (MM1S) exposed to lenalidomide and Aiolos silenced MM cells (OPM2). In primary samples, RNA-seq analysis was performed on paired CD138 selected cells sequentially collected from patients’ BM prior to lenalidomide treatment initiation (n=15) and at the time of acquired resistance (n=12) or ongoing response to therapy (n=3). Transcriptome sequence data was generated on the Ion Torrent Proton platform with a minimum of 70x106 reads per sample. Filtered Fastq files were mapped with the TopHat2 splice aligner against hg19. DESeq2 was used to detect differentially expressed (DE) genes. Amongst lenalidomide sensitive patients a total of 870 genes were identified as differentially expressed (FDR 〈 0.1) between the pre- and post-lenalidomide paired samples. Functional annotation of these DE genes using DAVID revealed enrichment of genes involved in immune mediated responses (Gene-Ontology). Of interest interferon γ (IFNγ) was upregulated 3.3 fold in the post-lenalidomide sensitive cohort and 20.4% of the DE genes are type I and II interferon regulated genes (Interferome v2.01). A similar Interferon type of response was also observed in MM1S (Len-sensitive MM cell line) and post Aiolos knockdown of OPM2 cells but not in the lenalidomide resistant cohort. Notably, while several genes that are required for the induction of an interferon response (IL1α, IL1β, TBK1, NLRP3) were upregulated post-lenalidomide in the sensitive cohort, they were downregulated in resistant patients. Of particular interest, two genes that play a key role in modulating IFN response were differentially expressed in the Len resistant cohort: 1) NLRP4 a member of the nucleotide-binding oligomerization domain (NOD)-like receptors (NLRs) was significantly upregulated in lenalidomide resistant patients. NLRP4 negatively regulates type I IFN signaling by targeting the kinase TBK1 for proteasomal degradation and is also recognized to suppress autophagy through Beclin1; 2) NFKBIZ (IkBζ), an atypical IkB kinase required for the induction of IFN response was significantly reduced in lenalidomide-resistant patients. Validation of this lenalidomide induced IFN response was carried out in vitro in MM cells exposed to lenalidomide 10 μM for 24 and 72 hours. A significant increase in IFN stimulated genes (ISGs) such as XAF1, DDX58, IFIT3 was observed following lenalidomide treatment. Similar changes were observed in Aiolos knockdown MM cells. Functionally, silencing of NFKBIZ (through lentiviral shRNA or transient siRNA expression) in MM1S cells resulted in 30% reduction in lenalidomide induced cell death and supressed p21 upregulation but had no effect on the downregulation Aiolos, IRF4 and MYC. Similarly stable overexpression of NLRP4 in MM cells, conferred resistance to lenalidomide. Conclusions: Through comparative transcriptome profiling of lenalidomide resistance and sensitive patients we have identified an Aiolos-dependent induction of interferon stimulated genes as a novel mechanisms of IMiDs mediated cytotoxicity and identified NLRP4 and NFKBIZ as potential mediators of IMiDs resistance. Disclosures Bahlis: Celgene: Honoraria, Research Funding.
