Staging and therapy monitoring of multiple myeloma by 99mTc-sestamibi scintigraphy: a five year single center experience

The aim of the present study was the evaluation of the diagnostic value of 99mTc-sestamibi (MIBI) in the detection of bone marrow involvement in patients suffering from multiple myeloma (MM) and its possible role in the follow-up. Between 1998 and 2003, 68 patients with MM and 42 pts with monoclonal gammopathy of undetermined significance (MGUS) were consecutively enrolled in this study. 51/68 MM patients had active disease (AD), 11/62 were in complete remission (CR) and 6/68 in partial remission (PR) after chemotherapy. 18 patients with MM repeated a 99mTc-MIBI scintigraphic study at least 2 months after high-dose chemotherapy. All the scans were scored semi quantitatively according to extension and intensity of tracer uptake. All MGUS pts had a negative 99mTc-MIBI. As far as the MM pts are concerned, 54/68 (49%) pts (48 with AD, 5 with PR and 1 with CR) had a positive 99mTc-MIBI scan, while the 99mTc-MIBI scan was negative in 14/68 pts (10 with CR, 1 with PR and 3 with AD). The overall sensitivity of the 99mTc-MIBI scintigraphy was 92%; specificity was 96%. In the follow up of the pts treated with chemotherapy 99mTc-MIBI closely paralleled the activity of myeloma bone disease. In conclusion, these results indicate that 99mTc-MIBI scintigraphy closely reflects myeloma disease activity in the bone marrow, and that a negative 99mTc-MIBI scan in patients with suspected MM clearly, though not absolutely, indicates absence of disease or clinical remission. The results of this study suggest a clear diagnostic value of 99mTc-MIBI scintigraphy in patients with MM and its potential role during the follow-up for the monitoring of MM bone disease.     

The use of 99mTc-MIBI scanning in multiple myeloma.

Tc-99m 2 methoxy-isobutyl-isonitrile (99mTc-MIBI), also called Sestamibi, is a safe and effective scanning agent in solid tumours. Its use in imaging lesions in multiple myeloma has been studied in 21 patients with either multiple myeloma (19/21) or monoclonal gammopathy of undetermined significance (MGUS) (2/ 21). 99mTc-MIBI scanning was positive in 14 patients, 13 with active myeloma and one patient with MGUS showing possible transformation to a more accelerated phase. In seven patients 99mTc-MIBI scanning was negative. In four of them, the result was unexpected, as they had the features of active myeloma. All four were either primarily or secondarily resistant to chemotherapy, with high total cumulative doses of doxorubicin. Overexpression of P-glycoprotein associated with multidrug resistance could be a factor, as it has been shown that 99mTc-MIBI is actively eliminated from the cell by P-glycoprotein. With this assumption, sensitivity of the scanning technique in this series is 100%, and the specificity 88%. No toxicity was experienced by any patient. 99mTc-MIBI scanning is a useful adjunct to the investigation of multiple myeloma, and may have potential as an in vivo test for multidrug resistance.     

Expression of MDR1/P-glycoprotein,the multidrug resistance protein MRP,and the lung-resistance protein LRP in multiple myeloma

The purpose of this study was to determine the incidence of three genes associated with multidrug resistance (MDR) in multiple myeloma in relation to treatment status. MDR1/Pgp (P-glycoprotein) expression was detected in 41% of 93 myeloma samples. Generally, the incidence of MDR1/Pgp expression was higher in pretreated samples, and treatments with doxorubicin and/or vincristine were more effective in MDR1/Pgp expression than with alkylating agents. A significant association was observed between MDR1/Pgp-positiveness and the ability of verapmil to increase doxorubicin sensitivity, suggesting functional relevance of MDR1/Pgp expression. MRP (multidrug resistance protein) expression was detected in 20.5% of 88 myeloma samples, in 26% at the mRNA level analyzed by quantitative reverse transriptase-polymerase chain reaction, and in only 3 of 79 samples by immunohistochemistry. LRP (lung-resistance protein) protein expression was observed in 12.5% of 72 myeloma samples. MRP and LRP expression was similar in samples with and without prior therapy. Approximately 80% of the myeloma samples with detectable mRNA expression of MDR1 and MRP exhibited low expression levels corresponding to <10% of the Pgp- and MRP-overexpressing multidrug-resistant human myeloma cell lines 8226/Dox6 and 8226/DOXint40c, respectively. Some normal bone marrow samples showed higher levels of MRP mRNA as compared to myeloma specimens, whereas MDR1 mRNA expression in normal bone marrow was much lower (≤ 5%) than that in 8226/Dox6. These findings indicate a requirement to develop single-cell assays for MRP detection in multiple myeloma that are more sensitive than immunohistochemistry and might be useful to evaluate the incidence of genes associated with MDR.     

