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PMCID: PMC4112539.-- International Myeloma Working Group: et al., Plasma cell leukemia (PCL) is a rare and aggressive variant of myeloma characterized by the presence of circulating plasma cells. It is classified as either primary PCL occurring at diagnosis or as secondary PCL in patients with relapsed/refractory myeloma. Primary PCL is a distinct clinic-pathological entity with different cytogenetic and molecular findings. The clinical course is aggressive with short remissions and survival duration. The diagnosis is based upon the percentage (≥20%) and absolute number (≥2 × 10 9/l) of plasma cells in the peripheral blood. It is proposed that the thresholds for diagnosis be re-examined and consensus recommendations are made for diagnosis, as well as, response and progression criteria. Induction therapy needs to begin promptly and have high clinical activity leading to rapid disease control in an effort to minimize the risk of early death. Intensive chemotherapy regimens and bortezomib-based regimens are recommended followed by high-dose therapy with autologous stem cell transplantation if feasible. Allogeneic transplantation can be considered in younger patients. Prospective multicenter studies are required to provide revised definitions and better understanding of the pathogenesis of PCL., This work has been supported in part by “Josep Font” Grant from Hospital Clínic de Barcelona and RD06/0020/0005 from Instituto de Salud Carlos III, Spain.

PURPOSE Interferon alfa treatment in multiple myeloma marginally improves relapse-free and overall survival. Often it does so at the expense of toxicity and financial cost. If patients are unwilling or unable to participate in the decision of whether to initiate such treatment, known patient preferences can serve as guidelines for the physician. We interviewed myeloma patients in the United States to obtain information that might facilitate medical decision-making. PATIENTS AND METHODS Three hundred fifty-five myeloma patients throughout the United States were interviewed by telephone. Without identifying interferon alfa as the treatment agent, interviewers described potential adverse effects, financial cost, and self-injection procedures. The potential benefits of four treatment choices, derived from a meta-analysis of published data, were presented as gains in remission rate (+10%), remission duration (an additional 4 and 7 months, respectively, for induction and maintenance treatment), and overall survival (an additional 3 and 6 months, respectively, for induction and maintenance treatment). Patients' choices for or against use of the unidentified substance were recorded, and interferon was subsequently disclosed as the treatment. The profiles of patients making different choices were determined using multivariate regression techniques. RESULTS Approximately half of the patients accepted the unidentified treatment if remission and/or survival improved by at least 6 months. Accepters were younger and more likely to have used interferon. Of patients who rejected the unidentified treatment, 25% to 50% would have been willing to accept it if the benefits were > or = 12 months. Test/retest reliability of all choices, determined in 36 cancer patients, was 0.896. CONCLUSION In multiple myeloma, interferon therapy and, by inference, other treatments with comparable features are acceptable to approximately half of the patients if a 6-month gain in relapse-free or overall survival can be expected.

Lytic bone disease is a frequent complication of multiple myeloma (MM). Lytic lesions rarely heal and X-rays are of limited value in monitoring bone destruction during anti-myeloma or anti-resorptive treatment. Biochemical markers of bone resorption (amino-and carboxy-terminal cross-linking telopeptide of type I collagen (NTX and CTX, respectively) or CTX generated by matrix metalloproteinases (ICTP)) and bone formation provide information on bone dynamics and reflect disease activity in bone. These markers have been investigated as tools for evaluating the extent of bone disease, risk of skeletal morbidity and response to anti-resorptive treatment in MM. Urinary NTX, serum CTX and serum ICTP are elevated in myeloma patients with osteolytic lesions and correlate with advanced disease stage. Furthermore, urinary NTX and serum ICTP correlate with risk for skeletal complications, disease progression and overall survival. Bone markers have also been used for the early diagnosis of bone lesions. This International Myeloma Working Group report summarizes the existing data for the role of bone markers in assessing the extent of MM bone disease and in monitoring bone turnover during anti-myeloma therapies and provides information on novel markers that may be of particular interest in the near future. Leukemia (2010) 24, 1700-1712; doi:10.1038/leu.2010.173; published online 2 September 2010

Several imaging technologies are used for the diagnosis and management of patients with multiple myeloma (MM). Conventional radiography, computed tomography (CT), magnetic resonance imaging (MRI) and nuclear medicine imaging are all used in an attempt to better clarify the extent of bone disease and soft tissue disease in MM. This review summarizes all available data in the literature and provides recommendations for the use of each of the technologies. Conventional radiography still remains the 'gold standard' of the staging procedure of newly diagnosed and relapsed myeloma patients. MRI gives information complementary to skeletal survey and is recommended in MM patients with normal conventional radiography and in all patients with an apparently solitary plasmacytoma of bone. Urgent MRI or CT (if MRI is not available) is the diagnostic procedure of choice to assess suspected cord compression. Bone scintigraphy has no place in the routine staging of myeloma, whereas sequential dual-energy X-ray absorptiometry scans are not recommended. Positron emission tomography/CT or MIBI imaging are also not recommended for routine use in the management of myeloma patients, although both techniques may be useful in selected cases that warrant clarification of previous imaging findings, but such an approach should ideally be made within the context of a clinical trial.

New uniform response criteria are required to adequately assess clinical outcomes in myeloma. The European Group for Blood and Bone Marrow Transplant/International Bone Marrow Transplant Registry criteria have been expanded, clarified and updated to provide a new comprehensive evaluation system. Categories for stringent complete response and very good partial response are added. The serum free light-chain assay is included to allow evaluation of patients with oligo-secretory disease. Inconsistencies in prior criteria are clarified making confirmation of response and disease progression easier to perform. Emphasis is placed upon time to event and duration of response as critical end points. The requirements necessary to use overall survival duration as the ultimate end point are discussed. It is anticipated that the International Response Criteria for multiple myeloma will be widely used in future clinical trials of myeloma.

