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Multiple myeloma (MM) is one of the most frequent cancerous diseases of the hemopoietic system. Over the past 60 years the systemic treatment has undergone multiple changes, from alkylating agents to high-dose therapy followed by autologous peripheral blood stem cell transplantation up to immunomodulating substances and proteasome inhibitors. The treatment of MM is currently undergoing a renewed transition. In recent years monoclonal antibodies have decisively extended the treatment options. Long-term remission is achieved more often. Due to progress in immuno-oncological treatment the prognosis of intensively treated patients with a very short life-expectancy can be improved in the future. It is to be expected that MM will be curable in the medium term. The concentration of free light chains in serum, lesions in magnetic resonance imaging (MRI) and bone marrow infiltration are parameters that are incorporated into the treatment indications. In clinical studies patients with smoldering myeloma are already being treated to delay progression, to increase the remission rates or to achieve long-term remission with negative minimal residual disease. Taking the chromosomal alterations and serological parameters into consideration, the prognosis of patients with MM can nowadays be very well discriminated. In currently running studies high-risk patients are being separately and mostly aggressively treated. Imaging is of great importance in MM. Using MRI focal lesions can be detected even before bone destruction. In this year chimeric antigen receptor (CAR) T cell treatment of MM will be approved for the first time in Germany. Novel antibody constructs, such as belantamab mafodotin, are or will be introduced for a late recurrence.Das multiple Myelom (MM) ist eine der häufigsten Krebserkrankungen des blutbildenden Systems. In den vergangenen 60 Jahren hat sich die systemische Behandlung mehrfach gewandelt, von Alkylanzien über die Hochdosistherapie gefolgt von autologer Transplantation peripherer Blutstammzellen bis zu immunmodulatorischen Substanzen und Proteasominhibitoren. Heute befindet sich die Therapie des MM erneut im Umbruch. In den letzten Jahren haben monoklonale Antikörper die Therapieoptionen entscheidend erweitert. Langzeitremissionen werden immer häufiger erreicht. Dank immunonkologischer Therapiefortschritte kann in Zukunft die Prognose von intensiv vorbehandelten Patienten mit sehr kurzer Lebenserwartung verbessert werden. Es ist zu erwarten, dass das MM mittelfristig heilbar wird. Die Konzentration der freien Leichtketten im Serum, Läsionen in der Magnetresonanztomographie (MRT) und die Knochenmarkinfiltration sind Parameter, die in die Behandlungsindikation einfließen. In klinischen Studien werden bereits Patienten mit „smoldering myeloma“ behandelt, um die Progression zu verzögern, Remissionsraten zu erhöhen oder Langzeitremissionen mit negativer „minimal residual disease“ zu erreichen. Unter Berücksichtigung chromosomaler Veränderungen und serologischer Parameter wird die Prognose der Patienten mit MM heute sehr gut diskriminiert. In laufenden Studien werden Hochrisikopatienten gesondert und meist aggressiver behandelt. Die Bildgebung hat beim MM einen hohen Stellenwert. Durch eine MRT lassen sich bereits vor einer Knochenzerstörung fokale Läsionen abbilden. In diesem Jahr wird die CAR-T-Zell-Therapie beim MM in Deutschland erstmalig zugelassen. Neue Antikörperkonstrukte sind oder werden eingeführt, so etwa Belantamab Mafodotin für das späte Rezidiv.

The treatment of multiple myeloma remains in a state of profound change. Over the past decades both disease-free survival and overall survival have been significantly prolonged by the approval of new drugs; however, despite high response rates and achievement of deep responses to primary treatment, recurrence of the disease is still expected in nearly all patients treated. Fortunately, good treatment options for myeloma patients in relapse are also currently available and the possible combinations of approved substances are numerous. Patient-specific criteria, such as primary response, comorbidities and treatment-associated toxicity can thus be taken into account more frequently in the selection of a suitable treatment of recurrences; however, the lack of comparative studies of new substances and extensive interindividual disease heterogeneity continue to make it difficult to select the best treatment of recurrence in a specific case. Therefore, the treatment of recurrence of multiple myeloma, especially for patients with high-risk features, remains a clinical challenge. This review article deliberately dispenses with the commonly used combination of mere study results and a more practical approach should be taught for the rational planning of treatment for recurrent multiple myeloma. This includes new insights into tumor evolution and taking current developments in the drug treatment of multiple myeloma into account.