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  • 5
    In: Blood, American Society of Hematology, Vol. 124, No. 21 ( 2014-12-06), p. 3432-3432
    Abstract: Numerous cellular effects have been attributed to IMiDs lenalidomide (LEN) and pomalidomide (POM) over the years. However, the zinc finger transcription factors Aiolos (IKZF3) and Ikaros (IKZF1) were identified only recently as substrates targeted for destruction in the presence of IMiDs compounds. LEN and POM bind directly to cereblon (CRBN), a substrate receptor of the cullin ring E3 ligase 4 (CRL4). Binding of these compounds to CRBN triggers the activation of CRL4CRBN, ubiquitylation and destruction of Aiolos and Ikaros. We systematically compared growth, gene expression, and signal transduction responses elicited by doxycycline-inducible, stable Aiolos knockdown or POM treatment in MM cell lines, and their POM-resistant counterparts. Upon exposure to POM, U266 MM cells undergo rapid degradation of Aiolos and Ikaros (90 min) and subsequent downregulation of IRF4 and Myc at 72 hr. At 72-96 hr, a decrease in proliferation and an increase in apoptosis are also observed. U266 MM cells selected in vitro for resistance to POM have lost CRBN expression and consequently no longer downregulate Aiolos and Ikaros after POM administration. Knockdown of Aiolos in these POM-resistant U266 MM cells is sufficient to inhibit their proliferative capacity by 50%, while Aiolos knockdown in POM-sensitive cells caused a greater inhibition of proliferation (90%). This suggests that MM cells with acquired resistance are still dependent on Aiolos for growth, but that a second mechanism may contribute to the antitumorigenic effect of Aiolos downregulation in POM-sensitive U266 cells. We have found that treatment with LEN or POM induces expression of antiviral response genes in MM cells. The induction of interferon (IFN)-stimulated genes (ISGs) such as DDX58, IFIT1, IFIT3, XAF1, ISG15, IFI44, and IFI27 are seen by qPCR in 8 hr of compound treatment (1.8- to 5-fold increase in transcript level) and this effect is further enhanced at 24 and 72 hr. Of note, this response is not accompanied by an increase in β IFN production. The IMiD compound-induced upregulation of the antiviral response correlates with CRL4-CRBN-mediated destruction of the lymphoid restricted transcription factor, Aiolos. In agreement with this, Aiolos knockdown by shRNA is sufficient to trigger a similar effect. These data suggest that Aiolos functions as a transcriptional repressor of ISGs, regulating the antiviral response. Consequently, Aiolos chromatin immunoprecipitation and sequencing (ChIP-Seq) experiments were performed, demonstrating that Aiolos binds near the transcription start site of numerous ISGs, including DDX58, IFIT1, ISG15, XAF1, IFI44, and IFI35. In addition, our data suggest that Aiolos co-binds with STAT and IRF family transcription factors and thereby co-regulates expression of these genes. STAT1 is part of the ISGF3 complex that drives ISG transcription upon viral infection. POM-resistant MM cells lacking CRBN expression do not have STAT1 activity and do not upregulate ISGs upon Aiolos knockdown, even though Myc and IRF4 are still being downregulated. In order to elucidate the relevance of the ISG expression in patients receiving IMiD treatment, we compared the gene expression profile of 12 patients after relapse or disease progression. Paired pre- and posttreatment samples from bone marrow-isolated CD-138 cells were evaluated with RNAseq and gene set enrichment analysis. We found an overall decrease in expression of ISGs, with significant negative enrichment of genes involved in IFN α, β, and γ signaling in relapsed patients. These data from clinical samples confirmed the importance and relevance of the ISGs in the response to IMiDs. In conclusion, our results indicate that Aiolos is a substrate of consequence in IMiD-sensitive MM cells, based on at least 2 pathways: driving the Myc-IRF4 feedback loop and repressing the antiviral pathway. Both in vitro and in vivo patient data suggest that one mechanism of IMiD resistance may be the abrogation of the STAT1 pathway resulting in subsequent blunting of the ISG induction. Finally, while upregulation of ISGs by IMiD treatment may serve as a relevant diagnostic marker of patient responsiveness to these drugs, these data highlight how response and resistance of the IMiD drugs are regulated by the interplay between complex pathway networks, suggesting that the measurement of only one component will not necessarily define the clinical course and outcomes for an individual patient. Disclosures Havens: Celgene Corporation: Employment, Equity Ownership. Bjorklund:Celgene Corp: Employment, Equity Ownership. Kang:Celgene Corp: Employment, Equity Ownership. Ortiz:Celgene Corp: Employment, Equity Ownership. Fontanillo:Celgene Corp: Employment, Equity Ownership. Amatangelo:Celgene Corporation: Employment, Equity Ownership. Lu:Celgene Corp: Employment. Lopez-Girona:Celgene Corp: Employment, Equity Ownership. Bahlis:Celgene Corp: Honoraria, Research Funding. Thakurta:Celgene Corp: Employment, Equity Ownership. Trotter:Celgene Corp: Employment, Equity Ownership. Gandhi:Celgene Corp: Employment, Equity Ownership. Klippel:Celgene Corp: Employment. Chopra:Celgene Corp: Employment, Equity Ownership.
