|
|||||||||
|
|
|
|
|
|
|
|
|
|
|
Prepublished online as a Blood First Edition Paper on May 17, 2002; DOI 10.1182/blood-2002-03-0749.
CLINICAL OBSERVATIONS, INTERVENTIONS, AND THERAPEUTIC TRIALS
From the Clinical Hematology Department and the
Hematology Laboratory, University Hospital, Nantes, France; and the
Clinical Hematology Department, University Hospital, Lille, France.
Recently, we have described the biological correlations associated
with the main translocations involving the 14q32 chromosomal region,
that is, t(14q32), in patients with multiple myeloma (MM). We have now
extended the analysis to the prognostic value of these chromosomal
rearrangements in 168 consecutive patients with newly diagnosed
MM receiving intensive chemotherapy within clinical trials of the Intergroupe Francophone du Myelome (IFM).
Patients with t(4;14) displayed a poor outcome (short event-free
survival and short overall survival), whereas those
with t(11;14) displayed long survival. On the other hand, patients with
neither t(4;14) nor t(11;14) presented an intermediate outcome.
Importantly, chromosome 13 abnormalities (C13As) significantly
influence the prognosis of this latter group. In contrast,
C13As affected the outcome of the other patients to a much lesser
extent, either because of an almost constant association (in
the t(4;14) group) or because of a lack of any
significant prognostic impact (in the t(11;14) group; only
one event occurred in the 10 patients with t(11;14) and C13As).
Considering that t(4;14) and t(11;14) (1) are the only (so far
recognized) true, recurrent t(14q32)'s, (2) are linked to specific
immunoglobulin isotypes, and (3) display specific outcomes, they represent distinct entities corresponding to a specific
oncogenesis and prognosis. These data emphasized the interest in
analyzing these two translocations by fluorescence in situ
hybridization in prospective therapeutic trials in order to consider
these translocations as distinct entities.
(Blood. 2002;100:1579-1583) Chromosomal abnormalities represent the main
prognostic parameter in several hematological malignancies, especially
acute leukemias. Such a prognostic value is less evident in other
hematological neoplasms, either because of a lower proliferative index
(preventing the obtaining of clonal metaphases) or because of
technical reasons (difficulties in harvesting tumor cells, such as in
lymph nodes). However, with the development of techniques circumventing
the nonproliferative pitfall, and especially interphase fluorescence in
situ hybridization (FISH) technologies, it is now possible to target
some specific recurrent chromosomal changes to assess their potential
impact on either response to therapy or survival. Recently, a nice
application of this approach has been demonstrated in chronic
lymphocytic leukemia. Whereas chromosomal abnormalities are
usually observed in fewer than 50% of the patients by means of
conventional cytogenetics, a systematic interphase FISH analysis identified chromosomal changes in up to 85% of the
patients.1 Moreover, this study demonstrated the high
prognostic significance of these abnormalities for patients' survival.
Multiple myeloma (MM) is characterized by a low proliferative index
(labeling index lower than 1%). This low proliferative capability is
correlated with a low cytogenetic informative capability. A
systematic literature survey was done to an informative capability of between 30% and 50% of the patients.2-4 This
low rate of abnormal karyotypes in MM does not correlate with a low
number of chromosomal changes. Analyses not based on metaphase
availability, such as DNA index measurement or interphase FISH
analyses, have shown that at least 90% of the patients with MM
displayed aneuploidy.5,6 This apparent discrepancy is
easily explained by the lack of sufficient proliferation within the
tumor compartment in 50% to 70% of the patients with MM. In these
cases, the karyotypically normal metaphases derived from the residual
normal bone marrow proliferative myeloid cells. Nevertheless, several
recent studies have demonstrated the highly significant prognostic
value of at least 2 chromosomal changes: chromosome 13 abnormalities
(C13As) and a hypodiploid mode.7-11 Patients presenting 1 of these 2 abnormalities present a poor survival, whatever the
treatment modalities. C13As are detected in about 50% of the
patients with an informative karyotype, that is, in 15% to 25% of the
patients with MM. We and others have demonstrated that a similar
proportion of patients without informative karyotypes displayed C13As
by interphase FISH analysis.8,9 Moreover, we have shown
that C13As detected by FISH conferred a similarly poor prognosis, even
in patients treated with intensive chemotherapy.9
Recently, we have reported the recurrence of several chromosomal
abnormalities in MM.12 We have shown that illegitimate rearrangements of the IgH gene were observed in at least
70% of the patients, 2 of them being recurrent reciprocal
translocations, with (1) the 11q13 (CCND1) and (2) the 4p16
(FGFR3) chromosomal regions occurring in 16% and
10% of the patients, respectively. However, so far, no systematic
analysis has evaluated the prognostic significance of these
recurrent abnormalities in MM in comparison with nonrecurrent
abnormalities or with the absence of any 14q32 rearrangement.
