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Prognostic and biological implications of genetic abnormalities in multiple myeloma undergoing autologous stem cell transplantation: t(4;14) is the most relevant adverse prognostic factor, whereas RB deletion as a unique abnormality is not associated with adverse prognosis

NC Gutie´rrez1,13, MV Castellanos1,13, ML Martıń2, MV Mateos1, JM Hernańdez1, M Fernańdez2, D Carrera3, L Rosinõl4, JM Ribera5, JM Ojanguren6, L Palomera7, S Gardella8, L Escoda9, JC Hernańdez-Boluda10, JL Bello11, J de la Rubia12, JJ Lahuerta2 and JF San Miguel1, on behalf of GEM/PETHEMA Spanish Group

1Servicios de Hematologıá: Hospital Universitario de Salamanca and Centro de Investigacioń del Cańcer (CIC), Universidad de Salamanca-CSIC, Spain; 2Hospital 12 de Octubre, Madrid, Spain; 3Hospital Central de Asturias, Oviedo, Spain; 4Hospital Clıńic Universitari, IDIBAPS, Barcelona, Spain; 5Hospital German Trias i Pujol, Badalona, Spain; 6Hospital de Galdakao, Bilbao, Spain; 7Hospital Clıńico, Zaragoza, Spain; 8Hospital Dr Josep Trueta, Gerona, Spain; 9Hospital Joan XXIII, Tarragona, Spain; 10Hospital Clıńico Universitario, Valencia, Spain; 11Hospital Universitario, Santiago de Compostela and 12Hospital Universitario La Fe, Valencia, Spain