Multiple myeloma (MM) is a malignancy of terminally differentiated B cells/plasma cells and is primarily located in the bone marrow. Symptomatic multiple myeloma typically presents with osteolyses, anemia, reduced renal function, and/or hypercalcemia. In the case of such MM-related end organ damage, urgent systemic treatment is indicated. In order to prevent end organ damage, current guidelines now recommend treatment initiation already when certain biomarkers are met. Current first-line treatment is based on proteasome inhibition and immunomodulation. Eligible patients still benefit from the addition of high-dose chemotherapy and autologous stem cell transplantation. Radiotherapy and orthopedic interventions play an important role in the treatment of localized skeletal complications. For relapsed MM, five novel agents have been approved in Europe during the last two years. These are second-generation proteasome inhibitors (carfilzomib, ixazomib) as well as first-in-class monoclonal antibodies (daratumumab, elotuzumab) and a histone deacetylase inhibitor (panobinostat). Triple combinations based on the established regimens lenalidomide/dexamethasone and bortezomib/dexamethasone plus one of the novel agents have been shown to significantly prolong progression-free survival. Median overall survival of patients with MM has doubled since the turn of the millennium.

In inhalation therapy, drugs are deposited as aerosols onto the air-facing lung epithelium. The currently used in vitro cell assays for drug testing, however, typically dissolve drugs in the medium, completely covering the cells, which represents an unphysiological drug application scenario. Although physiologically realistic in vitro cell culture models of the pulmonary air-blood barrier are available, reliable, easy-to-handle, and efficient technologies for direct aerosol-to-cell delivery are lacking. Here, we introduce the Air-Liquid Interface (ALI) Cell Exposure-Cloud (ALICE-CLOUD) technology, which uses principles of cloud motion for fast and quantitative delivery of aerosolized liquid drugs to pulmonary cells cultured under realistic ALI conditions. Aerosol-to-cell delivery proved to be highly efficient, reproducible, and rapid when using aerosolized fluorescein as surrogate drug. As a proof-of-concept study for the ALICE-CLOUD, we performed functional efficacy studies with the U.S. Food and Drug Administration-approved proteasome inhibitor, Bortezomib, a novel candidate drug for inhalation therapy. Aerosolized Bortezomib had a pronounced anti-inflammatory effect on human epithelial lung cells (A549), as indicated by a significant reduction of (TNFα-induced) IL-8 promoter activation. Importantly, cell-based therapeutic efficacy of aerosolized Bortezomib under ALI conditions was similar to that under dissolved and nonaerosolized submerged conditions, but with faster uptake kinetics. Our data indicate that the ALICE-CLOUD is a reliable tool for aerosolized drug screening with cells cultured under ALI conditions, which combines ease of handling with rapid, efficient, and dosimetrically accurate drug-to-cell delivery. This may pave the way for screening of inhalable drugs under physiologically more relevant and, hence, potentially more predictive conditions than the currently used submerged cell culture systems.

