Letters to the Editor
2254 definition comprise B-cell populations as the BH3 profiling assay here is performed on a patient specimen after purification and elimination of non-B-cells. Additional work will be required to further characterize the presence and composition of these distinct subpopulations. Priming by Noxa, a specific proapoptotic modulator of antiapoptotic Mcl-1, is not associated with either alvocidib response or TLS, consistent with Mcl-1 not being a driver mechanism. Conceivably, patients could be stratified by cytogenetics and BH3 profiling to increase the overall response rate from 35 to 50% as observed in previous clinical studies. In the current patient set, 23 of the 62 analyzed patients achieved a PR to alvocidib (37.1%.) In our analyses, the combination of Hrk and trisomy 12 yielded an AUC of 0.83. By closer examination of the ROC curves, 95.6% of responder patients were identified (sensitivity) concurrently to discrimination of 66.7% of likely PD/SD patients (specificity). If the predictive value of such an applied biomarker is to triage the likely non-responder patients (here the triaging of 26 PD/SD patients, while also mis-identifying 1 likely PR patient), then the response rate increases from 37.1 to 62.9% (an overall 69.5% improvement of response rate). Similarly, TLS incidence could be decreased from 13% observed in the EFC6663 study to a minimal number moving forward. While larger cohorts will be required to fully define the extent of medical utility for such diagnostics, these early observations may hold promise for alvocidib impact in CLL patient options and improved outcomes.
CONFLICT OF INTEREST WEP, CD, RJL, NB, ME, and MHC are employees of Eutropics, Inc. SLW and DJB are employees of Tolero Pharmaceuticals, Inc. JCB and MRG are co-inventors of a patent pending for the use of alvocidib. The remaining authors declare no conflict of interest.
WE Pierceall1, SL Warner2, RJ Lena1, C Doykan1, N Blake1, M Elashoff1, DV Hoff2,3, DJ Bearss2, MH Cardone1, L Andritsos4, JC Byrd4, MC Lanasa5, MR Grever4 and AJ Johnson4 1 Eutropics Inc., Cambridge, MA, USA; 2 Tolero Pharmaceuticals, Inc., Lehi, UT, USA; 3 Translational Genomics Research Institute, Scottsdale, AZ, USA; 4 Department of Internal Medicine, Division of Hematology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA and 5 Department of Medicine, Duke Cancer Institute, Durham, NC, USA E-mail:
[email protected] or
[email protected]
REFERENCES 1 Flinn IW, Byrd JC, Bartlett N, Kipps T, Gribben J, Thomas D et al. Flavopiridol administered as a 24-hour continuous infusion in chronic lymphocytic leukemia lacks clinical activity. Leuk Res 2005; 29: 1253–1257. 2 Byrd JC, Peterson BL, Gabrilove J, Odenike OM, Grever MR, Rai K et al. Treatment of relapsed chronic lymphocytic leukemia by 72-hour continuous infusion or 1-hour bolus infusion of flavopiridol: results from Cancer and Leukemia Group B study 19805. Clin Cancer Res 2005; 11: 4176–4181. 3 Lin TS, Ruppert AS, Johnson AJ, Fischer B, Heerema NA, Andritsos LA et al. Phase II study of flavopiridol in relapsed chronic lymphocytic leukemia demonstrating high response rates in genetically high-risk disease. J Clin Oncol 2009; 27: 6012–6018. 4 Byrd JC, Lin TS, Dalton JT, Wu D, Phelps MA, Fischer B et al. Flavopiridol administered using a pharmacologically derived schedule is associated with marked clinical efficacy in refractory, genetically high-risk chronic lymphocytic leukemia. Blood 2007; 109: 399–404. 5 Stephens DM, Ruppert AS, Blum K, Jones J, Flynn JM, Johnson AJ et al. Flavopiridol treatment of patients aged 70 or older with refractory or relapsedchronic lymphocytic leukemia is a feasible and active therapeutic approach. Haematologica 2012; 97: 423–427. 