0V0123,‘ N0 26
`
`'
`
`'
`
`'
`
`September 10; 2005 '
`
`NcOLO GY
`
`REVIEWS
`
`HEMATOLOGIC MALIGNANCIES
`Editors: B.D. Che‘s'on, SJ, Handing, KC. Anderson, and H. Ddhner
`
`Genetics of Myeloid Malignancies:
`Pathogenetic and Clinical Implications
`S Fro/Lung et at
`New Targeted ApproachesIn Chronic Myeloid Leukemia
`J’ Cortes et al
`
`Identification and Validation of Novel Therapeutic Targets
`for Multiple Myeloma
`,
`T. Hideshima et al
`
`Molecular Pathogenesis of Follicular Lymphoma: ,
`A Cross Talk of Genetic and Immunologic Factors
`D. deJong
`*
`v
`
`lmmunotherapy for Non-Hodgkin’s Lymphoma:
`Monoclonal Antibodies and Vaccines
`
`DJG. Maloney
`
`See complete Table of Contents inside
`
`\ r )
`
`Q)
`::l l.O
`
`Q)I'-
`
`
`
`z
`00 z
`?i8
`c::> co
`c--...J ~ra
`c::>
`<( (.J)
`a:-
`co~
`:::i u.. ~ "0-
`c3:
`«s
`:cc
`c,O ~
`5~
`e>o
`0...
`:c:S
`co(/) UJ
`0 «s
`wffi en
`LO:i:
`.....
`2:
`z ::,
`
`~
`
`· - (I)
`
`$Wwcho.org ,
`it
`yOfficial Journal of the American Society of Clinical Oncology
`*ASC-
`
`IPR2018-00685
`Celgene Ex. 2034, Page 1
`
`

`

`OURNAL OF CLINICAL ONCOLOGY
`
`o r fi cial Journal of the American Society of Clinical Oncology
`
`0123, No26
`
`REVIEWS
`Hematologic Malignancies September 10, 2005
`
`uest Editors: Sandra J. Horning, MD, Kenneth C. Anderson, MD, and Harmut Dohner, MD Associate Editor: Bruce D. Cheson, MD
`
`Editorial
`Individualizing Therapy for the Hematologic Malignancies: The Stuff of
`Genes and Dreams
`Bruce D. Cheson ....
`
`. .......
`
`.. .. ............................... ........................................... 6283
`
`Review Articles
`Genetics of Myeloid Malignancies: Pathogenetic and Clinical Implications
`Stefan Frohling, Claudia Scholl, D. Gary Gilliland, and Ross L. Levine ....
`. .................................................................................................................. 6285
`
`Gene Expression Profiling in Acute Myeloid Leukemia
`Lars Bullinger and Peter J.M. Valk ....
`
`6296
`
`Molecular Genetics of Acute Lymphoblastic Leukemia
`Scott A. Armstrong and A. Thomas Look ............................................. ........................................................................................................................................................................................................... 6306
`
`New Targeted Approaches in Chronic Myeloid Leukemia
`Jorge Cortes and Hagop Kantarjian .............................................................................................................................................................................................................................................................................. 6316
`
`Nhvel lmmune-Ba~ed Treatment Strategies for Chronic Lymphocytic Leukemia
`Wil liam G. Wierda, Thomas J. Kipps, and M ichael J. Keating .
`. .............. ........................................................................ 6325
`
`Molecular Pathogenesis and a Consequent Classification of Multiple Myeloma
`P. Leif Bergsagel and W. Michael Kuehl. ...
`
`.. ..
`
`6333
`
`Prognostic and Therapeutic Significance of Myeloma Genetics and Gene
`Expression Profiling
`A. Keith Stewart and Rafael Fonseca ...
`
`. ... ................................................. ................................................................................................................. 6339
`
`Identification and Validation of Novel Therapeutic Targets for Multiple Myeloma
`Teru Hideshima, Dharminder Chauhan, Paul Richardson, and Kenneth C. Anderson ..................................................... .......... .................... 6345
`
`(continued on following page)
`
`Journal of Clinical Oncology (ISSN 0732-183X) is published 36 times a year, three times monthly, by American Society of Clinical Oncology, 1900 Duke Street, Sujte 200,
`Alexandria, VA 22314. Periodicals postage is prud at Alexandria, VA, and at additional mailing offices. Publication Mail Agreement Number 863289.
`Eru torial correspondence should be addressed to Daruel G. Haller, MD, Journal of Clinical Oncology, 330 John Carlyle Street, Suite 300, Alexandria, VA 22314.