Because cytogenetics are often caught out by the low proliferation, and
because some chromosomal changes may be cytogenetically silent (cryptic
abnormalities), we have conducted a systematic interphase FISH study
analyzing all these genetic changes in a large cohort of patients
homogeneously treated with intensive chemotherapy in 2 French centers,
with the aim of defining the prognostic value of these genetic
abnormalities in MM.
Patients
Fluorescence in situ hybridization
Statistical analyses The following initial parameters were examined for their prognostic value on event-free survival (EFS) and overall survival (OS): age, Durie and Salmon stage, creatinine, 2-microglobulin (2m), calcium, albumin,
C-reactive protein (CRP), hemoglobin, bone marrow
plasmacytosis, and chromosomal abnormalities. EFS and OS were
calculated from the time of diagnosis (as defined by the time of
chemotherapy requirement) by means of the Kaplan-Meier method. All the
parameters reaching significance (ie, P < .05, or close
to that) in the univariate analysis were then included in a
multivariate analysis with the use of the Cox model.
Chromosomal rearrangements and presenting features Illegitimate IgH rearrangements, that is t(14q32), were found in 117 of 168 patients (70%), with the following distribution: t(4;14) in 22 of 168 patients (13%); t(11;14) in 26 of 168 patients (15.5%); t(14;16) in 4 of 168 patients (2%); and unknown chromosomal partner in 65 of 168 patients (39%). C13As were observed in 76 of 168 patients (45%). A significant association was observed between t(4;14) and C13As (82%), as well as between t(14;16) and C13As (100%). In contrast, patients lacking any t(14q32) displayed significantly less frequent C13As (13 of 51, 25%; P = .001 for difference with patients with t(14q32). No correlation between t(14q32) and C13As was observed in the 2 other categories, that is, t(11;14) (10 of 26 patients [38%] presented C13As), and patients with t(14q32) but with an unknown chromosomal partner (31 of 65 patients [48%] presented C13As). All these results were highly concordant with those recently published by us in a larger series.12 We then correlated t(14q32) types with immunoglobulin isotypes. As was previously published,12 we confirmed the strong associations between t(4;14) and the IgA isotype (P < .001), as well as the correlation between t(11;14) and light-chain only MM (P = .01), demonstrating that the immunoglobulin isotype and the recurrent t(14q32) are not random, but tightly associated. On the other hand, no correlation with a specific isotype was observed in patients with translocations involving another partner or those lacking any 14q32 rearrangement (the third group). In these patients, the prevalence of the different isotypes was normal.Chromosomal rearrangements correlate with clinical outcome The median EFS time of the whole series was 22.5 months, with a median follow-up of 27 months among the surviving patients. The actuarial OS in the whole series was 60.4% at 80 months. We then performed an analysis based on 14q32 abnormalities, by separating the patients presenting the 2 recurrent t(14q32)'s, that is, patients with t(4;14) and those with t(11;14), from the other patients. Three categories were thus defined: (1) patients with t(11;14); (2) patients with t(4;14); and (3) patients with either no 14q32 rearrangements, with another unknown chromosomal partner, or with t(14;16). This last group was formed because of the absence of any difference in either EFS or OS among the patients. This stratification enabled us to separate the patients into 3 groups with dramatically different outcomes (Figure 1). The median EFS was significantly shorter in patients with t(4;14) (20.7 months versus 28.5 months for other patients; P < .0001), but not significantly different in the 2 other categories. The median OS for patients with t(4;14) was 32.8 months versus not reached for patients without t(4;14) (expected survival at 80 months was 22.8% versus 66%; P = .002) (Figure 2). This shorter OS time was not related to lower complete response (CR) or very good partial response (VGPR) rates in patients with t(4;14) (12 of 22 patients (55%) with t(4;14) achieved CR or VGPR). In contrast, patients with t(11;14) displayed an exceptionally long OS (expected survival at 80 months was 87.5% versus 55.4% for patients without t(11;14); P = .055) (Figure 2). As for t(4;14), this better outcome was not the consequence of a higher response rate (10 of 26 patients [38%] with t(11;14) achieved CR or VGPR). As previously emphasized, the other cytogenetic rearrangements (ie, absence of 14q32 rearrangements or other t(14q32)) did not affect survival (expected OS at 80 months was 60%, identical to that of the overall population) (Figure 1). This model based on t(14q32) was highly powerful in predicting OS (P = .004). Whereas C13As did not affect survival in the t(11;14) group (actuarial OS at 80 months was 91% versus 87%, in patients with no C13As and with C13As, respectively) and in the t(4;14) group (because 18 of 22 patients of this group presented C13As), the introduction of this parameter in the third group enabled us to separate the intermediate survival curve into 2 different curves (Figure 2). This second model, including C13As for patients of the third group, was similarly powerful (P = .005).