Das Ubiquitin-Proteasom-System (UPS) ist als zentraler Proteinabbaumechanismus eukaryontischer Zellen verantwortlich für die Degradation defekter und nicht mehr benötigter Proteine. Zugleich ist es durch den regulierten Abbau von Mediatorproteinen an der Regulation zahlreicher Signalwege beteiligt. Entsprechend seiner essentiellen Bedeutung induziert eine potente Hemmung des UPS regelhaft eine Apoptose. Demgegenüber konnten wir in mehreren Arbeiten zeigen, dass eine partielle Hemmung des Proteasoms kardiovaskuläre Zellen vor oxidativem Stress schützt. Als zugrunde liegenden Mechanismus identifizierten wir eine Nrf2-vermittelte Induktion antioxidativer Enzyme in Kardiomyozyten, glatten Gefäßmuskelzellen sowie Endothelzellen. Diese nachhaltige Aktivierung der zelleigenen, antioxidativen Abwehrmechanismen steht im Kontrast zur Wirkung der von uns in einem parallelen Projekt untersuchten Polyphenole EGCG und TF3, die in unserem Stressmodell Kardiomyozyten durch ihre direkte antioxidative, d.h. radikalfangende Wirkung vor oxidativem Stress schützten. Das therapeutische Potential einer partiellen Proteasomhemmung unterstrichen Versuche in LDL-Rezeptor-defizienten Mäusen, in denen eine Behandlung mit Proteasominhibitoren die Akkumulation oxidierter Lipide und Proteine im Serum und in der Aorta reduzierte, was mit einer verringerten Atherogenese assoziiert war. In einem weiteren Projekt konnten wir zeigen, dass die aus sich teilenden Zellen bekannte antiproliferative Wirkung von Proteasominhibitoren durch Hemmung zentraler Wachstumssignalwege auch in postmitotischen Zellen positive Effekte haben kann: sowohl in vitro als auch in vivo führte eine niedrig-dosierte Proteasomhemmung zur Verminderung einer kardialen Hypertrophie. Schwerpunkt unserer jüngsten Projekte ist die Aufklärung einer möglichen Verbindung zwischen dem UPS und epigenetischen Regulationsmechanismen. In diesem Zusammenhang konnten wir erstmals zeigen, dass partielle Proteasominhibition in einer verminderten Expression der Histonmethyltransferase Ezh2 resultiert. Da zur physiologischen Rolle von Ezh2 in differenzierten Zellen bis dato keine Informationen vorlagen, identifizierten wir kürzlich die Zielgene von Ezh2 in Endothelzellen und konnten zeigen, dass Ezh2 an der epigenetischen Regulation von Angiogenese- Prozessen beteiligt ist. Zusammenfassend suggerieren unsere Ergebnisse ein therapeutisches Potential für Proteasominhibitoren bei kardiovaskulären Erkrankungen, das derzeit jedoch limitiert wird durch das Fehlen zelltypspezifischer Inhibitoren. Zugleich sind unsere Daten ein erster Hinweis auf eine mögliche Verbindung zwischen dem UPS und epigenetischen Regulationsmechanismen., The ubiquitin-proteasome-system (UPS) is the major protein degradation mechanism in eukaryotic cells responsible for the degradation of misfolded and aged proteins. Through regulated degradation of mediator proteins, the UPS is also actively involved in the regulation of various signaling pathways. In accordance with its essential role, potent inhibition of the UPS induces apoptosis. In contrast, partial proteasome inhibition protects cardiovascular cells from oxidative stress as it Nrf2-dependently induces antioxidative enzymes in cardiac myocytes, vascular smooth muscle cells and endothelial cells. This sustained induction of endogenous defense mechanisms differs distinctly from the effect of polyphenols, e.g. EGCG and TF3, which protected cardiac myocytes in our stress model only via their direct antioxidative, radical scavenging properties. The therapeutic potential of proteasome inhibitors was underscored by in vivo experiments which showed a diminished accumulation of oxidized lipids and proteins in the serum and aortas of LDL- receptor-deficient mice after treatment with proteasome inhibitors. This was associated with a markedly reduced atherogenesis. In another study, we could demonstrate that partial proteasome inhibition suppresses cardiac hypertrophy in vitro and in vivo through inhibition of central signaling pathways. In our most recent project, we explored a possible link between the UPS and the epigenome. In endothelial cells, proteasome inhibitors reduced the expression of the histone methyl transferase Enhancer of zeste homolog 2 (Ezh2). As little is known about the function of Ezh2 in differentiated cells, we identified the target genes of Ezh2 in endothelial cells and could demonstrate that Ezh2 is involved in the epigenetic regulation of angiogenesis. In summary, our results suggest a therapeutic potential of proteasome inhibitors in cardiovascular disease. Their use, however, is currently limited by the lack of cell type-specific inhibitors. In addition, our data indicate a link between the UPS and the epigenome.