Summary Monoclonal gammopathy of undetermined significance (MGUS) is different from multiple myeloma (MM) by a low proliferation and by its indolent clinical course. In this study, two biological parameters were investigated which mark the transition from MGUS to MM, i.e. expression of the P-170 glycoprotein associated with the multidrug resistance phenotype (MDR-1) and expression of the natural killer cell antigen, CD56. Strong MDR-1 expression was found in plasma cells of 32/38 untreated MGUS as compared with 33/105 untreated MM stage I–III (84%v 32%, P

Interferons (IFNs) were originally defined as antiviral substances but were subsequently found also to modulate the immune response and to inhibit the growth of normal and transformed cells. When the antiproliferative effect of interferon α-A in vitro was analyzed using the human tumor clonogenic assay (HTCA), tumor inhibition of greater than 50% of colony formation was found in about 36% of the human tumors tested. However, some of the fresh tumor specimens exhibited growth stimulation on exposure to interferon, manifested by a significant increase in the number of tumor colonies compared to the controls. This is in parallel to IFN’s immune modulatory effect: interferon has a stimulatory as well as an inhibitory effect on many different immunological reactions. In this paper we present the potential growth-stimulatory effect of IFNs on human tumors.

We have applied an in vitro soft-agar tumor-colony assay (which is now applicable to a variety of human cancers) to measurement of in vitro sensitivity to drugs and prediction of clinical response to cancer chemotherapy. The assay predicts drug resistance with 96% accuracy and sensitivity (in heavily pretreated patients) with 62% accuracy. On a pharmacokinetic basis the zone in vitro sensitivity for any given drug was only 5%–10% of the clinical concentration-time product (Cxt) achievable. This suggests that intratumoral drug concentrations in vivo may be lower than those in the plasma, and/or that > 2 log kills of tumor stem cells (not measurable in the assay) are required for clinical response. Serial in vitro studies showed that acquisition of drug resistance is a common clinical phenomenon which can be directly detected and quantitated in vitro.

Generation time (GT) of normal human bone marrow cells cultured in the CFC-gm assay was measured by using bromodeoxyuridine (BrdU) incorporation and sister chromatid differential staining. Cells were cultured in methylcellulose for 72 hr prior to the addition of BrdU and then harvested at 6-12 hr intervals for up to 72 hr. The time interval between the appearance of second and third division metaphases at the 50% level gave mean GTs which ranged from 32 to 43 hr. These values are longer than those reported for myeloblasts and promyelocytes but shorter than those previously reported for myelocytes.

The application of quantitative measurements in clinical oncology has been a major objective in our clinical research program. We believe that use of such techniques, plus reasonably enlightened empiricism, extrapolation from data on drug action, and availability of effective new drugs could result in major improvement in end results of cancer treatment. Such comments are particularly germane to multiple myeloma because substantial improvements in end results beyond those which can be obtained with alkylating agent-prednisone combinations have yet to be uniformly achieved. Our kinetic approach has already increased our understanding of the clinical phases of myeloma. We believe that we are now beginning to see clear-cut evidence of ways in which clinical staging and kinetic data have not only led to new clinical trials but have also begun to improve results of treatment. Some of our observations on staging, kinetics of response, and drug sensitivity are being put to the test in a large-scale clinical trial initiated in the Southwest Oncology Group (SWOG) in 1977. Newerobservations in our own institution suggest that an individualized approach to treatment based on measured drug sensitivity may also prove feasible.

With the introduction of clonogenic assay methods for human multiple myeloma and acute myelogenous leukemia, it has become possible to carry out in vitro drug testing in these diseases. Major goals of developing such techniques have included both the selection of the best treatment for individual patients and preclinical drug screening and new drug development. In this analysis, results of in vitro testing using both clonogenic assay methods and thymidine incorporation techniques will be summarized. Correlations between the in vitro methods and the subsequent clinical response of patients will be critically evaluated and the potential for these types of approaches discussed.

Prior studies have shown that PA levels are elevated in blood components of CF homozygotes. We have studied urinary PA levels and 14C spermidine metabolism in controls and CF patients. The urinary PA levels in 7 CF homozygotes were 2-10 fold higher than in 8 heterozygotes and 6 normals (p 70 (N = 8). These data show that although plasma decay curves for 14C spermidine are similar to normals, the urinary excretion pattern suggests sequestration in CF patients with severe clinical disease. Further, polyamine levels are elevated in the urine of CF homozygotes and appear to correlate well with the patient's clinical status. Supported by USPHS Grants CA-14783 and CA-17094 from the National Cancer Institute (D.H.R.). R.B. is an ALA Fellow.

The combination of serum β2-microglobulin and albumin levels has been shown to be highly prognostic in myeloma as the International Staging System (ISS). The aim of this study was to assess the independent contributions of ISS stage and cytogenetic abnormalities in predicting outcomes. A retrospective analysis of international studies looking at both ISS and cytogenetic abnormalities was performed in order to assess the potential role of combining ISS stage and cytogenetics to predict survival. This international effort used the International Myeloma Working Group database of 12 137 patients treated worldwide for myeloma at diagnosis, of whom 2309 had cytogenetic studies and 5387 had analyses by fluorescent in situ hybridization (iFISH). Comprehensive analyses used 2642 patients with sufficient iFISH data available. Using the comprehensive iFISH data, combining both t(4;14) and deletion (17p), along with ISS stage, significantly improved the prognostic assessment in terms of progression-free survival and overall survival. The additional impact of patient age and use of high-dose therapy was also demonstrated. In conclusion, the combination of iFISH data with ISS staging significantly improves risk assessment in myeloma.