Fluorescence in situ hybridization (FISH) has become a power- most important in order to obtain individualized information ful technique for prognostic assessment in multiple myeloma about disease outcome and to design risk-adapted therapeutic (MM). However, the existence of associations between cytoge- strategies. The cytogenetic status have emerged as the most netic abnormalities compels us to re-assess the value of each 2–5 abnormality. A total of 260 patients with MM at the time of relevant prognostic factor in MM. However, the low diagnosis, enrolled in the GEM-2000 Spanish transplant proto- proliferative activity of PC, as well as the limited extent of bone col, have been analyzed by FISH in order to ascertain the marrow (BM) involvement, reduce the number of analyzable independent influence on myeloma prognosis of IGH transloca- metaphases and hamper cytogenetic studies. In addition, the tions, as well as RB and P53 deletions. Survival analyses resolution of conventional cytogenetics makes it impossible to showed that patients with t(4;14), RB or P53 deletions had a recognize cryptic translocations.6–8 These factors are leading to significantly shorter survival than patients without these abnormalities. However, patients with RB deletions without the replacement of classical cytogenetics by interphase fluores- other abnormalities in FISH analysis, displayed a similar cence in situ hybridization (FISH) technology, which allows a outcome to those patients without genetic changes by FISH rapid and reproducible identification of specific target regions (46 vs 54 months, P ¼ 0.3). In the multivariate analysis the frequently affected in MM and with prognostic influence. presence of t(4;14), RB deletion associated with other abnorm- Several groups, including our own, have investigated by alities, age 460 years, high proportion of S-phase cells and FISH the cytogenetic abnormalities most frequently involved in advanced stage of the disease according to the International 3,4,9,10 Staging System retained their independent prognostic influ- MM. Immunoglobulin heavy-chain (IGH ) translocations, ence. In summary, RB deletion as a sole abnormality does not as well as retinoblastoma (RB) and P53 deletions represent lead to a shortening in the survival of MM patients, whereas chromosomal abnormalities with a widely recognized prognos- t(4;14) confers the worst prognosis in MM patients treated with tic impact. Although RB deletions have been considered as a high-dose chemotherapy. powerful adverse prognostic factor consistently reported in Leukemia (2007) 21, 143–150. doi:10.1038/sj.leu.2404413; large series,3–5,11,12 the coexistence of RB deletions and IGH published online 5 October 2006 translocations raises the question of whether the adverse Keywords: multiple myeloma; genetic abnormalities; FISH; RB deletion prognosis of each abnormality may be influenced by the other. In order to ascertain the individual contribution of each abnormality as well as the influence of associations between abnormalities in MM outcome, we have systematically analyzed by FISH RB and P53 deletions, and IGH translocations in 260 Introduction patients uniformly treated according to the GEM 2000 protocol, which includes an induction phase with VBCMP/VBAD Multiple myeloma (MM) is a clonal plasma cell (PC) disorder followed by autologous cell transplantation (ASCT). In addition, that remains as an incurable disease. Nevertheless, the survival we have explored whether or not these cytogenetic subgroups of myeloma patients is highly variable, ranging from a few display distinct clinical and biological disease characteristics. months to more than 10 years. This heterogeneity relates mainly to prognostic factors associated with specific characteristics of 1 both the tumor itself and the host. The identification of those Patients and methods characteristics associated with either a good or poor prognosis is Patients Correspondence: Professor JF San Miguel, Servicio de Hematologıá, Patients under the age of 70 years, with newly diagnosed MM, Hospital Universitario de Salamanca, Paseo San Vicente 58-182, enrolled in the GEM 2000 Spanish protocol (six alternating Salamanca 37007, Spain. cycles of VBCMP/VBAD followed by high-dose therapy – E-mail: [email protected] 2 13These authors contributed equally to this work melphalan 200 mg/m supported by ASCT) were included in Received 5 July 2006; revised 25 August 2006; accepted 30 August the study. The study was approved by the research ethics 2006; published online 5 October 2006 committees of all participating centers and written informed Genetic abnormalities in multiple myeloma NC Gutie´rrez et al 144 Table 1 Clinical and biological characteristics of MM patients analyzed using the scoring criteria recommended by the manufacturer. Based on the results using these probes in 25 Characteristics All patients healthy controls, the cutoff point for the identification of alteration was set at more than 8% cells with abnormal signal. Sex Male 55% Female 45% Statistical analysis Statistical analysis were performed using SPSS statistical soft- ISS 2 I 28% ware version 11.5 (SPSS Inc., Chicago, IL, USA). The w and the II 48% Fisher’s exact test were used to test associations between III 24% chromosomal abnormalities as well as between genomic changes and other categoric variables. For continuous variables, Ig subtype the Wilcoxon rank sum test and t-test were used. OS was IgG 52% calculated from the start of the initial treatment to the date of IgA 28% IgD 0.4% death or last visit. Time to progression (TTP) was estimated from Bence Jones protein 18% the day of initiation of treatment to the date of relapse or disease Non-secretory 1.2% progression. Survival curves were plotted by means of the Kaplan–Meier method and the difference in survival curves was ASCT (%) tested for statistical significance using the log-rank test. P-values Yes 82% below 0.05 were considered to reflect statistical significance. No 18% Multivariate analysis of survival was performed using the Cox Age (years) 60 (39–70) proportional hazards model (stepwise regression approach). b2-microglobulin (mg/l) 3.6 (0.2–28.7) Factors were retained in the model if they were statistically Hemoglobin (g/dl) 10.4 (4–15.5) significant at Pp0.05. Creatinine (mg/dl) 1.1 (0.3–13.3) Calcium (mg/dl) 9.6 (6.7–16.1) Albumin (mg/dl) 3.5 (1–5.2) Results C-reactive protein (mg/dl) 1.07 (0–25.5) S-phase plasma cells (%) 1.5 (0.2–14.6) Frequency of chromosomal abnormalities Abbreviations: ASCT, autologous stem cell transplantation; Ig, Chromosomal abnormalities explored by FISH were identified in immunoglobulin; ISS, International staging system; MM, multiple 151 (58%) of the 260 MM patients. IGH translocations and RB myeloma. Values are expressed as median (range). deletions were observed in 95 (36%) and 109 (42%) out of the 260 patients, respectively; whereas P53 deletions were present in 8.5% (22/260) of patients. The distribution of IGH translocations according to 14q32 partners were: t(11;14) in 13% (34/260 consent was obtained from all patients. In order to interpret patients), t(4;14) in 11% (29/260 patients), t(14;16) in 3% (7/260 accurately FISH analysis only those patients with BM PC patients) and IGH rearrangements with other unknown partners infiltration by flow cytometry above 10% were eligible for this in 10% (25/260 patients). study (n ¼ 260). The main clinical and laboratory characteristics of these patients are shown in Table 1. Forty-seven of 260 patients (18%) did not undergo ASCT because of comorbidity Correlations between chromosomal abnormalities (20 cases), progression of the disease (13 cases), failure in A significant association between t(4;14) and RB deletions mobilization (11 cases) or withdrawal of informed consent was observed. Thus, 79% of patients with t(4;14) had RB (three cases). The median overall survival (OS) for the whole deletions vs 37% of patients without t(4;14) (Po0.001). group was 43 months (95% confidence interval, 36–49), and the However, no correlation was found between this translocation median follow-up for survivors was 34 months. At the time of and P53 deletions (Table 2). In contrast, t(11;14) was signifi- study, 102 patients remained alive. cantly associated with P53 deletions but not with RB deletions (Table 2). Translocations involving 16q and other unknown IGH partners did not correlate with RB or P53 deletions. Finally, a FISH analysis significant association was observed between P53 and RB Interphase FISH studies for the detection of IGH rearrangements deletions (P ¼ 0.009) (Table 2). were carried out by means of LSI IGH dual color, break apart rearrangement probe (Vysis, Downers Grove, IL, USA). Patients with IGH translocations were explored firstly for Association between chromosomal abnormalities and t(11;14)(q13;q32) (LSI IGH/CCND1, dual fusion translocation clinical and biological parameters probe) (Vysis), and subsequently analyzed for t(4;14)(p16;q32) Overall, IGH translocations and RB deletions were significantly (4p – BAC clones L75b9, L190b4, L96a2, PAC 184d6–; 14q32– more frequent in younger patients (the incidence of IGH VH: cosmid yIgH6-9, CH: BAC B158 A2–) and finally for translocations was 66% in patients o60 years vs 34% in those t(14;16)(q32;q23) (16q23 – BAC clones 356D21, 484H2, 10205 460 years, P ¼ 0.006; and for RB deletions, 63% in patients and 10206–). The probes corresponding to the last two o60 years vs 37% in those 460 years, P ¼ 0.02). When clinical translocations were kindly provided by Rafael Fonseca from and laboratory parameters were correlated with the different the Mayo Clinic, Scottsdale, AZ, USA. The presence of 13q and subtypes of IGH rearrangements, it was observed that patients 17p deletions were evaluated with a specific probe for RB -LSI with t(4;14) more frequently had lower albumin levels (P ¼ 0.02) 13 (RB1) (Vysis) and for P53 – LSI P53 (17p13.1) (Vysis), and advanced International Staging System (ISS)14 (P ¼ 0.04); respectively. The interphase-FISH procedure has been described cases with t(14;16) were associated with lower hemoglobin (Hb) previously in detail.13 A total of 500 interphase nuclei were levels (P ¼ 0.005), and IGH translocations involving unknown