`Telephone: (703) 797-1900; Fax: (703) 684-8720.Email:jco@asco.org. Internet: www.jco.org.
`POSTMASTER: ASCO members send change of address to American Society of Clinical Oncology, 1900 Duke Street, Suite 200, Alexandria, VA 22314. Non-members send change
`of address to Journal of Clinical Oncology Customer Service, 330 John Carlyle Street, Suite 300, Alexandria, VA 22314.
`tate and possessions: inruvidual, $421 ; single issue, $35. International: individual, $587; single issue, $45.
`2005 annual subscription rates, effective September 1, 2004: Uruted
`Institutions: Tier 1: $580 US, $820 Int'!; Tier 2: $675 US, $915 Int']; Tier 3: $975 US, $1,215 Int'!; Tier 4: $1,075 US, $1,315 Int'!; Tier 5: contact JCO for a quote. See http://
`www.jco.org/subscriptions/tieredpricing.shtrnl for descriptions of each tier. Student and resident: Uruted States and possessions: $210; all other countries, $293. To receive student/
`resident rate, orders must be accomparued by name of affiliated institution, date of term, and the signature of program/residency coorrunator on institution letterhead. Orders will
`be billed at individual rate until proof of status is received. Current prices are in effect for back volumes and back issues. Back issues sold in conjunction with a subscription rate
`are on a prorated basis. Subscriptions are accepted on a 12-month basis. Prices are subject to change without notice. Single issues, both current and back, exist in limited quantities
`and are offered for sale subject to availability.
`
`IPR2018-00685
`Celgene Ex. 2034, Page 2
`
`

`

`V OLUME 23 · NUMBER 2 6
`
`· SEPTEMBER 10 2005
`
`J OURNAL OF CLINICAL ONCOLOGY
`
`REVIEW ARTICLE
`
`From the, Comprehensive Cancer
`Center; Division of Hematology(cid:173)
`Onrology, Mayo Clinic, Scottsdale, AZ;
`and the Genetics Branch , National
`Ca ncer Institute, Bethesda, M D.
`
`Submitted March 30, 2005; accepted
`June 7, 2005.
`
`Supported in part by National
`Institutes of Health Grant No.
`CA100707 (P.L B )
`
`Authors' disclosures of potential
`conflicts of interest are found at the
`end of this article.
`
`Add ress reprint requests to Mike Kuehl,
`8901 Rockville Pike, Bldg. 8, Rm 5101,
`Bethesda, M D 20889; e-mai l wmk@
`helix.nih.gov; or Leif Bergsagel, 13400 E.
`Shea Blvd , Scottsdale, AZ 85259;
`e-mail: bergsag.el.p@mayo.edu.
`
`0732-183X/05/2326-6333/$20.00
`
`DOI 10.1200/JCO 2005 05 021
`
`Molecular Pathogenesis and a Consequent Classification
`of Multiple Myeloma
`P. Leif Bergsagel and W. Michael Kuehl
`
`A B S T R A C T
`
`There appear to be two pathways involved in the pathogenesis of premalignant non(cid:173)
`immunoglobulin M (lgM) monoclonal gammopathy of undetermined significance (MGUS) and
`multiple myeloma (MM). Nearly half of tumors are nonhyperdiploid, and mostly have one of five
`recurrent lgH translocations: 16% 11q13 (CCN 01), 3% 6p21 (CCN 03), 5% 16q23 (MAF),
`2% 20q12 (MAFB) , and 15% 4p16 (FGFR3 and MMSET) . The remaining hyperdiploid tumors
`have multiple trisomies involving chromosomes 3, 5, 7, 9, 11, 15, 19, and 21, and infrequently
`one of these five translocations . Although cyclin D1 is not expressed by healthy lymphoid
`cells, it is bi-allelically dysregulated in a majority of hyperdiploid tumors. Virtually all MM
`and MGUS tumors have dysregulated and/or increased expression of cyclin D1, D2, or D3,
`providing an apparent early, unifying event in pathogenesis . The patterns of translocations
`and cyclin D expression (TC) define a novel classification that includes eight groups: 11 q;
`6p; MAF; 4p; D1 (34 %); D1 +D2 (6 % ); D2 (17 % ); and none (2 %). The hyperdiploid D1 group
`is virtually absent in extramedullary MM and MM cell lines, suggesting a particularly strong
`dependence on interaction with the bone marrow microenvironment. Despite shared progres(cid:173)
`sion events (RAS mutations, MYC dysregulation, p53 mutations, and additional disruption of
`the retinoblastoma pathway), the phenotypes of MGUS and MM tumors in the eight TC
`groups is determined mainly by early oncogenic events. Similar to acute lymphocytic leuke(cid:173)
`mia, MM seems to include several diseases (groups) that have differences in early or initiating
`events, global gene expression patterns, bone marrow dependence, clinical features, prog(cid:173)
`nosis, and response to therapy.