Comparison with other standard prognostic parameters We then performed a prognostic analysis that included the chromosomal abnormalities and the common prognostic parameters. In the univariate analysis, the following parameters were tested for correlation with EFS and OS: age,2m, albumin, calcium,
creatinine, hemoglobin, CRP, bone marrow plasmacytosis, Durie and
Salmon stage, isotype, C13A, t(14q32) t(4;14), and t(11;14). Four
factors were significantly associated with a shorter EFS: t(4;14)
(P < .0001); CA13 (P < .005);
2m (P < .008); and IgA type
(P < .05). In the multivariate analysis, only C13As were
significant (P = .002). More parameters significantly
correlated with OS. Patients with 2m above 3.1 mg/L,
those with an IgA isotype, and patients with hemoglobin level below
10.9 g/dL displayed a significantly shorter OS (50.2% versus 70.6%,
30% versus 68%, and 48.1% versus 70.2% at 80 months, respectively).
C13A also revealed significant prognostic differences. The OS for
patients with C13As was 52.5% at 80 months versus 67% for patients
lacking C13As (P < .002). In the multivariate analysis,
all the parameters with a P < .1 in the univariate
analysis for OS were included in the Cox model (ie, 2m,
albumin, hemoglobin, IgA type, C13A, t(4;14), and t(11;14)). In this
model, the only 2 significant factors were C13As
(P = .003) and 2m
(P = .05).
For the first time, this study analyzed the prognostic impact of 14q32 abnormalities in MM in a large cohort of patients receiving homogeneous therapeutic approaches based on intensive chemotherapy. This analysis demonstrated the highly prognostic and antinomic influence of the 2 main recurrent 14q32 rearrangements (ie, t(11;14) and t(4;14)) in these patients, affecting 16% and 13% of them, respectively. So far, analyses of the prognostic value of cytogenetics in MM have been hampered by the low proliferative index of malignant plasma cells, only one third of the patients being informative. Nevertheless, some chromosomal abnormalities have been correlated with a short survival, especially C13A and hypodiploidy.7,11 However, these studies probably do not reflect the prognostic value of the sole chromosomal changes, but also include the prognostic value of proliferation. The best demonstration of this assessment has been brought by the numerous studies dedicated to the prognostic impact of C13A. This abnormality is observed in roughly 50% of the patients with an abnormal karyotype, and in the same proportion of patients analyzed by interphase FISH. However, whereas FISH explores 100% of the patients, cytogenetics is informative in about 30% of them. Thus, cytogenetics detects only one third of the patients with C13A. Despite these differences, C13As as detected by cytogenetics appear to confer a stronger prognostic value than the same abnormality as detected by FISH. Consequently, the prognostic value of cytogenetically detected C13A does include other parameters than the sole chromosomal changes. One of the most evident cofactors is proliferation, since the obtaining of clonal metaphases implies that the cell pass through mitosis. Thus, a general conclusion of the prognostic value of cytogenetic studies in MM is that the obtaining of clonal metaphases in this hypoproliferative disease is conditioned by a high proliferative index, a well-known indicator of short survival in MM. To circumvent this pitfall, and to get information in 100% of the
patients, we used interphase FISH with probes specific to the main
chromosomal changes. Furthermore, to avoid the heterogeneity introduced
by different treatment modalities (essentially conventional versus
high-dose chemotherapy), we have selected a series of 168 patients
consecutively treated in 2 French centers with intensive chemotherapy.