Das Humane Cytomegalievirus (HCMV) ist ein ubiquitäres Pathogen, welches den Metabolismus der Wirtszelle auf vielfältige Weise manipuliert, um seine eigene Vermehrung zu begünstigen. In der vorliegenden Arbeit konnte nachgewiesen werden, dass auch das Ubiquitin-Proteasom-System in die HCMV-Replikation involviert ist. So konnte zunächst gezeigt werden, dass die Chymotrypsin-ähnliche (CT-L) Aktivität des konstitutiven Proteasoms in HCMV-infizierten Zellen signifikant erhöht ist. Wurde die CT-L Proteasomaktivität durch Proteasominhibitoren (PI) blockiert, so hatte dies die Hemmung der HCMV-Replikation zur Folge. Die Charakterisierung des Einflusses von PI auf die virale Proteinexpression ergab, dass bei niedriger MOI (MOI 0.1) deutlich verringerte Mengen der sehr frühen Proteine vorlagen, dieser Effekt jedoch bei hoher MOI (ab MOI 1) aufgehoben war. Die Expression früher Proteine war MOI-unabhängig reduziert. Hingegen war die Expression der späten Proteine MOI-unabhängig vollständig unterdrückt. Studien mit dem Nukleosidanalogon BrdU ergaben zudem, dass die de novo Synthese viraler DNA blockiert war. Um erste Hinweise auf den Wirkungsmechanismus von PI zu erhalten, wurde untersucht, ob der Transkriptionsfaktor NF-kappaB oder zelluläre Transkriptionsrepressoren wie z.B. hDaxx am anti-HCMV-Effekt beteiligt sind. Durch die Charakterisierung einer Virusmutante mit Deletion der NF-kappaB-Bindestellen im MIE-Enhancer/Promotor konnte gezeigt werden, dass der antivirale Effekt von PI nicht auf der Hemmung der Aktivierung von NF-kappaB beruht. Experimente mit hDaxx-knockdown Zellen ergaben hingegen, dass die Stabilisierung des Transkriptionsrepressors hDaxx partiell zum anti-HCMV-Effekt von PI beiträgt. Darüber hinaus müssen jedoch weitere virale oder zelluläre Zielproteine existieren, deren Beeinflussung durch PI kritisch für die Virusreplikation ist. Zusammenfassend stellt das Proteasom somit einen neu identifizierten potentiellen Angriffspunkt für die anti-HCMV-Therapie dar. The Human Cytomegalovirus (HCMV) is a ubiquitous pathogen that manipulates many aspects of the host cell metabolism to enhance viral replication. This work demonstrates that the ubiquitin-proteasome system is also involved in HCMV replication. First of all, the chymotrypsin-like (CT-L) activity of the constitutive proteasome was significantly increased in HCMV infected cells. In the presence of proteasome inhibitors (PI) viral replication was efficiently blocked. Characterisation of the influence of PI on viral protein expression showed that immediate early protein expression was clearly reduced at low MOI (MOI 0.1); however, this effect was abolished at high MOI (starting from MOI 1). Expression of early proteins was significantly decreased independently of the MOI used for infection. In contrast, late protein expression was completely suppressed at both low and high MOI. Additionally, studies using the nucleoside analogue BrdU showed that PI block the de novo synthesis of viral DNA. In order to gain insight into the working mechanism of PI the involvement of the transcription factor NF-kappaB and cellular repressors of transcription (e.g. hDaxx) in the antiviral effect of PI was examined. Studies using a mutant virus carrying deletions of the NF-kappaB binding sites in the MIE-enhancer/promoter revealed that the anti-HCMV effect of PI is not due to inhibition of NF-kappaB activation. Analyses using hDaxx-knockdown cells showed that stabilisation of the transcriptional repressor hDaxx partially contributes to the antiviral effect of PI. However, the existence of additional viral or cellular target proteins of PI is very likely. In summary, the proteasome thus represents a newly identified and promising target for anti-HCMV therapy.

Advanced stage mantle cell lymphoma (MCL) with a median survival of only three years and virtually no long-term survivors represents the lymphoma subtype with the poorest prognosis and remains incurable with conventional chemotherapy. Recently two randomized trials of the German Low Grade Lymphoma Study Group (GLSG) demonstrated the superiority of a combined immunochemotherapy with the anti-CD20 antibody rituximab in first-line therapy (R-CHOP) as well as in relapsed disease (R-FCM). In addition, in a trial of the European MCL Network, intensified-consolidation with high-dose radiochemotherapy followed by autologous stem cell transplantation significantly improved the progression-free survival in patients up to 65 years of age. However, the vast majority of patients with MCL will eventually relapse. Thus, new strategies such as allogenic transplantation after dose-reduced conditioning or novel molecular targeting agents (e. g. proteasome inhibitors or radiolabeled antibodies) are urgently warranted to further improve the long-term outcome of MCL.

New perspectives in prostate cancer genesis and putative clinical management have emerged in recent years . Apoptosis plays a major role in this environment. Proteasome inhibitors block the action of a multicatalytic proteinase complex involved in the degradation of intracellular proteins, particularly with regard to cell cycle regulation and apoptosis. Numerous in vitro studies have demonstrated the ability of these compounds to induce apoptosis and enhance the activity of conventional tumoricidal agents in many cancer cell types, including prostate cancer cells. They point out the use of these potent inhibitors as a new potential molecular approach to the therapeutic management of prostate cancer. Furthermore, the action of proteasome inhibitors has been tested in animal models and in patients with hormone refractory prostate cancer, resulting in both PSA and tumor volume decrease. PS-341 (bortezomib, Velcade) is the first proteasome inhibitor with clinical application in cancer therapy that has been used in clinical trials to date. This report reviews the current status of those papers that have tried to analyze the connection between the proteasome pathway and apoptosis. We present our results of proteasome inhibition in individual prostate cancer cell lines. Proteasomal inhibition may offer a new therapeutic access in "molecular targeting" of prostate cancer.