`
`J C!in Oneal 23:6333-6338.
`
`INTRODUCTION
`Multiple myeloma (MM), presently an in(cid:173)
`curable plasma cell (PC) malignancy with
`a yearly incidence of 14,000 in the United
`States and a median survival of 3 years, ac(cid:173)
`counts for approximately 20% of deaths
`from hematologic malignancy and nearly
`2% of deaths from cancer. 1 Often it is
`preceded by a premalignant tumor called
`monoclonal gammopathy of undetermined
`significance (MGUS), which occurs
`in
`about 3% of individuals over the age of
`50.2 The prevalence of both MGUS and
`MM increases markedly with age, and is
`about two-fold higher in African Ameri(cid:173)
`cans than in whites. 3 Despite evidence for
`some clustering of MM and MGUS within
`
`families, the roles of genetic background
`5
`and environment remain unclear. 4
`'
`
`MM Is a Plasmablast/Plasma-Ce/1
`Tumor of Post-Germinal
`Center B Cells
`Most B-cell tumors, including MM, in(cid:173)
`volve germinal center (GC) or post-GC B
`cells that have modified their immunoglob(cid:173)
`ulin (Jg) genes by sequential rounds of so(cid:173)
`matic hypermutation and antigen selection,
`and sometimes by IgH switch recombina(cid:173)
`tion. These two B cell-specific DNA mod(cid:173)
`ification processes, which occur mainly in
`GC B cells, sometimes can cause mutations
`or double-strand DNA breaks in or near
`non-Jg genes, including oncogenes.6 Post(cid:173)
`GC B cells can generate plasmablasts
`
`6333
`
`IPR2018-00685
`Celgene Ex. 2034, Page 3
`
`

`

`Bergsagel and Kuehl
`
`(PBs) that have successfully completed somatic hypermu(cid:173)
`tation, antigen selection, and IgH switching before migrat(cid:173)
`ing to the bone marrow (BM ), where stromal cells enable
`terminal differentiation into long-lived PCs. 7 Although
`PCs can be generated from pre-GC B cells, MM and
`non-IgM MGUS are exclusively post-GC tumors that
`have phenotypic features of PBs/long-lived PCs, and usu(cid:173)
`ally are distributed at multiple sites in the BM. A critical
`feature shared by MGUS and MM is an extremely low
`rate of proliferation, usually with no more than a small
`percentage of cycling cells until late stages of MM. 8 There
`appear to be two kinds of cell populations in non-IgM
`MGUS or MM tumors. A small fraction of proliferative
`tumor cells have a phenotype that is similar to a PB or
`a pre-PB that might express some B-cell markers (CD19,
`CD20, CD45) but not some PC markers (CD138),
`although the precise phenotype(s) and location(s) of the
`10
`proliferating tumor cell remains a contentious issue. 9
`'
`However, most of the tumor cells are nonproliferative;
`although perhaps not fully differentiated, these cells
`have a phenotype that is similar to healthy, terminally
`differentiated, long-lived BM PCs. It is unclear if this
`second cell population retains the ability to revert to a pro(cid:173)
`liferative phenotype. In any case, the occurrence of these
`two kinds of tumor cells is an important consideration
`in the design and evaluation of therapies.
`
`Stages of MM
`A clonal PC neoplasm must expand to approximately
`109 cells before it produces enough lg to be recognized as
`a monoclonal lg (M-Ig) by serum electrophoresis. For
`
`MGUS, the M-Ig is 0.5 to 3g/dl, and the tumor cells com(cid:173)
`prise no more than 10% of the mononuclear-cells in the
`BM (Fig 1). Depending on the level of M-lg, 0.6% to
`3% per year of patients with non-IgM MGUS progress
`to MM expressing the same M-Ig. 11 There are no unequiv(cid:173)
`ocal genetic or phenotypic markers that distinguish MGUS
`from MM tumor cells, so that it is not possible to predict if
`and when an MGUS tumor will progress to MM. Also, it
`remains unclear to what extent intrinsic genetic or epige(cid:173)
`netic changes in the MGUS tumor cell versus extrinsic
`changes in non-tumor cells affect progression. Primary
`amyloidosis is caused by an MGUS tumor (sometimes
`with such a small number of tumor cells that M-Ig is
`not detected by serum electrophoresis) that is symptoL1-
`atic because of pathologic deposits of portions of the
`M-lg in critical tissues. 12 MM is distinguished from
`MGUS by having a BM tumor content > 10%.13 Smolder(cid:173)
`ing MM, which has a stable BM tumor content of > 10%,
`but no osteolytic lesions or other complications of malig(cid:173)
`nant MM, has a high probability of rapidly progressing to
`frankly malignant MM with osteolytic lesions and/or an
`increasing tumor mass. Further progression of MM is as(cid:173)
`sociated with increasingly severe secondary features (lytic
`bone lesions, anemia, immunodeficiency, renal impair(cid:173)
`ment), and in some patients the occurrence of tumor in
`extramedullary locations. Extramedullary MM is a more
`aggressive tumor that often is called secondary 0-r primary
`plasma cell leukemia (PCL), depending on whether or not
`preceding intramedullary myeloma has been recognized.