Leukemia Genetic abnormalities in multiple myeloma NC Gutie´rrez et al 145 Table 2 Associations between chromosomal abnormalities

RB1 deletion P-value P53 deletion P-value

IGH translocation 62% (59/95) o0.001 14% (13/95) 0.02 Normal IGH 30% (50/165) F 5% (9/165) F t(11;14) 50% (17/34) NS 21% (7/34) 0.01 No t(11;14) 41% (92/226) F 7% (15/226) F t(4;14) 79% (23/29) o0.001 10% (3/29) NS No t(4;14) 37% (86/231) F 8% (19/231) F t(14;16) 71% (5/7) NS 29% (2/7) NS No t(14;16) 41% (104/253) F 8% (20/253) F

Other IGH translocation 52% (13/25) NS 4% (1/25) NS No other IGH translocation 41% (96/235) F 9% (21/235) F

P53 deletion 68% (15/22) 0.009 FFFF Normal P53 39% (94/238) FFF Bold values indicate statistically signiﬁcant. Abbreviation: NS, not signiﬁcant.

Table 3 Median OS and TTP of patients with different chromosomal abnormalities

Chromosomal abnormality N Response X %PR (%CR) P-value TTP, months (95% CI) P-value OS, months (95% CI) P-value

RB deletion 109 83 (18) NS 25 (23–27) o0.0001 34 (29–39) o0.0001 Normal RB 151 84 (27) F 39 (34–45) F 51 (45–57) F

P53 deletion 22 87 (31) NS 20 (14–25) 0.003 29 (22–35) 0.004 Normal P53 238 83 (23) F 34 (29–39) F 46 (39–52) F

IGH Tx 95 85 (21) NS 26 (21–30) 0.0001 34 (28–41) o0.0001 Normal IGH 165 82 (25) F 39 (36–42) F 51 (45–57) F t(11;14) 34 93 (23) NS 29 (17–40) NS 49 (38–61) NS No t(11;14) 226 82 (23) F 32 (26–38) F 40 (33–47) F t(4;14) 29 82 (18) NS 20 (15–25) o0.0001 24 (17–32) o0.0001 No t(4;14) 231 84 (24) F 37 (31–43) F 48 (42–54) F t(14;16) 7 83 (17) NS 24 (17–31) NS 36 (34–38) NS No t(14;16) 253 83 (23) F 32 (27–37) F 44 (38–50) F