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  • 6
    In: Blood, American Society of Hematology, Vol. 124, No. 21 ( 2014-12-06), p. 639-639
    Abstract: Background: IMiDs cytotoxicity in MM cells is mediated through their binding to CRBN within the cullin ring (CRL4) ligase. This binding triggers the ubiquitylation and proteasomal degradation of IKZF1/3. CRBN thalidmomide binding domain (TBD) was mapped to its C-terminus and the crystal structure of the CRBN-IMiDs bound complex identified several aa within exons 10 and 11 as essential for the IMiDs glutarimide ring binding to CRBN. Several groups including ours have reported that loss of CRBN is associated with resistance to IMiDs, however this does not appear to be the sole mechanism of resistance in primary MM cells. Furthermore, and while CRBN mutants (Y384A and W386A) are defective for IMiDs binding, acquisition of CRBN mutation is a rare event in MM patients suggesting alternative mechanisms of resistance. Thirteen splice variants of CRBN are reported (ensembl.org), however to date it is unclear whether these isoforms are expressed as proteins and their contribution to IMiDs resistance is yet to be defined. Methods and Results: In this study we investigated whether expression of full length CRBN (FL-CRBN) relative to its variants lacking the TBD and particularly the splice variant CRBN-005 (ENST00000424814) lacking exon 10, contribute to IMiDs resistance. RNA-seq analysis was performed on CD138 sorted cells in 15 paired patients samples obtained sequentially prior to lenalidomide treatment initiation and after development of resistance. Transcriptome sequence data was generated by RNA-seq with a minimum of 70x106 reads per sample. Filtered Fastq files were processed with the splice aligner TopHat against hg19. Of interest, splice isoforms of CRBN including isoforms lacking exon 10 and to a lesser extent exon 8 were identified in nearly all patients, albeit with at variable frequency. Splicing almost universally involved the full length of exon 10 including aa W382 and H378 that are now recognized to bind the 2 carbonyls residues on the IMiDs glutarimide ring and hence required for IMiDs binding to CRBN. Of note, mutation analysis of these 30 samples using the GATK RNAseq pipeline did not identify any mutations within CRBN exons 10 or 11. Furthermore, exome sequencing of CD138 cells from 10 additional lenalidomide resistant patients did not identify any CRBN SNVs or indels confirming the rarity of this event. In order to assess the contribution of FL-CRBN transcript and/or its splice variant (CRBN-005) to IMiDs sensitivity, we first confirmed by qRT-PCR (n=26, amplicons with 2 sets of primers overlapping exons 8-9 and exons 10-11) that low pre-treatment CRBN levels was significantly associated with shorter PFS (p=0.008) to lenalidomide. We next compared FL-CRBN (probe spanning exons 10-11) and CRBN-005 (Taqman probe spanning exons 9-11 junction) mRNA expression (qRT-PCR) in paired samples (n=21 patients - 42 pairs) collected immediately pre-treatment and at the time of progression post-lenalidomide. In 9/21 (42.8%), a significant reduction (2-ΔΔCT 〈 0.75) in the FL-CRBN amplicon levels was observed between the paired pre- and post-treatment samples. The ratio of spliced CRBN-005 to full length CRBN (CRBN-005 / FL-CRBN) was significantly higher (1.3 to 54 fold) at the time of relapse in 11/21 (52.3%), including 5 patients where CRBN-FL transcript levels were unchanged. Lastly, to confirm whether CRBN-005 expresses a stable protein and to evaluate its role in IMiDs resistance, we cloned spliced CRBN-005 isoform (Δ10-CRBN) or full length CRBN (WT-CRBN) into pcDNA3 plasmid and transfected them in HEK293T cells. The Δ10-CRBN and WT-CRBN plasmids expressed a ~ 45 and 51 kDa proteins respectively that were detectable by western blotting with CRBN65 antibody (Celgene). Functionally, we co-transfected HEK293T cells with a lentiviral plasmid expressing Aiolos and the Δ10-CRBN or WT-CRBN plasmids. While treatment of WT-CRBN expressing cells with lenalidomide resulted in full loss of Aiolos, the expression of Δ10-CRBN significantly mitigated this effect. Conclusions: Study of the transcriptome of paired pre- and post-IMIDs in myeloma primary cells confirms the expression of CRBN-005 splice isoform lacking the IMiDs binding domain and reveals its enrichment in a subset of IMiDs resistance patients. Functionally we have demonstrated a novel mechanism of IMiDs resistance where the spliced isoform CRBN-005 acts as a dominant negative blocking IMiDs binding the CRL4 E3 ligase. Disclosures Bahlis: Celgene: Honoraria, Research Funding.