`Human MM cell lines (HMCL) sometimes can be gener(cid:173)
`ated, but usually only from extramedullary tumors.
`
`• • • • • • • -
`
`Increased DNA labeling index•
`
`- Bone destruction•
`
`-Angiogenesis -
`
`Germinal
`center
`B cell
`
`Smoldering
`myeloma
`
`lntra(cid:173)
`medullary
`myeloma
`
`-+
`
`- - - - - - - - - - - - -Ka ryo typ i c abnormalities---------
`
`-+------- Secondary (lg) TLC----------
`
`·············---
`
`Activating mutations: N, K-ras, FGFR3
`-
`
`p18 deletion -
`
`-
`
`MYC dysregulation -
`
`-
`
`p53 mutation-
`
`Fig 1. Disease stages and ti ming of
`oncogenic events. Th e ea rli est onco(cid:173)
`genic changes are present in mono(cid:173)
`clonal gammopathy of undetermined
`significa nce (MGUS), and involve two
`min imally
`overlapping
`pathways
`(ovals) , both of w hich substa ntially
`overlap the del 13 pathway (striped
`oval). Prima ry
`immunoglobulin (lg)
`translocations (TLC) are thought to
`occur in germ inal center B cells (bi(cid:173)
`directional arrow) but the ti mi ng for
`th e oth er two pathways
`(dashed
`arrows) is unclear. Other karymypic
`abnormal ities,
`includi ng secondary
`(lg) TLC may occur at all swges.
`Activating mutati ons of K- or N-RAS
`appear to mark,
`if not cau se, the
`MGU S to multiple myeloma (MM)
`transition in some cases, but s')me(cid:173)
`ti mes occu r during subsequent pro(cid:173)
`gression of MM. Late oncocienic
`events that occur at a ti me w hen
`tu mors are becom ing more aggres(cid:173)
`sive include MYC dysregulation by
`secondary (lg) TLC, bi-allel ic deletion
`of pl 8, and loss or mutation of p53.
`
`6334
`
`J OURNAL OF CLINICAL O NCOLOGY
`
`IPR2018-00685
`Celgene Ex. 2034, Page 4
`
`

`

`Molecular Pathogenesis and MM Classification
`
`Jg Translocations Are Present in a Majority of
`MM Tumors
`Many B-cell tumors, including MM, have chromo(cid:173)
`somal translocations that are mediated by errors in VDJ re(cid:173)
`combination or one of the other two B cell specific DNA
`modification mechanisms. The consequence of these trans(cid:173)
`locations is dysregulation or increased expression of an on(cid:173)
`cogene that is positioned near a strong lg enhancer. The .