6 Phelps MA, Lin TS, Johnson AJ, Hurh E, Rozewski DM, Farley KL et al. Clinical response and pharmacokinetics from a phase 1 study of an active dosing schedule of flavopiridol in relapsed chronic lymphocytic leukemia. Blood 2009; 113: 2637–2645. 7 Ni Chonghaile T, Sarosiek KA, Vo TT, Ryan JA, Tammareddi A, Moore Vdel G et al. Pretreatment mitochondrial priming correlates with clinical response to cytotoxic chemotherapy. Science 2011; 334: 1129–1133. 8 Pierceall WE, Kornblau SM, Carlson NE, Huang X, Blake N, Lena R et al. BH3 profiling discriminates response to Cytarabine-based treatment of acute myeloid leukemia. Mol Cancer Ther 2013; 12: 2940–2949. 9 Chen S, Dai Y, Pei X-Y, Myers J, Wang L, Kramer LB et al. CDK inhibitors up-regulate BH3-only proteins to sensitize human myeloma cells to BH3 mimetic therapies. Cancer Res 2012; 72: 4225–4237. 10 Woyach JA, Lozanski G, Ruppert AS, Lozanski A, Blum KA, Jone JA et al. Outcome of patients with relapsed or refractory chronic lymphocytic leukemia treated with flavopiridol: impact of genetic features. Leukemia 2012; 26: 1442–1444. 11 Byrd JC, Shinn C, Waselenko JK, Fuchs EJ, Lehman TA, Nguyen PL et al. Flavopiridol induces apoptosis in chronic lymphocytic leukemia cells via activation of caspase-3 without evidence of bcl-2 modulation or dependence on functional p53. Blood 1998; 92: 3804–3816. 12 Döhner H, Stilgenbauer S, Benner A, Leupolt E, Krober A, Bullinger L et al. Genomic aberrations and survival in chronic lymphocytic leukemia. New Engl J Med 2000; 343: 1910–1916. 13 AbdelSalam M, El Sissy A, Samra MA, Ibrahim S, El-Markaby D, Gadallah F. The impact of trisomy 12, retinoblastoma gene and P53 in prognosis of B-cell chronic lymphocytic leukemia. Hematology 2008; 13: 147–153. 14 Balatti V, Bottoni A, Palamarchuk A, Alder H, Rassenti LZ, Kipps TJ et al. NOTCH1 mutations in CLL associated with trisomy 12. Blood 2012; 119: 329–331. 15 Willander K, Dutta RK, Ungerback J, Gunnarsson R, Juliusson G, Fredrikson M et al. NOTCH1 mutations influence survival in chronic lymphocytic leukemia patients. BMC Cancer 2013; 13: 274.
Supplementary Information accompanies this paper on the Leukemia website (http://www.nature.com/leu)
Immunoglobulin light-chain amyloidosis shares genetic susceptibility with multiple myeloma Leukemia (2014) 28, 2254–2256; doi:10.1038/leu.2014.208 Amyloid light-chain (AL) amyloidosis is a rare clonal plasma cell disorder with an estimated incidence of 3 per million.1 The disease is characterized by deposition of amyloid fibers derived from immunoglobulin light chains systematically in many organs.2 The symptoms arise in the organs where amyloids accumulate, including the heart, kidney, liver and peripheral nerves; heart failure is the critical life-threatening condition that may ensue in a few months after diagnosis.2 Monoclonal gammopathy of undetermined significance (MGUS) is an asymptomatic premalignant clonal condition, through which all cases of multiple
myeloma (MM) pass with a relative risk of 25.3,4 AL amyloidosis, MGUS and MM are hypothesized to be the same disease entity at the cellular level, with AL amyloidosis just being a clonal plasma cell disorder with an ‘unlucky protein’.5 Nevertheless, the genetic etiology of AL amyloidosis is poorly understood. According to a 15-year follow-up study of MGUS patients the relative risk for AL amyloidosis was 8.4.3 Two recent genome-wide association studies (GWAS) of MM have identified seven single-nucleotide polymorphisms (SNPs) that are associated with disease risk, including loci mapping to 2p23.3 (rs6746082), 3p22.1 (rs1052501), 3q26.2 (rs10936599), 6p21.33 (rs2285803), 7p15.3 (rs4487645), 17p11.2 (rs4273077) and 22q13.1 (rs877529).6,7 These
Accepted article preview online 3 July 2014; advance online publication, 25 July 2014