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    Publisher: American Society of Hematology
    Publication Date: 2014
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  • 7
    In: Blood, American Society of Hematology, Vol. 124, No. 21 ( 2014-12-06), p. 5751-5751
    Abstract: Introduction With the advent of novel drugs for the treatment of Multiple Myeloma (MM), the clinical outcomes have significantly improved over the last decade both in the setting of stem cell transplant eligible and non-eligible patients. Combinations of novel drugs have improved and deepened response and this is true for CyBORD, a regimen able to induce rapid and deep responses. Based on the above mentioned, we aimed to assess the role and feasibility of CyBORD as upfront therapy for non-transplant eligible patients with MM. Methods. All consecutive patients with documented symptomatic MM not eligible for transplant treated with CyBORD at our Institution were evaluated. Treatment consisted of a 28-day cycle of bortezomib 1.3 mg/m2 or 1.5 mg/m2 intravenously or subcutaneously on days 1, 8, and 15, cyclophosphamide 300 mg/m2 orally administered on days 1, 8, and 15 and dexamethasone 20-40 mg orally on weekly basis. Definitions of response and progression were used according to the EBMT modified criteria and a category of very good partial response (VGPR) was added. The primary endpoint of the study was to assess the efficacy and feasibility of CyBORD in this group of patients. All analyses were performed using the SPSS 20.0 software and all p-values were 2-sided and statistically significant if 〈 0.05. Results Between 07/11 and 07/14, 20 patients were identified for the study. Clinical and laboratory characteristics are listed in Table 1. The median age for this cohort of patients was 76 years (range 66-90). Sixty-five percent of patients had IgG isotype, 5% had IgA, and 30% had light chain only disease. After a median of 5 cycles, the overall response rate was 95% (19/20) with 70% of patients achieving VGPR or better response. (Table 2 ) The median time to first response was 6 weeks with majority of cases achieving at least PR after 2 cycles of therapy. At a median follow-up of 9.5 months, all patients are alive and 5 had already progressed at a median time of 12 months. With regards to toxicity, 6 patients experienced non-hematological grade 3/4 adverse events (20%), including muscle weakness, sepsis and pneumonia. Neutropenia and thrombocytopenia were seen in 2 patients (10%), both patients required dose reduction of cyclophosphamide with one patient being discontinued of cyclophosphamide after 2 cycles but still receiving bortezomib and dexamethasone. In conclusion, CyBORD is a highly active and viable option for the treatment of non-transplant eligible patients with MM. As suggested by other studies, elderly patients required dose adjustments and special considerations while receiving active therapy, balancing the efficacy and toxicity given by the different drug combinations. Table 1. Clinical and Laboratory characteristics of non-transplant eligible MM patients treated with CyBORD Characteristic N Median Range % Age (years) 20 76 66-90 Gender -Male -Female 11 9 55% 45% ISS Stage I II III 5 7 8 25% 35% 40% Heavy chain IgG IgA Free light chain only Light chainKappa Lambda 13 1 6 11 9 65% 5% 30% 55% 45% Hemoglobin (g/L) 20 106 73-158 Creatinine (µmol/L) 20 117 49-671 Calcium (µmol/L) 20 2.4 2.0-2.99 LDH (IU/L) 20 229 118-814 B2-microglobulin (mg/L) 20 4.1 1.41-19 Albumin (g/L) 20 32 22-37 FISH Cytogenetics Standard risk High risk 18 2 90% 10% Table 2. Response rates for non-transplant eligible MM patients treated with CyBORD Characteristic Median (Range) N % Number of cycles 5 (1-12) Overall Response rate 19/20 95% Near Complete Response Complete Response 1 2 5% 10% Very Good Partial Response 11 55% Partial Response 5 25% Less than PR 1 5% Progression 5/20 25% Time to progression (months) 12 (3-15) Alive 20 100% CyBORD: Cyclophosphamide, bortezomib and dexamethasone Disclosures Jimenez Zepeda: Janssen Ortho: Honoraria. Bahlis:Celgene: Honoraria, Research Funding.