`prevalence of IgH translocations varies somewhat with
`the disease stage: nearly 50% in MGUS or SMM, 55% to
`73% in intramedullary, MM, 85% in primary PCL, and
`> 90% in HMCL. 14
`16 There are five recurrent chromosomal
`-
`partners (oncogenes) that are involved in IgH transloca(cid:173)
`tions in MGUS and MM: 4pl6 (MMSET and usually
`(CCN D3), llql3 (CCN DI), 16q23
`FGPR3), 6p21
`(c-MAP), and 20ql 1 (MAPB). 17
`22 Together, the combined
`-
`p1evalence of these five IgH translocation partners is about
`40% in MM, with approximately 15% 4pl6, 3% 6p21, 15%
`l lq l3, 5% 16q23, and 2% 20qll. The apparent markedly
`decreased prevalence of IgH translocations involving 4pl6
`and l 6q23 in MGUS suggests that these translocations
`can cause de novo MM and/or are associated with rapid
`progression from MGUS to MM. The mostly simple recip(cid:173)
`rocal translocations involving the five recurrent transloca(cid:173)
`tion partners appear to be primary translocations that
`usually are mediated by errors in IgH switch recombination
`during the maturation of B cells in germinal centers. 23
`About 3% of MM tumors have secondary IgH translo(cid:173)
`cations that target c-myc at 8q24. Secondary translocations
`that dysregulate an MYC gene ( c- » N- > L-) by juxtapos(cid:173)
`ing it to an lg locus (IgH ~ lg;\ >> lgK) or to one of many
`other poorly characterized chromosomal loci are late pro(cid:173)
`22
`24 The MYC translocations are absent
`gression events. 16
`'
`'
`or rare in MGUS but occur in 15% of MM tumors, 45%
`of advanced tumors, and 90% of HMCL. These translo(cid:173)
`cations are not mediated by the B cell-specific DNA mod(cid:173)
`ification mechanisms, which are inactive in healthy or
`tumor PCs. In contrast to the primary translocations de(cid:173)
`scribed above, these secondary events often include unbal(cid:173)
`anced and complex translocations and insertions that can
`involve three chromosomes, sometimes with associated
`amplification, duplication, inversion, or deletion.
`Other IgH translocation partners have been identified
`in about 15% of MM tumors, and in more than 25% of
`22
`25 The other translocation partners,
`15
`MGUS tumors. 14
`'
`'
`'
`which are poorly characterized, appear to be mostly non(cid:173)
`recurrent or rare. These translocations seem to share the
`structural complexity and lack of IgH switch region in(cid:173)
`volvement observed for MYC translocations, suggesting
`that they may represent secondary translocations, which
`can occur at any time during tumor progression, including
`MGUS (A. Gabrea, unpublished data). 23 Translocations
`involving an lg;\ locus occur in approximately 10% of
`GUS tumors, and approximately 20% of advanced
`
`25 Translocations involving an
`MM tumors or HMCL. 22
`'
`lgK locus are rare, occurring in only a small percentage
`of MM tumors. Nearly half of IgL translocations in ad-
`. vanced MM tumors or HMCL target an MYC gene. Signif(cid:173)
`icantly, although all HMCL analyzed have either an IgH or
`IgL translocation, approximately 30% of MM tumors and
`45% of MGUS tumors do not have either an IgH or IgL
`translocation. Surprisingly, however, two independent lg
`translocations are found in 5% of MGUS tumors, 25%
`of advanced MM tumors, and 58% of HMCL, consistent
`with an accumulation of secondary lg translocations dur(cid:173)
`ing tumor progression (A. Gabrea, unpublished data). 24
`
`Hyperdiploid and Nonhyperdiploid Tumors
`All MGUS and MM tumors have numeric and/or
`structural chromosome abnormalities. 22 Although no
`gene has yet been identified, loss of chromosome13/13q/
`13q 14 sequences, which occurs in approximately 60% of
`MM tumors and nearly 50% of MGUS tumors, was one
`of the first chromosomal abnormalities associated with
`27 Nearly half of MM tumors are
`a poor prognosis. 26
`'
`hyperdiploid (HRD; 48-75 chromosomes), and often
`have multiple trisomies involving eight odd chromosomes
`(3,5,7,9,l l,15,l9,21). Nonhyperdiploid (NHRD) tumors
`( < 48 or > 75 chromosomes), which can be hypodiploid,
`pseudodiploid or subtetraploid, were noted to have
`a poorer prognosis than HRD tumors. 28 More recently
`it was reported that at least three of the five recurrent
`IgH
`translocations occur predominantly
`in NHRD
`tumors. 29
`30 Secondary translocations, which appear to
`•
`include all MYC translocations, most-if not all-IgL
`translocations, most IgH translocations not involving
`the five recurrent partners, and some IgH translocations
`involving the five recurrent partners, seem to occur with
`a similar prevalence in HRD and NHRD tumors. Loss
`of chromosome 13 sequences occurs in 72% of NHRD
`tumors but only 37% of HRD tumors. It remains to be
`clarified if ploidy and loss of chromosome 13 sequences
`are independent prognostic factors.