In this series, an extensive analysis of chromosomal changes was
performed. Then, the prognostic impact of these chromosomal rearrangements was calculated, as well as the prognostic impact of the
main other prognostic parameters. For the first time, we demonstrated
the strong prognostic value of the 2 recurrent 14q32 translocations,
ie, t(4;14) and t(11;14) in contrast to the neutral effect of either
translocation with an unknown chromosomal partner, or lack of any
translocation. First, t(4;14), which was found in 22 of 168 patients
(13%), in agreement with the incidence found in a much larger series
(10%),12 predicted both a shorter EFS time (20.7 months
versus 28.5 months; P < .005) and a shorter OS time
(expected survival at 80 months was 22.8% versus 66%; P = .002). Of note, these shorter OS and EFS times were
not the consequence of a lower response rate. Patients with t(4;14)
presented CR or VGPR in more than 50% of the cases (not different from
other patients), but relapsed rapidly after high-dose therapy. Despite this strong prognostic impact, t(4;14) did not show any significance in
the multivariate analysis. This is probably explained by the tight
correlation found between t(4;14) and C13As (18 of 22 patients with
t(4;14) displayed C13As), and by the much larger number of patients
presenting C13As than t(4;14). However, t(4;14) appears to
weight the prognostic impact of C13As (the OS curve is below that of other patients with C13As, even though the P is not
significant [P = .3], possibly because of the number of
patients) and to confer an especially aggressive phenotype, with both
short EFS and OS, possibly reflecting a specific biology (this
translocation is tightly associated with the IgA isotype and a high
In contrast to this translocation predicting a poor outcome, we
identified a novel translocation predicting long survival: translocation t(11;14). This translocation was observed in 26 of 168 patients (15.5%), an incidence identical to that found in a larger
series (16%).12 Translocation t(11;14) was associated with a longer OS time (expected survival at 80 months was 87.5% versus
55.4% for patients without t(11;14); P = .05). These
results contrast with those published so far. Two cytogenetic studies based on a small number of patients have reported the poor outcome associated with t(11;14).15,16 However, both studies were
retrospective cytogenetic reports on patients treated with various
strategies and were based on chromosomal analyses. Here again, the poor
outcome might be related to the high proliferative index of these
patients, rather than to the chromosomal rearrangement itself. A recent meeting report on patients treated with conventional chemotherapy did
confirm the non-poor prognosis value of t(11;14).17
However, as shown by the OS curves, patients with this translocation
may benefit especially from high-dose therapy, as recently demonstrated for patients with low We recently demonstrated that patients lacking any chromosome 14q32
rearrangements (about 25% of the patients) usually do not present
C13As, display low In conclusion, this study demonstrated for the first time the
prognostic value of specific translocations involving the 14q32 region,
one, t(4;14), predicting a short OS time and the other, t(11;14),
predicting an especially long survival, at least with the use of
intensive chemotherapy strategies. These results have recently
been partially corroborated in patients treated with conventional-dose chemotherapy, except for patients with t(11;14) who
did not present a significant better outcome.17 Thus,
intensive chemotherapy might be especially indicated for patients with
good prognosis, that is, those with t(11;14) or those with no C13A and
a low
We thank Marine Aliaga and Karine Pennarun for excellent technical assistance.
Submitted March 15, 2002; accepted April 19, 2002.
Prepublished online as Blood First Edition Paper, May 17, 2002; DOI 10.1182/blood-2002-03-0749.
Supported by grants from the Association pour la Recherche contre le Cancer and from Programme Hospitalier de Recherche Clinique.
The publication costs of this article were defrayed in part by page charge payment. Therefore, and solely to indicate this fact, this article is hereby marked "advertisement" in accordance with 18 U.S.C. section 1734.
Reprints: Hervé Avet-Loiseau or Régis Bataille, Laboratoire d'Hématologie, Institut de Biologie, 9 quai Moncousu, 44093 Nantes Cedex 1, France; e-mail: havetloiseau{at}chu-nantes.fr or frb{at}nantes.inserm.fr.
1.
Dohner H, Stilgenbauer S, Benner A, et al.
Genomic aberrations and survival in chronic lymphocytic leukemia.
N Engl J Med.
2000;343:1910-1916
2.
Gould J, Alexanian R, Goodacre A, Pathak S, Hecht B, Barlogie B.
Plasma cell karyotype in multiple myeloma.
Blood.
1988;71:453-456 3. Sawyer JR, Waldron JA, Jagannath S, Barlogie B. Cytogenetic findings in 200 patients with multiple myeloma. Cancer Genet Cytogenet. 1995;82:41-49[CrossRef][Medline] [Order article via Infotrieve].