Predicting chemotherapy response and comparing with P-glycoprotein expression using technetium-99m tetrofosmin scan in untreated malignant lymphomas

The purposes of this study were to predict the chemotherapy response of untreated malignant lymphomas (ML) using a technetium-99m tetrofosmin (Tc-TF) scan and to compare Tc-TF results with P-glycoprotein (Pgp) expression. Before undergoing chemotherapy, 25 patients with ML were enrolled in this study. Tc-TF scan was performed 10 min after intravenous injection of Tc-TF. Immunohistochemical analyses were performed on multiple sections of ML specimens to evaluate Pgp expression. The chemotherapy response was evaluated in the first 1–2 years after the completion of treatment. The mean tumor-to-background ratio of the 15 patients with good responses (3.23±0.56) was significantly higher than that of the ten patients with poor responses (1.18±0.11). All of the 15 patients with good responses had positive Tc-TF scan results, but negative Pgp expression. Among the ten patients with poor responses, all had negative Tc-TF scan results, but six had positive Pgp expression and four had negative Pgp expression. Significant differences in the incidences of good and poor responses were found between patients with positive Tc-TF scan results and patients with negative Tc-TF scan results and between patients with positive Pgp expression and patients with negative Pgp expression. No significant differences in the incidences of good and poor responses were found between Hodgkin's disease patients and non-Hodgkin's lymphoma patients, stage I–II patients and III–IV patients, patients aged >40 and patients aged ≤40 years, and patients with and without B symptoms. Compared with other prognostic factors, Tc-TF scan results and Pgp expression more accurately predict the chemotherapy response in patients with ML.     

Expression of receptor activator of nuclear factor kappaB ligand on bone marrow plasma cells correlates with osteolytic bone disease in patients with multiple myeloma.

PURPOSE: Increased bone resorption is a hallmark of multiple myeloma and is attributable to osteoclast activation. Recent studies showed that the receptor activator of nuclear factor kappaB ligand (RANKL) is the key mediator of osteoclastogenesis and plays a crucial role in bone destruction in malignant bone disease. We found that human myeloma cells express RANKL and analyzed the association of the RANKL expression with the presence of osteolytic bone disease in patients with multiple myeloma. EXPERIMENTAL DESIGN: Flow cytometry was performed on bone marrow samples derived from controls and multiple myeloma patients with or without osteolytic bone lesions on conventional radiography. Plasma cells were identified as CD38++/CD138+ cells. The level of RANKL expression on the surface of bone marrow plasma cells was correlated with the bone status of the patients. RESULTS: The bone marrow plasma cells from controls showed no or only a weak surface expression of RANKL, and the median mean fluorescence index (MFI) was 6. In contrast, expression of RANKL could be detected on bone marrow plasma cells from all of the patients with multiple myeloma, and median MFI was 47. The difference in MFI for RANKL expression of bone marrow plasma cells from controls and myeloma patients was highly significant (P < 0.0005). Myeloma patients with osteolytic bone lesions showed a significantly higher expression of RANKL (median MFI = 60; range, 16-2494) compared with patients without osteolysis (median MFI = 16; range, 6-229; P < 0.0005). CONCLUSIONS: These results show for the first time that the level of RANKL expression by myeloma cells correlates significantly with osteolytic bone disease.     