`
`Dysregulation of cyclin D1, -2, or -3: A Unifying,
`Early Oncogenic Event in MM and MGUS
`Most tumor cells in MGUS and MM appear more
`similar to healthy, nonproliferating PCs than to healthy,
`but highly proliferating PBs, for which 30% or more of
`the cells can be in S phase. Surprisingly, however, despite
`a very low proliferation index, the level of cyclin D l, cyclin
`D2, or cyclin D3 mRNA in virtually all MM and MGUS
`tumors is relatively high, comparable with the level of
`cyclin D2 mRNA expressed in healthy proliferating PBs,
`and distinctly higher than in healthy BM PCs. 3 1 Approx(cid:173)
`imately 25% of MGUS or MM tumors have an IgH trans(cid:173)
`location that directly dysregulates CCN D 1 (11 q 13), CCN
`D3 (6p21), or a MAP gene (MAP, 16q23 or MAPB, 20qll)
`encoding a transcription factor that targets cyclin D2
`
`www.jco.org
`
`6335
`
`IPR2018-00685
`Celgene Ex. 2034, Page 5
`
`

`

`Bergsagel and Kuehl
`
`(Fig 2). Nearly 40% of MGUS and MM tumors do not
`have a t(l 1;14), but are HRD and bi-allelically express
`cyclin Dl, whereas healthy BM PCs generally do not ex(cid:173)
`press detectable cyclin D 1. Most other tumors, including
`those with a t(4;14), have increased expression of cyclin D2
`compared with healthy BM PCs.
`
`Model for the Molecular Pathogenesis of
`MGUSandMM
`It has been proposed that there are two pathways of
`pathogenesis: an NHRD pathway that usually includes one
`of the five recurrent IgH translocations as an early event, and
`an HRD pathway that is associated with multiple trisomies
`of eight odd chromosomes but is mediated by a yet-to-be(cid:173)
`29
`determined mechanism. 22
`31 As summarized in the pre(cid:173)
`'
`'
`ceding section, dysregulation of a cyclin D gene- sometimes
`as a consequence of a primary IgH translocation but other(cid:173)
`wise by presently unknown mechanisms-appears to be
`a unifying and early event. The dysregulation of a cyclin D
`gene may render the cells more susceptible to proliferative
`stimuli, resulting in selective expansion as a result of inter(cid:173)
`action with BM stromal cells that produce interleukin-6,
`insulin-like growth factor l, and other cytokines. Loss of
`chromosome 13/13q sequences also seems to be an early
`event shared by MGUS and MM tumors. Unfortunately,
`we do not yet understand the relative timing of primary
`IgH translocations, aneuploidy (including multiple trisomies
`and loss of chromosome 13 sequences), and cyclin D dysre(cid:173)
`gulation. Secondary chromosome translocations and other
`karyotypic abnormalities can occur at all stages of tumori(cid:173)
`genesis. Mutually exclusive activating mutations of K- or
`N-RAS (or FGFR3 when there is a t(4;14) translocation)
`
`are rare in MGUS, but the prevalence of RAS mutations is
`30% to 40% in early MM and slightly higher in advanced
`MM; FGFR3 mutations may occur more frequently in ad(cid:173)
`vanced MM. 32 Secondary MYC translocations are late pro(cid:173)
`gression events that may occur as a tumor becomes less
`dependent on BM stromal cells and/or more proliferative.
`Despite alteration of the RB pathway by dysregulation of
`a cyclin D gene in virtually all MGUS and MM tumors, in(cid:173)
`activation of an additional component of this pathway
`(p18INK4c or retinoblastoma) can be a late-progression
`event that is associated with enhanced proliferation. Muta(cid:173)
`tions and/or mono-allelic deletion of p53 also appear to be
`late-progression events. The timing of other events, such as
`PTEN mutations, is unknown. 22
`
`Translocationlcyclin D Expression Classification
`Based on Early Pathogenic Events
`On the basis, in large part, of the hypotheses presented
`in the preceding paragraphs, a supervised analysis of gene
`expression profiles provides 'the basis for a molecular clas(cid:173)
`sification of MM. 31 In addition to determining the expres(cid:173)
`sion level of cyclin Dl, -2, and -3, gene expression profiling
`can effectively identify MM tumors that overexpress the
`oncogenes dysregulated by the five recurrent IgH translo(cid:173)
`cations: llq13 (CCN DI); 6p21 (CCN DJ); 4p16 (MMSET
`and usually FGFR3); 16q23 (ma!); and 20qll (mafB ).