Other IGH Tx 25 75 (25) NS 26 (22–30) NS 37 (24–50) NS No other IGH Tx 235 84 (23) F 34 (28–40) F 46 (39–52) F Bold values indicate statistically significant. Abbreviations: CR, complete response; NS, not significant; OS, overall survival; PR, partial response; TTP, time to progression; Tx, translocation. partners significantly correlated with lower serum creatinine with t(14;16) or IGH rearrangements with an unknown partner (P ¼ 0.001), b2microglobulin levels (P ¼ 0.01) and lower % of S- also showed a shorter survival, although the differences did not phase cells (P ¼ 0.006). There was no association between reach statistical significance (Table 3). Finally, t(11;14) did not t(11;14) and clinical and standard laboratory findings. RB influence the outcome of MM patients (Table 3 and Figure 2). deletions were associated with bone disease (P ¼ 0.02) and Given the frequent coexistence of RB deletion and IGH low Hb levels (P ¼ 0.02), whereas no clinical or laboratory translocations, we performed a survival analysis based on correlations were found for P53 deletions. both the influence of RB deletions on patients with IGH translocations, and the other way around, the influence of IGH translocations in patients with RB deletions. We observed Prognostic impact of chromosomal abnormalities and that cases with RB deletions negatively influenced the survival other biological parameters of patients with translocations involving other unknown IGH In the univariate analysis, patients with IGH translocations, RB partners (26 vs 49 months, P ¼ 0.02). By contrast, RB deletion or P53 deletions had a significantly shorter OS and TTP than did not influence the outcome of patients with t(11;14), t(4;14) patients without these abnormalities (Table 3, and Figures 1 and or t(14;16). On the other hand, when we analyzed the effect of 2). The sub-analysis of the prognostic influence of each IGH IGH translocations on the patients who had RB deletions, the translocation showed that only t(4;14) was associated with presence of t(4;14) or IGH translocations affecting another significantly shorter OS and TTP (Table 3 and Figure 2). Patients unknown partner added a negative impact in patients with RB

Leukemia Genetic abnormalities in multiple myeloma NC Gutie´rrez et al 146 N Median in months N Median in months a 1.0 Normal RB 151 51 b 1.0 Normal patients 109 54 RB deletion as a RB deletion 109 34 46 46 single abnormality 0.8 0.8

0.6 0.6

0.4 0.4 P = 0.3 P < 0.0001 Overall survival Overall survival Overall

0.2 0.2

0.0 0.0 0 10 20 30 40 50 60 70 80 0 10 20 30 40 50 60 70 80 Months from diagnosis Months from diagnosis

N Median in months N Median in months RB deletion without RB deletion without 50 40 50 40 1.0 1.0 IGH translocations c IGH translocations d RB deletion with IGH translocations RB deletion with t(4;14) 23 25 13 26 involving other unknown partners 0.8 0.8

0.6 0.6

0.4 P = 0.0002 0.4 P = 0.02 Overall survival Overall survival Overall

0.2 0.2

0.0 0.0 0 10 20 30 40 50 60 70 80 0 10 20 30 40 50 60 70 80 Months from diagnosis Months from diagnosis

N Median in months N Median in months e 1.0 RB deletion without 50 40 f 1.0 RB and P53 normal 144 51 IGH translocations RB deletion plus P53 deletion 15 28 RB deletion with t(11;14) 17 49 0.8 0.8

0.6 0.6

0.4 P = 0.2 0.4

Overall survival Overall survival Overall P < 0.0001 0.2 0.2

0.0 0.0 0 20 40 60 80 0 10 20 30 40 50 60 70 80 Months from diagnosis Months from diagnosis

Figure 1 Impact of RB deletion on OS of patients with myeloma. (a) Patients with RB deletion vs patients with normal RB.(b) Patients with RB deletion as a single abnormality vs patients without genetic abnormalities. (c) Patients with RB deletion and t(4;14) vs patients with RB deletion without IGH translocations. (d) Patients with RB deletion and IGH translocations involving other unknown partners vs patients with RB deletion without IGH translocations. (e) Patients with RB deletion and t(11;14) vs patients with RB deletion without IGH translocations. (f) Patients with both RB and P53 deletions vs patients with normal RB and P53.