    Type of Medium: Online Resource
    ISSN: 0006-4971 , 1528-0020
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    Language: English
    Publisher: American Society of Hematology
    Publication Date: 2014
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  • 8
    In: Blood, American Society of Hematology, Vol. 124, No. 21 ( 2014-12-06), p. 3422-3422
    Abstract: Background and rational: The B cell specific zinc finger transcription factors Ikaros (IKZF1) and Aiolos (IKZF3) were recently identified as ubiquitylation substrates of the IMiDs bound CLR4-CRBN E3 ligase complex resulting in their proteasomal degradation. This downregulation of Ikaros and Aiolos represses the transcription of IRF4 and MYC and is believed to trigger MM cells death. It is clear however that Aiolos and Ikaros and in addition to IRF4 and MYC do activate or repress the transcription of other genes that contribute to the IMiDs effect in myeloma cells, in particular since overexpression of IRF4 was not sufficient to rescue MM cells from lenalidomide cytotoxic effects. Our group (Slaby J et al. Blood ASH 2013) has recently demonstrated that lenalidomide induces a ribosomal stress response with induction of TP53, downregulation of c-Myc and cell cycle arrest. This ribosomal stress response is mediated by the direct binding of ribosomal proteins (RPs), particularly RPL11 and RPL5 to Mdm2 and c-Myc. In the current study, and since IMiDs effects are Aiolos-dependent, we investigated how Aiolos contributes to ribosomal biogenesis and IMiDs induced stress response. Methods and Results: In order to investigate the impact of IKZF3 inhibition on ribosome biogenesis we stably transduced OPM2 myeloma cell lines with lentiviral plasmids carrying a doxycycline inducible shRNA targeting IKZF3. As expected, Aiolos silencing in these cells resulted in IRF4 and MYC downregulation. In addition, and as we previously observed with lenalidomide treatment, Aiolos silencing transiently stabilised and subsequently down-regulated MDM2 expression with up-regulation of p53 and its down-stream targets (p21, PUMA). Under ribosomal stress conditions, polysome-free RPs are released into the nucleoplasm where they bind MDM2 and suppress its E3 ligase activity. Consistent with this effect, in Aiolos silenced cells MDM2 co-immunoprecipitated with RPL11 and RPL5 with p53 protein stabilization (no change in TP53 mRNA). Furthermore Aiolos resulted in a rapid and robust decrease in the level of transcription of rDNA by RNA polymerase I as determined by qRT-PCR quantification of pre-rRNA (47S). The downregulation of 47S in lenalidomide treated cells is observed within 2 hours of treatment and mimics the kinetics of Aiolos downregulation. In addition ChiP assay of lenalidomide treated cells revealed decreased binding of RNA polymerase 1A to the 18S ribosomal DNA promoter region. Of note silencing of CRBN in OPM2 cells, blocks lenalidomide dowregulation of Aiolos and fully abrogated the supression of rDNA transcription. Overall these findings are consitent with an Aiolos-dependent suppression of RNA polymerase I activity. Lastly, and examining the effects of lenalidomide of the RNA polymerase I complex, we observed a significant transcriptional downregulation of the TAF-1A subunit and Aiolos ChiP studies revealed strong binding at TAF-1A TSS. Conclusions: Our studies indicate that IMiDs downregulation of Aiolos results in the suppression of RNA-polymerase I activity with the disruption of ribogenesis and induction of a ribosomal stress response. Disclosures Bahlis: Celgene: Honoraria, Research Funding.