Prediction of chemotherapy response in untreated malignant lymphomas using technetium-99m methoxyisobutylisonitrile scan: comparison with P-glycoprotein expression and other prognostic factors. A preliminary peport

BACKGROUND: The purpose of this study was to predict chemotherapy response in untreated malignant lymphomas using technetium-99m methoxyisobutylisonitrile (Tc-MIBI) scan. METHODS: Twenty-five patients with malignant lymphoma were studied before receiving chemotherapy. Early Tc-MIBI scan was performed 10 min after intravenous injection of Tc-MIBI. Immunohistochemical analyses were performed on multiple non-consecutive sections of the biopsy specimens to determine Pgp expression. Chemotherapy response was evaluated in the first 1-2 years after completion of treatment by clinical and radiological methods. RESULTS: The mean tumor-to-background ratio of the 15 patients with good response (3.3 +/- 0.6) was significantly higher than that of the 10 patients with poor response (1.2 +/- 0.1). Among the 15 patients with good response to chemotherapy, all had positive Tc-MIBI scan results but negative Pgp expression. Among the 10 patients who had poor response to chemotherapy, all 10 had negative Tc-MIBI scan, but six patients had positive Pgp expression and four had negative Pgp expression. Significant differences were found in the incidences of good and poor responses determined by Tc-MIBI scan and Pgp expression. However, there were no significant differences in the incidences of good and poor responses for other prognostic factors. CONCLUSION: Compared with other prognostic factors, early Tc-MIBI scan more accurately predicts chemotherapy response in patients with malignant lymphoma.     

Scintigraphic detection of multidrug resistance in cancer

One of the most extensively studied mechanisms of drug resistance involves the drug efflux pump P-glycoprotein (Pgp). The availability of radiolabeled substrates of Pgp such as 99mTc-MIBI and analogous 99mTc-labeled agents allows the clinical assessment of Pgp function in cancer patients. The consistency of the results from different institutions and trials strongly support the clinical application of this imaging technique for individual tailoring of chemotherapeutic regimens and for designing clinical trials with Pgp modulators.     

Dose‐intensified bendamustine followed by autologous peripheral blood stem cell support in relapsed and refractory multiple myeloma with impaired bone marrow function

Therapeutic options in heavily pretreated relapsed/refractory multiple myeloma patients are often very limited because of impaired bone marrow function. Bendamustine is effective in multiple myeloma and has a favourable toxicity profile. We hypothesized that dose‐intensified bendamustine (180 mg/m², day 1 and 2) followed by autologous blood stem cell support (ASCS) would improve bone marrow function with low post‐transplant toxicity in patients with severely impaired haematopoiesis. We analyzed 28 consecutive myeloma patients, with a median of three prior lines of therapy (range 2–7), who had relapsed from the last treatment with very limited bone marrow function and were therefore ineligible for conventional chemotherapy, novel agents or trial enrolment. Dose‐intensified bendamustine with ASCS improved haematopoiesis as reflected by increased platelet counts (median 40/nl vs 94/nl, p = 0.0004) and white blood cell counts (3.0/nl vs 4.8/nl, p = 0.02) at day +100. The median time until engraftment of platelets (>50/nl) was 11 days (0–24 days) and of white cell counts (>1.0/nl) 0 days (0–24 days). At least, a minimal response was achieved in 36% of patients. The disease stabilization rate was 50% while the median progression‐free survival rate was limited to 2.14 months. Most importantly, patients were once again eligible for alternative treatments including enrolment into clinical trials. We conclude that dose‐intensified bendamustine followed by ASCS is safe and feasible for multiple myeloma patients with very limited bone marrow reserve. Copyright © 2015 John Wiley & Sons, Ltd.     

MicroRNA-145和KLF5在多发性骨髓瘤骨髓液中的表达及其临床意义

目的:分析微小RNA-145(microRNA-145,miR-145）和Krüpple 样因子5(Krüepple-like factor 5,KLF5)在多发性骨髓瘤（multiple myeloma,MM）骨髓液中的表达及其临床意义。方法:收集2015年1月至2016年3月住院MM诊治患者65例（疾病组）和体检健康正常者36例（对照组）作为研究对象,采用实时荧光定量PCR（qRT-PCR）法检测骨髓液中miR-145 mRNA和KLF5 mRNA表达水平;采用Western Blot检测KLF5蛋白表达水平;分析miR-145与KLF5 mRNA在MM髓液中表达的相关性。结果:miR-145 mRNA在MM骨髓液中的表达水平显著低于对照组（P<0.05）;KLF5 mRNA及蛋白表达水平显著高于对照组（P<0.05）;与I期、Ⅱ期比较,Ⅲ期MM患者骨髓液中miR-145表达水平显著降低（P<0.05）,KLF5 mRNA表达水平显著升高（P<0.05）;与IgG 型和IgA 型相比,轻链型与非分泌型MM患者骨髓液中miR-145相对表达量明显降低（P<0.05）;KLF5 mRNA在不同免疫分型中的表达水平比较,差异无统计学意义（P>0.05）;miR-145和KLF5的表达呈负相关（r=-0.452,P<0.05）;死亡MM患者骨髓液中miR-145表达水平显著低于存活患者（P<0.05）,KLF5 mRNA表达水平显著高于存活患者（P<0.05）。结论:miR-145在MM患者骨髓液中低表达,KLF5高表达,二者表达可能与MM的发生和病情发展密切相关。     