deletion (Figure 1). We also analyzed the survival of patients to induction treatment was evaluated for each chromosomal with RB deletion as a single abnormality and it was not different abnormality and no correlations were found (Table 3). from that of normal patients (46 vs 54 months, P ¼ 0.3) (Figure 1). Regarding the influence of other clinical and biological Only t(4;14) showed a significant influence on survival as a parameters in disease outcome, the following factors were single aberration, with patients displaying a shorter OS as com- significantly associated with a shorter OS: age 460 years pared to normal patients (21 vs 54 months, P ¼ 0.008). When (P ¼ 0.002), ISS ¼ 3(P ¼ 0.002), Eastern Cooperative Oncology both RB and P53 deletions were present, OS was 28 months, a Group (ECOG) X2(P ¼ 0.02), percentage of S-phase PC 42.5% survival which is shorter than that observed in patients without (P ¼ 0.004), b2-microglobulin 43 mg/l (P ¼ 0.03), Hb o9 g/dl these two deletions (51 months, Po0.0001) (Figure 1). Response (P ¼ 0.02) and albumin o2.5 mg/dl (P ¼ 0.007). For multivariate

Leukemia Genetic abnormalities in multiple myeloma NC Gutie´rrez et al 147 N Median in months N Median in months a 1.0 Normal P53 238 46 b 1.0 No t(4;14) 231 48 P53 deletion 22 29 t(4;14) 29 24 0.8 0.8

0.6 0.6

0.4 0.4 P < 0.0001 P = 0.004 Overall survival Overall survival Overall

0.2 0.2

0.0 0.0 0 10 20 30 40 50 60 70 80 0 10 20 30 40 50 60 70 80 Months from diagnosis Months from diagnosis

N Median in months N Median in months c 1.0 No t(11;14) 226 40 d 1.0 No IGH translocations involving other unknown partners 235 46 t(11;14) 34 49 IGH translocations involving 25 37 0.8 0.8 other unknown partners

0.6 0.6

0.4 P = 0.8 0.4 P = 0.2 Overall survival Overall survival Overall

0.2 0.2

0.0 0.0 0 10 20 30 40 50 60 70 80 0 10 20 30 40 50 60 70 80 Months from diagnosis Months from diagnosis

Figure 2 OS of patients with MM according to the presence of P53 deletions (a), t(4;14) (b), t(11;14) (c) and IGH translocations involving other unknown partners (d).

Table 4 Multivariate analysis of features affecting OS

Prognostic variables HRa (95% CI) P-value

Multivariate analysis 1b t(4;14) 2.6 (1.5–4.3) o0.001 RB deletions 2 (1.4–2.9) o0.001 ISS ¼ 3 2 (1.3–2.9) 0.001 Age460 1.8 (1.3–2.6) 0.001 S-phase PC42.5% 1.8 (1.2–2.7) 0.002

Multivariate analysis 2c RB deletions associated with other abnormalities 1.3 (1.1–1.4) o0.001 Age460 1.9 (1.3–2.8) o0.001 ISS ¼ 3 1.9 (1.3–2.9) 0.001 S-phase PC42.5% 1.9 (1.3–2.8) 0.001 t(4;14) 1.8 (1–3.3) 0.03 Abbreviations: CI, confidence interval; HR, hazard ratio; ISS, International staging system; OS, overall survival; PC, plasma cell. aHazard rate. bIn multivariate analysis 1, RB deletions refer to all patients with RB deletion (associated or not to other abnormalities). cIn multivariate analysis 2, we have distinguished between patients with the coexistence of RB deletions plus other cytogenetic abnormalities from patients with only RB deletions. As it is shown in the model, this latter variable did not have independent prognostic value. analysis, all parameters with a Po0.1 in the univariate analysis the prognostic influence of RB deletion was attributable to for OS were included in the Cox proportional hazards model. this genetic change by itself or whether it was owing to its In this model five variables retained independent prognostic association with other cytogentic abnormalities, a second influence: t(4;14) (Po0.001), RB deletions (Po0.001), stage multivariate analysis was carried out. For that purpose, the according to ISS (P ¼ 0.001), age (P ¼ 0.001) and proportion of variable corresponding to RB deletion was re-codified into two S-phase cells (P ¼ 0.002) (Table 4). In order to clarify whether new variables for defining RB status: one, which distinguishes