    Type of Medium: Online Resource
    ISSN: 0006-4971 , 1528-0020
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    Language: English
    Publisher: American Society of Hematology
    Publication Date: 2014
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  • 9
    In: Blood, American Society of Hematology, Vol. 108, No. 11 ( 2006-11-16), p. 655-655
    Abstract: Monoclonal gammopathy of undetermined significance (MGUS) is an indolent condition that may be modulated by various factors including immunologic responses directed at the monoclonal cells. Several evidences have supported the idea that the immune system, in patients with MGUS, may play a role in controlling the progression to myeloma (MM) and the identification of antigenic targets could open the way for future immunotherapeutic approaches to delay or prevent such progression. We have screened a cDNA expression library from primary myeloma cells and used Serological Analysis of Recombinant cDNA Expression Library (SEREX) to identify antigens that are recognized by antibodies in MGUS patients and therefore may be targets of the immune system and possibly involved in the pathogenesis of this disease. We used high dilution (1:500) serum from 3 MGUS patients with stable disease for 1 to 4 years and identified a panel of 11 novel antigenic targets eliciting an immune response. Antibody response appeared to be directed against intracellular proteins involved in apoptosis (SON, Hip1), DNA and RNA binding proteins (KIAA0530, GPATC4), signal transduction regulators (AKAP11), developmental proteins (OFD1), transcriptional co-repressors (IRF2BP2), proteins of the ubiquitin-proteosome pathways (PSMC1). We have further analyzed frequency of antibody response against these antigens in additional 26 MGUS sera, 10 newly diagnosed and 10 MM patients in remission after auto-transplant and 25 normal donors. We have observed antibody response against OFD1 (20.6 %); KIAA0530 (10.3%); AKAP11 (10.3%); and GPATC4 (6.8%) in patients with MGUS. Interestingly, 1/10 patients with newly diagnosed MM (10%) and 3/10 (30%) patients in remission after auto-transplant had an antibody response against OFD1 with evidence of increase in antibody titer in one patient after transplant suggesting its importance as a target. No significant antibody responses were observed against any of these antigens in the sera of 25 health donors. We have further focused our studies on OFD1, a protein developmentally expressed in adult human organs that colocalizes with γ-tubulin in the centrosome and has LIS1 homology motifs suggesting its contribution in regulation of microtubule dynamics. We have confirmed, by western blot analysis and RT-PCR, the expression of OFD1 in MM cell lines and lack of its expression in normal cells including normal BMSC. In addition some myeloma cell lines express different spliced variant of this protein. Specific T cell responses directed at OFD1 and its role in cell signaling are under investigation. These data open the possibility to identify target antigens that are important in the disease process of MGUS and may allow us to design future vaccines and immunotherapeutic approaches targeting these antigens in MGUS as well as in MM.
    Type of Medium: Online Resource
    ISSN: 0006-4971 , 1528-0020
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    Language: English
    Publisher: American Society of Hematology
    Publication Date: 2006
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  • 10
    In: Blood, American Society of Hematology, Vol. 104, No. 11 ( 2004-11-16), p. 764-764
    Abstract: Mitochondrial signaling is an important component of chemotherapy-induced apoptosis in cancer cells. Stress-inducers trigger the following sequence of events: Smac (second mitochondria-derived activator of caspases)/ DIABLO is released from the mitochondrial inner membrane to cytosol; activated/cytosolic Smac binds to XIAP, a protein belonging to the family of IAPs (Inhibitors of apoptosis proteins), thereby abrogating its inhibitory effects on caspase-9 and resulting in activation of caspase-9-mediated apoptotic cascade. IAPs play a key role in regulating the apoptotic signaling, and overexpression of IAPs confer chemoresistance in various tumor types. Here we show that a low molecular weight synthetic Smac mimetic (Novartis) by virtue of its ability to bind and inhibit IAPs, block the growth of MM cell lines, including those resistant to conventional agents including dexamethasone, melphalan or doxorubicin. Examination of purified patient MM cells demonstrated similar results. In contrast, no significant toxicity of Smac mimetic was noted against normal peripheral blood mononuclear cells. Moreover, Smac mimetic also did not affect viability of MM patient-derived bone marrow stromal cells (BMSCs). Treatment of MM cells overexpressing anti-apoptotic protein Bcl2 with Smac mimetic significantly decreases their viability. Importantly, combined treatment of MM cells with Smac mimetic and Tumor necrosis factor-related apoptosis inducing ligand (TRAIL, Apo-2 ligand) trigger synergistic anti-MM activity, without significant toxicity in normal cells. Finally, Smac mimetic enhances the anti-MM activity of conventional Melphalan. Collectively, these findings provide the rationale for clinical evaluation of Smac mimetic alone and in combination with Melphalan or TRAIL, to enhance MM cell killing, overcome drug-resistance, and improve patient outcome in MM.
    Type of Medium: Online Resource
    ISSN: 0006-4971 , 1528-0020
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    Language: English
    Publisher: American Society of Hematology
    Publication Date: 2004
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