Leukemia (2014) 2241 – 2272
© 2014 Macmillan Publishers Limited
Letters to the Editor
2255 Table 1.
Association results for AL amyloidosis (443 cases and 2107 controls) and multiple myeloma (1014 cases and 2107 controls)
Chromosome (SNP)
Disease
RA
RAF cases
RAF controls
2p23.3 (rs6746082)
AL amyloidosis Multiple myeloma AL amyloidosis Multiple myeloma AL amyloidosis Multiple myeloma AL amyloidosis Multiple myeloma AL amyloidosis Multiple myeloma AL amyloidosis Multiple myeloma AL amyloidosis Multiple myeloma
A
0.81 0.82 0.19 0.20 0.78 0.79 0.36 0.36 0.72 0.75 0.13 0.14 0.47 0.45
0.78 0.78 0.16 0.16 0.75 0.75 0.31 0.31 0.68 0.68 0.11 0.11 0.43 0.43
3p22.1 (rs1052501) 3q26.2 (rs10936599) 6p21.3 (rs2285803) 7p15.3 (rs4487645) 17p11.2 (rs4273077) 22q13.1 (rs877529)
G C A C G A
OR (95% CI) 1.27 1.33 1.26 1.33 1.21 1.25 1.30 1.24 1.22 1.37 1.27 1.40 1.19 1.09
(1.05–1.53) (1.20–1.50) (1.05–1.52) (1.20–1.50) (1.02–1.45) (1.10–1.41) (1.12–1.52) (1.11–1.39) (1.03–1.43) (1.20–1.50) (1.02–1.58) (1.20–1.64) (1.03–1.38) (0.98–1.21)
P
Heterogeneity
0.01 3.5 × 10 − 5 0.01 6.5 × 10 − 5 0.03 1.48 × 10 − 3 6.3 × 10 − 4 1.2 × 10 − 4 0.02 3.2 × 10 − 7 0.04 6.2 × 10 − 4 0.02 0.11
Phet = 0.67 I2 = 0% Phet = 0.64 I2 = 0% Phet = 0.78 I2 = 0% Phet = 0.62 I2 = 0% Phet = 0.24 I2 = 27.4% Phet = 0.46 I2 = 0% Phet = 0.33 I2 = 0%
Abbreviations: 95% CI, 95% confidence interval; I2, measure for inconsistency for which 475% is considered substantial heterogeneity; OR, odds ratio; Phet, significance for heterogeneity; RA, risk allele; RAF, risk allele frequency.
Table 2.
Association results for the SNP rs603965 (11q13.3) in AL amyloidosis and multiple myeloma patients with the t(11;14) translocation Case–control analysis
Disease
RA
AL amyloidosis Myeloma
G
RAF Cases 0.67 0.67
RAF Controls 0.53 0.53
t(11;14) Cases
Controls
190 179
2106 2106
P
OR 1.81 (1.45–2.26) 1.72 (1.37–2.16)
Heterogeneity −7
1.5 × 10 7.7 × 10 − 6
Phet = 0.76 I2 = 0%
Case–case analysis Disease Al amyloidosis Myeloma
RA G
RAF t(11;14) 0.67 0.67
RAF Non t(11;14) 0.58 0.52
t(11;14) Cases 190 179
Non-t(11;14) Cases 139 709
OR 1.51 (1.09–2.08) 1.89 (1.48–2.43)
P
Heterogeneity −2
1.2 × 10 5.7 × 10 − 7
Phet = 0.27 I2 = 16.54%
Abbreviations: 95% CI, 95% confidence interval; I2, measure for inconsistency for which 475% is considered substantial heterogeneity; OR, odds ratio; Phet, significance for heterogeneity; RA, risk allele; RAF, risk allele frequency.