Leukemia Genetic abnormalities in multiple myeloma NC Gutie´rrez et al 148 the patients with RB as a single abnormality, and another, which any abnormalities (46 vs 54 months, P ¼ 0.3). Therefore, the RB identifies patients with RB plus other abnormalities. In this deletion on its own would not represent a negative prognostic second analysis the former variable was not selected as an characteristic in contrast to what has previously been widely independent prognostic factor (Table 4). assumed.22,27 Although the low number of patients with deletions on P53 prevents us from reaching a similar conclusion, it should be noted that the only five patients with P53 deletion, as a single Discussion abnormality had the same OS than cytogenetically normal patients, whereas patients with concomitant RB and P53 deletions In the present study, the prognostic influence of chromosomal had a significantly shorter survival. When the effect of the RB abnormalities detected by FISH was assessed in a large series of deletion on the survival of patients with IGH translocations was myeloma patients uniformly treated with high-dose therapy and explored, it was observed that RB deletion did not modify the autologous stem cell support. The most relevant finding of this survival of patients with t(11;14) and t(4;14). This latter finding study is the lack of prognostic influence of RB deletion when it is could be explained by the fact that t(4;14) is associated with a very the only abnormality, whereas t(4;14) by itself is associated with poor outcome by itself, and therefore RB deletion does not make a dismal outcome. the prognosis of the patients with these abnormalities any worse. The incidence of chromosomal abnormalities detected in the Patients in whom the t(11;14) translocation coexisted with RB present series by FISH (58%), is notably higher than that usually deletion displayed a similar survival to those without the RB obtained by conventional cytogentetics.15–17 The global inci- deletion. In contrast to these results, RB deletion did negatively dence of IGH translocations detected in our study was lower influence the prognosis of patients with IGH translocations in than that described by the Mayo Clinic group (55%),18 and the other unknown partners as reported in a previous study.3 French group (70%),3 which could be explained by the lack of In our multivariate analysis, t(4;14) and RB deletions PC selection. Regarding each particular IGH translocation,3,4,9 when associated with other abnormalities, but not as a single as well as RB and P53 deletions,3,4,9,19–22 the frequency change, were the only chromosomal abnormalities that retained observed was consistent with that described by other groups. independent prognostic influence, and therefore, they could This study demonstrates the important prognostic impact of be considered the most important cytogenetic prognostic factors the t(4;14) in the survival of MM patients treated with high-dose in MM patients treated with high-dose chemotherapy. Regarding chemotherapy. Moreover, the presence of t(4;14) on its own was non-chromosomal prognostic features, age 460 years, stage sufficient for shortening MM patient survival. This reinforces according to ISS ¼ 3 and proportion of S-phase cells 42.5% previous results from other series of patients treated with retained statistical significance in the multivariate model. conventional chemotherapy,4 as well as two series of stem cell In summary, our study illustrates the importance of perform- transplantation,3,9 illustrating that this is probably the most ing a systematic FISH analysis on all newly diagnosed myeloma relevant cytogenetic prognostic factor for MM patients, inde- patients. This should include the investigation of IGH transloca- pendently of the therapeutic strategies used. Whether or not this tions plus RB and P53 deletions, in order to detect the adverse influence could be overcome by novel agents remains simultaneous presence of some of the changes, as the prognostic to be elucidated. Recent reports indicate that the response rate value of each one of them greatly depends on its coexistence to Bortezomib is independent of cytogenetic abnormalities.23 In with one of the others. the present study, response was not affected by cytogenetic changes either, and the poor outcome mainly derived from rapid Acknowledgements relapse. Initial cytogenetic studies by FISH in MM revealed that 24 t(11;14) was associated with an adverse outcome in MM. We thank Arturo Touchard and Manuel Delgado for data However, this translocation has recently been associated with managing; Beleń Gonza´lez, M A´ ngeles Hernańdez and Isabel good prognosis in large series of patients,3 or with a similar 4 Isidro for technical assistance; and Mark Anderson from the outcome to that of patients without IGH translocations. In the University Technology Transfer Office. This study was partially present study we failed to observe a significant longer survival supported by Spanish Myeloma Network Program (G03/136) and for patients with t(11;14) compared to patients without IGH ‘Ministerio de Ciencia y Tecnologia’ grant (SAF 04/06587). translocations. Finally, regarding patients with t(14;16) and translocations involving other IGH partners, these abnormalities References tended to be associated with shorter survival, although the differences did not reach statistical significance.3,4,25 The adverse prognosis of RB,asitwasalsoobservedinour 1 San Miguel JF, Garcıá-Sanz R. Prognostic features of multiple myeloma. Best Pract Res Clin Haematol 2005; 18: 569–583. patients, has almost become an axiom in MM, independently of 2 Tricot G, Barlogie B, Jagannath S, Bracy D, Mattox S, Vesole DH the detection method used (karyotype vs FISH) and the treatment et al. Poor prognosis in multiple myeloma is associated only with approaches (conventional chemotherapy vs high-dose chemo- partial or complete deletions of chromosome 13 or abnormalities therapy).3,5,11,22,26–28 Our results also confirm that P53 deletions involving 11q and not with other karyotype abnormalities. Blood confer an adverse outcome even though they are present in a low 1995; 86: 4250–4256. proportion of patients. Similar observations have been described 3 Moreau P, Facon T, Leleu X, Morineau N, Huyghe P, Harousseau JL et al. Recurrent 14q32 translocations determine the prognosis of for patients who received conventional chemotherapy or high- multiple myeloma, especially in patients receiving intensive 4,9,20,29 dose therapy. However, the strong association observed chemotherapy. Blood 2002; 100: 1579–1583. between chromosomal abnormalities raises two important ques- 4 Fonseca R, Blood E, Rue M, Harrington D, Oken MM, Kyle RA tions: (1) what is the prognostic impact of each single abnormality? et al. Clinical and biologic implications of recurrent genomic and (2) to what extent does the coexistence of another change aberrations in myeloma. Blood 2003; 101: 4569–4575. modify its prognosis? The results obtained in the present study 5 Shaughnessy Jr J, Tian E, Sawyer J, McCoy J, Tricot G, Jacobson J et al. Prognostic impact of cytogenetic and interphase fluorescence showed that the presence of t(4;14) by itself significantly reduces in situ hybridization-defined chromosome 13 deletion in multiple survival in MM. However, patients with RB deletions as a sole myeloma: early results of total therapy II. Br J Haematol 2003; 120: abnormality displayed the same prognosis than patients without 44–52.