Production of Wnt inhibitors by myeloma cells: potential effects on canonical Wnt pathway in the bone microenvironment

Osteoblast impairment occurs within multiple myeloma cell infiltration into the bone marrow. Canonical Wnt signaling activation in osteoprogenitor cells is involved in osteoblast formation through the stabilization of dephosphorylated beta-catenin and its nuclear translocation. The effects of multiple myeloma cells on Wnt signaling in human mesenchymal/osteoprogenitor cells are unclear. In 60 multiple myeloma patients checked, we found that among the Wnt inhibitors, Dickkopf-1 and secreted frizzled-related protein-3 were produced by multiple myeloma cells. However, although multiple myeloma cells or multiple myeloma bone marrow plasma affected expression of genes in the canonical Wnt signaling and inhibited beta-catenin stabilization in murine osteoprogenitor cells, they failed to block the canonical Wnt pathway in human mesenchymal or osteoprogenitor cells. Consistently, Wnt3a stimulation in human osteoprogenitor cells did not blunt the inhibitory effect of multiple myeloma cells on osteoblast formation. Consequently, despite the higher Wnt antagonist bone marrow levels in osteolytic multiple myeloma patients compared with nonosteolytic ones, beta-catenin immunostaining was not significantly different. Our results support the link between the production of Wnt antagonists by multiple myeloma cells and the presence of bone lesions in multiple myeloma patients but show that myeloma cells do not inhibit canonical Wnt signaling in human bone microenvironment.     

Management of bone lesions in multiple myeloma

Bone destruction is a key feature of multiple myeloma, which causes significant impairment of patients' activity. Some of the mechanisms regulating bone destruction have recently been clarified, and the management of bone diseases in myeloma patients has made considerable progress. Moreover,imaging techniques for screening bone lesions have been developed, such as PET scan or (99m)Tc scan, other than regular X-ray analysis. We describe here strategies for the management of bone disease in myeloma, e.g., ( I ) effective chemotherapy against myeloma cells, (II) decrease of osteoclasts by bisphosphonates, (III) surgical treatment of damaged bone, (IV) irradiation to lytic bone lesion and (V) other forms of supportive care. All of these approaches should be effectively integrated to improve the quality of life of myeloma patients.     

多发性骨髓瘤骨髓组织中p53与血管新生的关系

目的　研究多发性骨髓瘤骨髓组织中 p5 3基因和VEGF表达与血管新生的关系。 方法　应用原位杂交及免疫组化染色技术对 4 2例多发性骨髓瘤患者骨髓组织中VEGF、p5 3及微血管密度 (MVD)进行检测。结果　VEGF的阳性率为 5 2 .4 % (2 2 /4 2 ) ,p5 3的阳性率为2 1.4 % (9/4 2 )。经连续切片对比及统计学分析显示 ,p5 3的表达与VEGF的表达显著相关 (P <0 .0 5 ) ;并且p5 3阳性组MVD显著高于阴性组MVD(P <0 .0 1) ,VEGF阳性组MVD显著高于阴性组MVD(P <0 .0 1)。结论　多发性骨髓瘤骨髓组织中 p5 3突变可以上调VEGF的表达 ,促进血管新生。     