`These groups (Table 1) can be distinguished oh the basis
`of the lg translocation present, . and cyclin D expression:
`llql3 (16%) and 6p21 tumors (3%) express high levels
`of either cyclin D 1 or cyclin D3 as a result of an Jg trans(cid:173)
`location; DI tumors (34%) ectopically express low to
`moderate levels of cyclin D 1 despite the absence of
`
`/
`
`~
`
`t
`
`~
`
`•
`"
`
`mat
`16q23 c-maf
`20q11 mafB
`
`G1
`Phase
`
`OFF
`
`• • ~ ~ p16
`
`INK4a
`
`~ INK4b
`,___
`~
`
`INK4c
`
`INK4d
`
`ON
`
`. Fig 2. Alteration of Rb pathway by
`both early and late pathogenic events
`An early pathogenic event in tu mors
`fro m seven of the translocations and
`cyclin D expression (TC) groups is dys(cid:173)
`regulation of one of the three eye/in D
`genes, either as a consequence of an lg
`translocations (TLC; solid arrow), or by
`an unknow n mechanism (dashed ar(cid:173)
`row ). Increased expression of one of
`the cyclin D proteins facilitates activa(cid:173)
`tion of CDK4 (or CDK6), w hich then
`phosphorylates and inactivates Rb so
`that E2F can facilitate G1 > S cell cycle
`progression. This reaction is reg ulated
`by CDK inhibitors (INK4a-d), so 1:1at
`increased proliferation of some M M
`tumors occurs only after a late onco(cid:173)
`inactivates Rb or
`genic event that
`p181NK4c.
`
`6336
`
`JOURNAL OF CLINICAL O NCOLOGY
`
`IPR2018-00685
`Celgene Ex. 2034, Page 6
`
`

`

`Molecular Pathogenesis and MM Classification
`
`Table 1. Translocation and eye/in O Groups
`
`Group
`
`6p21
`11q13
`01
`07+ 02
`02
`None
`4p1 6
`rra f
`
`Primary
`Tra nslocation
`
`Gene at
`Breakpoint
`
`D-Cyclin
`
`Ploidy
`
`Pro liferation
`Index
`
`Bone disea se
`(% MRI Pos)
`
`Frequency
`(%)
`
`Prog nosis
`
`6p2 1
`11 q13
`None
`None
`None
`None
`4p16
`16q23
`20q11
`
`CCN03
`CCNOJ
`Non e
`None
`None
`None
`FGFR3/MMSET
`c-ma f
`mafB
`
`D3
`D1
`D1
`D1 and D2
`D2
`None
`D2
`D2
`
`NH
`D, NH
`H
`H
`H, NH
`NH
`NH > H
`NH
`
`Average
`Ave rage
`Low
`High
`Average
`Average
`Average
`High
`
`100
`94
`86
`100
`67
`100
`57
`55
`
`3
`16
`34
`6
`17
`2
`15
`5
`2
`
`? Good
`Good
`Good
`? Poor
`?
`? Good
`Poor
`Poor
`
`Aubreviation s: MRI , magnet ic reso,,a nce imaging; pos, positive; D, diploid; H, hyperdiploid; NH, nonhyperdi ploid .
`
`a tf11;14) translocation; Dl + D2 (6%) in addition express
`cyclin D2. D2 tumors (17%)yre a mixture of tumors that
`do not fall into one of the .other groups, and express cyclin
`D2; None (1 %) express no D-type cyclins. 4p16 tumors
`(1 5%) express high levels of cyclin D2, and also MMSET
`(and in most cases FGFR3) as a result of a t( 4;14) trans(cid:173)
`location; maf tumors (7%) express the highest levels of
`cyclin D2, and also high levels of either c-maf or mafB,
`consistent with the possibility that both maf transcription
`factors upregulate the expression of cyclin D2. Supervised
`hierarchical cluster analysis of gene expression profiles
`demonstrates that the translocation/ cyclin D expression
`(TC) classification identifies homogeneous groups of tu(cid:173)
`mors with distinctive patterns of gene expression, and
`by corollary, phenotype. Although not unequivocally es(cid:173)
`tablished, we think that the basis for assignment of tumors
`to the TC groups is focused primarily on very early if not
`initiating oncogenic events that are shared by MGUS and
`MM tumors, although the DI+ D2 group might represent.
`an exception.