4.
Laï JL, Zandecki M, Mary JY, et al.
Improved cytogenetics in multiple myeloma: a study of 151 patients including 117 patients at diagnosis.
Blood.
1995;85:2490-2497
5.
Barlogie B, Alexanian R, Dixon D, Smith L, Smallwood L, Delasalle K.
Prognostic implications of tumor cell DNA and RNA content in multiple myeloma.
Blood.
1985;66:338-342
6.
Drach J, Schuster J, Nowotny H, et al.
Multiple myeloma: high incidence of chromosomal aneuploidy as detected by interphase fluorescence in situ hybridization.
Cancer Res.
1995;55:3854-3859 7. Desikan R, Barlogie B, Sawyer J, et al. Results of high dose therapy for 1000 patients with multiple myeloma: durable complete remissions and superior survival in the absence of chromosome 13 abnormalities. Blood. 2000;96:4008-4010.
8.
Zojer N, Königsberg R, Ackermann J, et al.
Deletion of 13q14 remains an independent adverse prognostic variable in multiple myeloma despite its frequent detection by interphase fluorescence in situ hybridization.
Blood.
2000;95:1925-1930
9.
Facon T, Avet-Loiseau H, Guillerm G, et al.
Chromosome 13 abnormalities identified by FISH analysis and serum
10.
Fonseca R, Harrington D, Oken MM, et al.
Biological and prognostic significance of interphase fluorescence in situ hybridization detection of chromosome 13 abnormalities (
11.
Smadja NV, Bastard C, Brigaudeau C, Leroux D, Fruchart C, for the Groupe Français de Cytogénétique Hématologique.
hypodiploidy is a major prognostic factor in multiple myeloma.
Blood.
2001;98:2229-2238
12.
Avet-Loiseau H, Facon T, Grosbois B, et al.
Oncogenesis of multiple myeloma: 14q32 and 13q chromosomal abnormalities are not randomly distributed, but correlate with natural history, immunological features, and clinical presentation.
Blood.
2002;99:2185-2191
13.
Avet-Loiseau H, Facon T, Daviet A, et al.
14q32 translocations and monosomy 13 observed in monoclonal gammopathy of undetermined significance delineate a multistep process for the oncogenesis of multiple myeloma.
Cancer Res.
1999;59:4546-4550
14.
Fonseca R, Oken MM, Greipp PR.
The t(4;14)(p16.3;q32) is strongly associated with chromosome 13 abnormalities in both multiple myeloma and monoclonal gammopathy of undetermined significance.
Blood.
2001;98:1271-1272 15. Fonseca R, Witzig TE, Gertz MA, et al. Multiple myeloma and the translocation t(11;14)(q13;q32): a report on 13 cases. Br J Haematol. 1998;101:296-301[CrossRef][Medline] [Order article via Infotrieve]. 16. Laï JL, Michaux L, Dastugue N, et al. Cytogenetics in multiple myeloma: a multicenter study of 24 patients with t(11;14)(q13;q32) or its variant. Cancer Genet Cytogenet. 1998;104:133-138[CrossRef][Medline] [Order article via Infotrieve]. 17. Fonseca R, Harrington D, Blood E, et al. A molecular classification of multiple myeloma (MM), based on cytogenetic abnormalities detected by interphase FISH, is powerful in identifying discrete groups of patients with dissimilar prognosis [abstract]. Blood. 2001;98:3059.
18.
Avet-Loiseau H, Daviet A, Brigaudeau C, et al.
Cytogenetic, interphase and multicolor fluorescence in situ hybridization analyses in primary plasma cell leukemia: a study of 40 cases at diagnosis.
Blood
2001;97:822-825 19. Hanamura I, Iida S, Akano Y, et al. Ectopic expression of MAFB gene in human myeloma cells carrying the t(14;20)(q32;q11) chromosomal translocations. Jpn J Cancer Res. 2001;92:638-644[CrossRef].
20.
Shaughnessy J Jr, Gabrea A, Qi Y, et al.
Cyclin D3 at 6p21 is dysregulated by recurrent chromosomal translocations to immunoglobulin loci in multiple myeloma.
Blood.
2001;98:217-223
© 2002 by The American Society of Hematology.
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
 |
 |
|||||||
 |
 |
 |
 |
 |
 |
 |
 |
||
Top
Abstract
Introduction
13) in multiple myeloma: an Eastern Cooperative Oncology Group study.
Cancer Res.
2002;62:715-720