多发性骨髓瘤患者Survivin、VEGF表达及其相关性

目的:研究多发性骨髓瘤（MM）患者血清及骨髓Survivin、VEGF表达及意义。方法:酶联免疫法（ELASA）检测60例初诊多发性骨髓瘤患者及30例对照组患者血清Survivin、VEGF表达情况;免疫细胞化学法（SABC法）检测骨髓单个核细胞中Survivin、VEGF阳性率。酶联免疫法（ELASA）检测VAD联合沙利度胺治疗4周期后患者血清Survivin、VEGF水平,与治疗前比较。结果:初诊多发性骨髓瘤患者血清Survivin、VEGF表达水平较对照组明显升高;初诊骨髓瘤患者骨髓单个核细胞Survivin、VEGF阳性率较对照组明显提高;经统计学分析,P＜0.05,差异有统计学意义。治疗后患者,血清Survivin、VEGF在不同疗效组有差异,疗效良好组与疗效较差组差异比较,P＜0.05。骨髓中Survivin与VEGF表达阳性率呈正相关,与疾病疗效呈负相关。结论:Survivin及VEGF在多发性骨髓瘤患者中表达增加,二者表达水平与疾病疗效密切相关。二者存在协同关系,可作为评估疗效、预后指标。     

Multiple myeloma: an immunologic profile. II. Bone marrow studies.

Bone marrow mononuclear cell populations were studied in 35 patients without myeloma, 39 patients with multiple myeloma, and 15 patients with benign monoclonal gammopathy. Bone marrow mononuclear cell receptors, responses to mitogens or allogeneic stimuli, and suppressive effects on in vitro peripheral blood lymphocyte (PBL) function were studied. In bone marrow cell populations from patients with untreated multiple myeloma, the percent of complement receptor-bearing cells and the pokeweed mitogen- and concanavalin A-stimulated responses were significantly greater than were those in bone marrow cell populations from patients without myeloma. Sheep red blood cell receptor-bearing cells were significantly greater in marrow populations from treated multiple myeloma patients compared to those from untreated multiple myeloma patients. Sheep red blood cell receptor-bearing cells from the bone marrow of multiple myeloma patients suppressed responses of the multiple myeloma patients' PBL's to autologous mitomycin C-treated bone marrow plasma cells and to allogeneic stimuli in one-way mixed leukocyte culture. Complement receptor-bearing cells suppressed the response to pokeweed mitogen. The presence of lymphocytes in the marrow compartment that are capable of suppressing the response of myeloma patients' PBL's to plasma cell antigens may be significant in the pathogenesis of multiple myeloma.     

Using technetium-99m-tetrofosmin scan to predict chemotherapy response of malignant lymphomas, compared with P-glycoprotein and multidrug resistance related protein expression

The ability of technetium-99m tetrofosmin (Tc-TF) scan to predict chemotherapy response in malignant lymphomas (ML) was compared with the predictive ability of P-glycoprotein (Pgp) and multidrug resistance related protein (MRP) expression. Before chemotherapy, 25 ML patients were enrolled in this study. Scans were performed 10 min after intravenous injection of Tc-TF. Immunohistochemical analyses were performed on ML specimen sections to evaluate Pgp and MRP expression. Chemotherapy response was evaluated in the first 1-2 years after completion of chemotherapy. Based on Tc-TF scan results, the mean tumor-to-background (T/B) ratio of the 15 patients with good response (3.23 +/- 0.56) was significantly higher than that of the 10 patients with poor response (1.18 +/- 0.11). All 15 patients with good response had positive Tc-TF scan results but negative Pgp and MRP expression. All 10 patients with poor response had negative Tc-TF scan results but positive Pgp or MRP expression. No significant differences in the incidences of good and poor response results were found for patients with Hodgkin's disease versus non-Hodgkin's lymphoma, with stage I-II versus stage III-IV, with age > 40 versus age < or = 40 years, or with B symptoms versus without B symptoms. Tc-TF scan results, which may represent either Pgp or MRP expression, accurately predict chemotherapy response in patients with ML.     

Tumor-associated antigens in human myeloma.