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Appendix General de Mataro´ (Luis Rodrı´guez Fernańdez); Hospital Val D’Hebron Barcelona (Manuel Callis de Nadal); Hospital San List of the members of GEM 2000 group: Hospital General de Pedro de Alcańtara Caćeres (Juan Miguel Bergua Burgue´s, Maria Albacete (A´ ngela Ibań˜ez, Fe´lix Manso, Juan Carlos Go´mez Luz Amigo Lozano); Hospital Punta de Europa Algeciras Garcıá); Hospital General Universitario de Alicante (Concep- (Rosario Butroń Vila); Hospital General de Jerez de la Frontera cioń Rivas Gonza´lez, Pascual Fernańdez Abellań); Hospital (A´ ngel Leoń Lara, Jose´ Luı´s Guzmań Zamudio, Patricio Leiva); General Universitario Marina Alta Alicante (Rosa Ferrer Marco); Hospital General de Castelloń (Maria Guinot Martinez, Rai- Hospital Nuestra Senõra de Sonsoles A´ vila (Abelardo Ba´rez mundo Garcıá Boyero); Hospital Nuestra Senõra de Alarcos Garcıá); Complejo Asistencial Son Dureta Palma de Mallorca Ciudad Real(Beleń Hernańdez Ruiz); Hospital Clıńico Universi- (Joan Besalduch Vidal, Mariana Canaro); Hospital Verge del tario de Santiago de Compostela (Jose´ Luı´s Bello Lo´pez, Natalia Toro Mahon (Pilar Galań Alvarez); Hospital Son Llatzer Palma Alonso Vicente); Hospital Virgen de la Luz Cuenca (Jose´ Luı´s de Mallorca (Joan Bargay LLeonart); Hospital del Mar Barcelona Guerra Moyano, Marıá Jose´ Busto Medina); Hospital de Girona (Eugenia Abella Monreal); Hospital Clıńic Universitari Barcelo- Josep Trueta (Santiago Gardella Company, Yolanda Gonza´lez na (Joan Blade´ Creixenti, Laura Rosinõl Dach); Hospital Sant Montes); Hospital General de Guadalajara (Fe´lix Fuentes Pau Barcelona (Anna Sureda Balari); Clıńica Corachan Barce- Galvań, Miguel Dıáz Morfa); Hospital de San Jorge Huesca lona (Alfons Modolell Roig); Hospital de Badalona Germans (Fernando Puente Mangiroń); Complejo Hospitalario de Jaeń Trias i Pujol Barcelona (Josep Marıá Ribera Santasusana); (Antonio Alcala´ Munõz); Hospital de Jaeń (Pilar Mesa Valle); Hospital General de Manresa (Maricel Subira´); Complejo Hospital del Bierzo Ponferrada (Josefina Galende del Canto); Hospitalario del Parc Tauli Barcelona (Juan Alfonso Soler Hospital Ramoń y Cajal Madrid (Jose´ Garcıá Laranã); Hospital Campos); Hospital del Espı´ritu Santo (Albert Altes); Hospital 12 de Octubre Madrid (Carlos Grande Garcıá, Juan Jose´