`
`Implications of the TC Classification of MGUS
`and MM
`In addition to having shared gene expression profiles,
`we have
`identified
`important biologic and clinical
`correlates associated with the TC groups (Table 1).3 1 For
`example, the TC Dl group of tumors is absent or under(cid:173)
`represented in PCL and HMCL, suggesting that these tu(cid:173)
`mors have a particularly strong dependence on a continued
`interaction with bone marrow stromal cells. In addition, we
`have found that lytic bone disease correlates with the TC
`classification, with high prevalence ( approximately 90%)
`in TC 6p21, TC llql3, TCDl and TCD1+D2, and lower
`prevalence (approximately 55%) in TC 4pl6 and TC maf It
`ha~ also become clear that specific IgH translocations have
`a profound prognostic significance.33
`34 Patients with tu(cid:173)
`'
`mors that have a t(4;14) translocation (TC 4pl6) have
`a substantially shortened survival either with standard or
`
`high-dose therapy (median overall survival, 26 months
`and 33 months, respectively), and patients with a
`t(l4;16) (TC ma!) have a similarly poor if not worse prog(cid:173)
`nosis (median overall survival, 16 months with conven(cid:173)
`tional therapy). By contrast, patients with tumors that
`have a t(ll;l4) translocation (TC llql3) appear to have
`a better survival following both conventional chemother(cid:173)
`apy and high-dose therapy. Similarly we suspect that the
`TC DI group, representing most of the hyperdiploid pa(cid:173)
`tients, shares the good prognosis associated with hyperdi(cid:173)
`ploidy. There are too few patients to draw conclusions
`about TC 6p21 but given the overlapping gene expression
`profile with TC 11 q 13 and obvious mechanistic similarities,
`it makes sense to group them together. Similarly it makes
`sense to group the t(l4;16) (c-maf) with t(l4;20) (mafB)
`into the TC maf group. Although we do not have mature
`data at this time we suspect that D 1 + D2, which have
`a higher proliferative index, and are over-represented in re(cid:173)
`lapsed patients, have a poor prognosis. The TC none group
`is very small, but because it represents patients with macro(cid:173)
`focal disease it would appear to have a good prognosis.
`These results suggest that the TC classification, which ap(cid:173)
`pears to be based on the earliest events in pathogenesis,
`may be a clinically useful way to classify patients into
`groups that have distinct subtypes of MM (and MGUS) tu(cid:173)
`37 One might argue that some or all of the TC
`35
`mors. 33
`,
`-
`groups represent different disease that may require differ(cid:173)
`ent therapeutic approaches. However, it is likely that a de(cid:173)
`finitive molecular classification will require modification as
`additional initiating and progression events are identified.
`In fact, it seems unlikely there will be a single classification
`system, but instead the classification of MM tumors
`will depend on the availability and response to an ever(cid:173)
`widening variety of therapeutic regiments.Yet the TC groups
`that are based on what appear to be early, or initiating,
`pathogenic events should continue to provide a foundation
`for clinically relevant insights.
`
`www.jco.org
`
`6337
`
`IPR2018-00685
`Celgene Ex. 2034, Page 7
`
`

`

`Bergsagel and Kuehl
`
`Authors' Disclosures of Potential Conflicts of Interest
`Although all authors completed the disclosure declaration, the following author or their immediate family members
`indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part
`of the investigation. For a detailed description of the disclosure categories, or for more information about ASCO's conflict
`of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts oflnterest seccion
`in Information for Contributors.
`
`Author Name
`P Leif Bergsagel
`
`Employment
`
`Leadership
`
`Consultant
`Millenium (A)
`
`Stock
`
`Honoraria
`
`Research Fund
`
`Testimony
`
`Other
`
`Dollar Amount Codes
`
`(A) < $10,000
`
`(B) $10,000-99,999
`
`(C) 2! $100,000
`
`(N/R) Not Requ ired
`
`REFERENCES
`
`1. Ries LAG, Eisner MP, Kosary CL, et al:
`SEER Cancer Statistics Review, 1975-2001.
`Bethesda, MD, National Cancer
`Institute,
`2004
`2. Kyle RA. Therneau TM, Rajkumar SV, et al:
`Prevalence of monoclonal gammopathy of un(cid:173)
`determined
`significance
`(MGUS)
`among
`Olmsted County, MN residents over 50 years
`of age. Blood 102, 2003 (abstr 3476a)
`3. Cohen HJ, Crawford J, Rao MK, et al:
`Racial differences in the prevalence of mono(cid:173)
`clona l gammopathy in a community-based sam(cid:173)
`ple of the elderly. Am J Med 104:439-444, 1998
`4. Lynch HT, Watson P, Tarantolo S, et al :
`Phenotypic heterogeneity in mu ltiple myeloma
`families. J Clin Oncol 23:685-693, 2005
`5. Lynch HT, Sanger WG, Pirruccello S, et al:
`Familial multiple myeloma : A fami ly study and
`review of the literature. J Natl Cancer Inst
`93:1479-1483, 2001
`6. Pasqua lucci L, Neumeister P, Goossens T,
`et al : Hypermutation of multiple proto-onco(cid:173)
`genes in B-cell diffuse large-cell lymphomas.
`Nature 412:341 -346, 2001
`7. Kuehl WM, Bergsagel PL: Multiple mye(cid:173)
`loma: Evolving g