seven SNPs also independently influence MGUS risk.8 MM and MGUS are characterized by a high cytogenetic heterogeneity.5,9 The two main pathogenetic groups hyperdiploidy and nonhyperdiploidy can be further subdivided based on the presence of IgH translocations.9 The cytogenetic patterns of AL amyloidosis are similar, but the frequencies of aberrations differ.5 Recently we showed by stratified analyses that the CCND1 c.870G4A splice site polymorphism (rs603965) was strongly associated with the t(11;14)(q13;q32) in MM and MGUS.9 This IgH translocation can only be detected in ~ 20% of MM and MGUS cases.9 In contrast, it is a common event (53%) in AL amyloidosis.5 In the present study we analyzed the seven MM risk alleles in 443 German AL amyloidosis cases and used published data on German MM and control samples as references. We additionally tested the possible association between rs603965 and the translocation t(11;14) in 329 AL amyloidosis cases with FISH data. Collection of samples and information from subjects was undertaken with informed consent and approval of the ethical review board of the University of Heidelberg in accordance with the tenets of the Declaration of Helsinki. AL amyloidosis patients were ascertained through the Amyloidosis Center at University Clinic Heidelberg and Department of Internal Medicine, University Clinic Ulm. Blood sample was drawn from newly diagnosed patients. IgM cases were not included. Of 443 patients, 257 were men (58%) and the median age was 61 years (s.d. ± 10). The diagnostic criteria used were as described.10 DNA was © 2014 Macmillan Publishers Limited
genotyped using Illumina Human OmniExpress-12 v1.0 arrays. General genotyping quality control assessment was as previously described and all SNPs and samples presented in this study passed the required thresholds.6,7 Fluorescence in situ hybridization (FISH) was performed as previously published.9 Genotype frequencies were compared with recently published genotype data of 1014 German MM patients and 2107 individuals from the German Heinz-Nixdorf Recall study, which had been genotyped using Illumina Human OmniExpress arrays.6,7,9 Table 1 shows genotyping results for the seven SNPs in the newly genotyped AL amyloidosis patients compared to the published data on German MM and controls. The odds ratio of AL amyloidosis associated with each of these SNPs was calculated by unconditional logistic regression. ORs were similar in the two disease groups (Supplementary Figure 1), with only the rs4487645 association showing low heterogeneity between AL amyloidosis and MM (Table 1). The higher effect of rs4487645 in MM may in part be a consequence of a winner’s curse, that is, regression toward the mean implies that by chance the first reported result is higher than the replication result. For AL amyloidosis all risk associations were significant at nominal level o0.05 and rs2285803 was significant even after Bonferroni correction for multiple testing (Po7 × 10 − 3). These data are consistent with MM and AL amyloidosis showing similarity of the underlying genetic mechanisms. Next, we tested whether the strength of the association was different between AL amyloidosis with o10% vs 410% bone Leukemia (2014) 2241 – 2272
Letters to the Editor