Antiserum was generated in rabbits to the RPMI 8226 tissue culture line of human myeloma cells, and its reactions with fixed smears of bone marrow aspirates from patients with multiple myeloma, macroglobulinemia, benign monoclonal gammopathy (BMG), leukemia, and nonneoplastic plasmacyosis was assessed by indirect immunofluorescence. After absorption with preparations of bone marrow from normal individuals, the antiserum reacted to a significantly higher titer with a specific subpopulation of plasma cells in smears from 81% of patients having multiple myeloma and 50% of patients having BMG than with cells in smears of bone marrow aspirates from normal individuals or patients having leukemia or nonneoplastic plasmacytosis, or than with cells in smears of peripheral blood from patients having Hodgkin's and non-Hodgkin's lymphoma. Absorption of the antiserum with RPMI 8226 cells or with a bone marrow preparation from a patient with multiple myeloma but not the Jijoye line of Burkitt's lymphoma reduced reactivity for cells in myeloma bone marrow. The antiserum reacted at a lower titer with the Jijoye and EB-3 lines of Burkitt's lymphoma, the RPMI 4098 cell line of normal human lymphocytes, and culture lines of human melanoma and osteogenic sarcoma than with the RPMI 8226 cells or bone marrow from certain patients having multiple myeloma. Approximately 50% of the cells reactive with antiserum to RPMI 8226 cells in the bone marrow of patients with multiple myeloma were not producing immunoglobulin, as assessed by double immunofluorescence assay. The data suggested that a subpopulation of plasma cells in the bone marrow of patients with multiple myeloma possesses a tumor-associated antigen.     

多发性骨髓瘤骨病的诊断与治疗新进展

 约90 %的多发性骨髓瘤（MM）患者存在骨损害。常规X线检查只有在30 %的骨小梁缺失后才能发现溶骨性损害,对于初诊MM患者的分期,常规X线检查仍是"金标准"。在发现小的溶骨性病变方面CT扫描比常规X线检查更敏感,但对怀疑有椎体压迫的患者应行磁共振成像（MRI）或CT扫描。同位素骨扫描常常低估MM患者骨损害的程度。MM骨病的治疗包括双磷酸盐、新的靶向治疗、外科手术、放射治疗等治疗措施。     

Technetium-99m tetrofosmin SPECT predicts chemotherapy response in small cell lung cancer.

The multidrug resistance gene 1 encoding human P-glycoprotein (Pgp) is thought to play an important role in the multidrug resistance of lung cancer. The purpose of this study was to predict chemotherapy response by technetium-99m tetrofosmin (Tc-99m TF) lung single photon emission computed tomography (SPECT) and compare Pgp expression in patients with untreated small cell lung cancer (SCLC). Forty patients with untreated SCLC received Tc-99m TF lung SPECT prior to chemotherapy. The chemotherapy response was evaluated in the 3rd month after completion of treatment. Immunohistochemical staining of Pgp expression was performed on multiple nonconsecutive sections of biopsy specimens. By quantitative analyses, tumor to background ratios were 1.86 +/- 0.27 and 1.17 +/- 0.26 for patients with a good and poor response, respectively (p < 0.05). All of the 20 patients with a good chemotherapy response also had a positive Tc-99m TF lung SPECT and negative Pgp expression. In contrast, only 4 of the 20 patients with a poor chemotherapy response had a positive Tc-99m TF lung SPECT. Moreover, 10 of the 20 patients with a poor chemotherapy response also had negative Pgp expression (p < 0.05). Therefore, we concluded that Tc-99m TF lung SPECT can accurately predict the chemotherapy response, and Tc-99m TF lung SPECT findings can be partially compatible with Pgp expression in patients with untreated SCLC.     

Technetium-99m sulfur colloid scanning and correlative magnetic resonance imaging in patients with hairy cell leukemia and hypocellular bone marrow biopsies after 2-chlorodeoxyadenosine.

It has been observed that some patients in complete remission (CR) after 2-chlorodeoxyadenosine (2-CdA) for hairy cell leukemia (HCL) have hypocellular bone marrow biopsies despite normal peripheral blood cell counts. This discrepancy between bone marrow cellularity and peripheral blood cell counts suggests the possibility of abnormal sites of hematopoiesis. To determine sites of hematopoiesis, 11 radionuclide scans using technetium-99m (99mTc) sulfur colloid were performed in eight patients. Although no single, pattern was observed on the 99mTc sulfur colloid scans, two of the eight patients, both with virtually aplastic marrows, had multiple areas of increased uptake in the distal appendicular skeleton, suggesting abnormal sites of hematopoiesis. The same two patients had magnetic resonance imaging (MRI), which confirmed the abnormal sites of hematopoiesis.