Leukemia Genetic abnormalities in multiple myeloma NC Gutie´rrez et al 150 Lahuerta); Complejo Universitario San Carlos Madrid (Rafael Martıń); Hospital Joan XXIII Tarragona (Andre´s Llorente, Lourdes Martıńez Martıńez); Hospital Universitario La Princesa Madrid Escoda Teigell); Hospital Virgen de la Cinta Tortosa (Llorenç (Adriań Alegre Amor, Beatriz Aguado Bueno, Flor Lara Garcıá- Font Ferre´ ); Hospital Nuestra Senõra del Prado Talavera de la Escribano); Fundacioń Jimeńez Dıáz Madrid (Elena Prieto Reina (Fernando Solano Ramos); Hospital Virgen de la Salud Pareja); Hospital Prıńcipe de Asturias Madrid (Carmen Burga- Toledo (Felipe Casado Montero); Hospital Universitario La Fe leta, Gemma Moreno Jimeńez); Hospital Severo Ochoa Madrid Valencia (Isidro Jarque, Javier de la Rubia Comos); Hospital (Pedro Sańchez Godoy); Hospital de Fuenlabrada Madrid (Jose´ Doctor Peset Valencia (Marıá Jose´ Sayas LLoris, Paz Ribas A´ ngel Hernańdez Rivas); Hospital Universitario de Getafe Garcıá); Hospital Arnau de Vilanova Valencia (Aurelio Lo´pez (Marıá del Carmen Monteserıń); Hospital Universitario Virgen Martıńez, Encarna Monzo´ Castellano, Jose´ Mayans Ferrer); de la Victoria Ma´laga (Inmaculada Pe´rez Fernańdez, Marıá Jose´ Hospital Clıńico Universitario de Valencia (Inmaculada Blasco Moreno); Hospital General Morales Messeguer Murcia (Felipe Blasco, Juan Carlos Hernańdez Boluda, Mara´ Jose´ Terol de Arriba de la Fuente, Jose´ Marıá Moraleda Jimeńez); Hospital Castera´); Hospital General Universitario de Valencia (Fe´lix Nuestra senõra del Rosell Cartagena (Jerońima Ibań˜ez Garcıá); Carbonell Ramoń, Maite Otero Castello´); Fundacioń Instituto Clıńica Universitaria de Navarra Pamplona (Elena Carrascal, Valenciano de Oncologıá Valencia (Pablo Llorente Alegre); Felipe Prosper Cardoso, Jose´ Rifon); Hospital de Jarrio Oviedo Hospital Francesc de Borja Gandia (Marıá Jose´ Fernańdez, (Ana Dıáz Trapiella, Manuel Vargas Paboń); Hospital Central de Marıá A´ ngeles Ruiz Guinaldo); Hospital de Sagunto (Ana Carral Asturias Gijoń (Consuelo Rayoń Sua´rez, Dolores Carrera); Tatay, Isabel Navarro Gonzalo); Hospital Rıó Hortera Valladolid Hospital Rıó Carrioń Palencia (Fernando Ortega Rivas, Jose´ (Javier Garcıá Frade, Marıá Jesu´s Penãrrubia); Hospital Clıńico Marıá Alonso Alonso); Complejo Hospitalario Materno-insular Universitario de Valladolid (Francisco Javier Fernańdez Calvo, Las Palmas (Jose´ David Gonza´lez San Miguel ); Complejo Rebeca Cuello Garcıá); Hospital de Cruces Barakaldo (Elena Hospitalario Xeral-Cies Vigo (Carmen Albo Lo´pez, Concha Amutio Dıéz, Juan Carlos Garcıá Ruiz); Hospital de Galdakao Poderos Baeta); Hospital Clıńico de Salamanca (Jesu´s San (Jesu´s Marıá Ojanguren Bergaz., Koldo Atutxa Aresti); Hospital Miguel Izquierdo); Hospital Universitario de Canarias Santa Virgen de la Concha Zamora (Alejandro Martıń Garcıá); Cruz de Tenerife (Miguel Hernańdez Garcıá); Hospital Uni- Hospital Clıńico Universitario Lozano Blesa Zaragoza (Luı´s versitario Marques de Valdecilla Santander (Eulogio Conde Palomera Bernal); Hospital Miguel Server Zaragoza (Pilar Garcıá); Hospital General de Segovia (Jose´ Mariano Hernańdez Giraldo).

Leukemia