2256 marrow plasma cells (BMPCs), a recently proposed cut point for the differentiation between AL amyloidosis with and without MM11 (Supplementary Table 1). The SNPs rs1052501 at 3p22.1 and rs4273077 at 17p11.2 showed non-significant heterogeneity between the two almost equally large groups. In AL amyloidosis with o10% BMPCs the direction of effect of rs1052501 was the same as that of AL amyloidosis with 410% BMPCs, but the effect size was lower. In this subgroup the risk allele frequency of rs4273077 was similar to controls. Except for rs4273077 the data support our recent result that the risk alleles influence the early stage of clonal plasma cell disorders.8 Nevertheless, due to the low case number definite conclusions about genetic similarity or dissimilarity cannot be drawn. The functional basis of the seven MM risk associations is not known. Notably, SNPs rs6746082, rs1052501, rs4487645 and rs877529 map to genes or are in linkage with genes that code for proteins interacting with MYC (DNMT3A, CDCA7L, CBX7) or activating MYC transcription (CTNNB1).4 MYC deregulation has been hypothesized to be critical for myeloma pathogenesis.4 SNP rs10936599 is located 5′ to the telomerase RNA component gene (TERC) that together with telomerase reverse transcriptase (TERT) maintains telomere ends.4 According to the genomic annotation, SNP rs2285803 at 6p21.3 localizes to intron 5 of a putative psoriasis susceptibility gene PSORS1C1.7 However, the locus contains many linked genes and is adjacent to the HLA loci.7 Finally, SNP rs4273077 maps to the gene encoding TACI, a receptor for the key MM growth factors BAFF and APRIL.4 Recently we showed by stratified analysis a relationship between CCND1 c.870G4A and risk of t(11;14) MM and MGUS.9 For AL amyloidosis FISH data were available for 329 cases and the t(11;14) was detected in 190 of the patients (58%). SNP rs603965 was also associated with t(11;14) AL amyloidosis, confirming for the first time this translocation-specific effect in a plasma-cell clone. It showed an OR of 1.81 (P = 1.5 × 10 − 7) in the stratified case–control analysis and an OR of 1.51 in the case–case study (P = 0.01) (Table 2). The size of effect was comparable in AL amyloidosis with o10% or 410% BMPCs (Supplementary Table 2). As AL amyloidosis with o 10% BMPCs is a very early stage of a monoclonal plasma-cell disorder this result supports the hypothesis that the effect of rs603965 arises early in the evolution of a t(11;14) plasma-cell clone.9 However, the molecular basis of the association remains unclear. The risk-associated G allele of rs603965 creates an optimal splice donor site at the exon 4/intron 4 boundary, resulting in the cyclin D1a transcript. The A allele allows read-through into intron 4, resulting in the cyclin D1b transcript.12 Data have shown that cyclin D1a but not cyclin D1b participates in DNA double-stranded repair by binding RAD51.13,14 Recently we have shown that the A allele is associated with non-specific chromosomal aberrations in circulating lymphocytes of healthy donors, indicating that depending on the cell type different effects may be exerted by the CCND1 polymorphism.15 In conclusion, these data show similarities in inherited susceptibility between AL amyloidosis and MM. The similarity is extended to equally strong effects of the CCND1 c.870G4A on t(11;14) defined cases. CONFLICT OF INTEREST The authors declare no conflict of interest.
ACKNOWLEDGEMENTS Funding was provided to Dietmar-Hopp-Stiftung in Walldorf, The German Ministry of Education and Science (Gliommics 01ZX1309B), the German Cancer Aid no. 110131, GERAMY (BMBF 01GM1107A) and the University Hospital Heidelberg. Additional
funding was also provided by the German Ministry of Education and Science and the German Research Council (DFG; Projects SI 236/8-1, SI236/9-1 and ER 155/6-1).
N Weinhold1, A Försti2,3, MI da Silva Filho2, J Nickel1, C Campo2, P Hoffmann4,5, MM Nöthen4,6, D Hose1,7, H Goldschmidt1,7, A Jauch8, C Langer9, U Hegenbart1, SO Schönland1 and K Hemminki2,3 1 Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; 2 German Cancer Research Center, Heidelberg, Germany; 3 Center for Primary Health Care Research, Lund University, Malmo, Sweden; 4 Institute of Human Genetics, University of Bonn, Bonn, Germany; 5 Department of Biomedicine, University of Basel, Basel, Switzerland; 6 Department of Genomics, Life & Brain Research Center, University of Bonn, Bonn, Germany; 7 National Centre of Tumor Diseases, Heidelberg, Germany; 8 Institute of Human Genetics, University of Heidelberg, Heidelberg, Germany and 9 Department of Internal Medicine III, University of Ulm, Ulm, Germany E-mail:
[email protected]
REFERENCES 1 Hemminki K, Li X, Försti A, Sundquist J, Sundquist K. Incidence and survival in non-hereditary amyloidosis in Sweden. BMC Public Health 2012; 12: 974. 2 Merlini G, Seldin DC, Gertz MA. Amyloidosis: pathogenesis and new therapeutic options. J Clin Oncol 2011; 29: 1924–1933. 3 Kyle RA, Rajkumar SV. Epidemiology of the plasma-cell disorders. Best Pract Res Clin Haematol 2007; 20: 637–664. 4 Morgan GJ, Johnson DC, Weinhold N, Goldschmidt H, Landgren O, Lynch HT et al. Inherited genetic susceptibility to multiple myeloma. Leukemia 2014; 28: 518–524. 5 Bochtler T, Hegenbart U, Heiss C, Benner A, Moos M, Seckinger A et al. Hyperdiploidy is less frequent inAL amyloidosis compared with monoclonal gammopathy of undetermined significance and inversely associated with translocation t(11;14). Blood 2011; 117: 3809–3815. 6 Broderick P, Chubb D, Johnson DC, Weinhold N, Försti A, Lloyd A et al. Common variation at 3p22.1 and 7p15.3 influences multiple myeloma risk. Nat Genet 2012; 44: 58–61. 7 Chubb D, Weinhold N, Broderick P, Chen B, Johnson DC, Försti A et al. Common variation at 3q26.2, 6p21.33, 17p11.2 and 22q13.1 influences multiple myeloma risk. Nat Genet 2013; 45: 1221–1225. 8 Weinhold N, Johnson DC, Rawstron AC, Försti A, Doughty C, Vijayakrishnan J et al. Inherited genetic susceptibility to monoclonal gammopathy of unknown significance. Blood 2014; 123: 2513–2517. 9 Weinhold N, Johnson DC, Chubb D, Chen B, Försti A, Hosking FJ et al. The CCND1 c.870G4A polymorphism is a risk factor for t(11;14)(q13;q32) multiple myeloma. Nat Genet 2013; 45: 522–525. 10 Schoenland SO, Hegenbart U, Bochtler T, Mangatter A, Hansberg M, Ho AD et al. Immunohistochemistry in the classification of systemic forms of amyloidosis: a systematic investigation of 117 patients. Blood 2012; 119: 488–493. 11 Kourelis TV, Kumar SK, Gertz Ma, Lacy MQ, Buadi FK, Hayman SR et al. Coexistent multiple myeloma or increased bone marrow plasma cells define equally high-risk populations in patients with immunoglobulin light chain amyloidosis. J Clin Oncol 2013; 31: 4319–4324. 12 Knudsen KE, Diehl JA, Haiman CA, Knudsen ES. Cyclin D1: polymorphism, aberrant splicing and cancer risk. Oncogene 2006; 25: 1620–1628. 13 Li Z, Jiao X, Wang C, Shirley LA, Elsaleh H, Dahl O et al. Alternative cyclin D1 splice forms differentially regulate the DNA damage response. Cancer Res 2010; 70: 8802–8811. 14 Jirawatnotai S, Hu Y, Michowski W, Elias JE, Becks L, Bienvenu F et al. A function for cyclin D1 in DNA repair uncovered by protein interactome analyses in human cancers. Nature 2011; 474: 230–234. 15 Hemminki K, Musak L, Vymetalkova V, Smerhovsky Z, Halasova E, Osina O et al. Cyclin D1 splice site variant triggers chromosomal aberrations in healthy humans. Leukemia 2014; 28: 721–722.
Supplementary Information accompanies this paper on the Leukemia website (http://www.nature.com/leu)
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© 2014 Macmillan Publishers Limited
