The proposed work describes preliminary results of a research project based on the realization of... more The proposed work describes preliminary results of a research project based on the realization of a Decision Support System -DSS- platform embedding medical and artificial intelligence -AI- algorithms. Specifically the telemedicine platform is suitable for the optimization of assistance processes of patients affected by Monoclonal Gammopaty. The results are related to the whole design of the platform implementing a DSS based on a multi-level decision making process. Starting from the main architecture specifications, is formulated a flowchart based on different alerting levels of patient risk including artificial intelligence -AI- decision supporting facilities. Finally, the perspectives of the performed research are discussed.
Multiple myeloma plasma cells home and expand in the bone marrow where cause an unbalanced bone r... more Multiple myeloma plasma cells home and expand in the bone marrow where cause an unbalanced bone remodelling with increased bone resorption and low bone formation that represent the typical feature in the majority of patients. A clinically relevant aspect of the interactions of multiple myeloma plasma cells in the bone marrow microenvironment is neovascularization, a constant hallmark of disease progression. This process is only partially supported by factors such as vascular endothelial growth factor, fibroblast growth factor-2 and metalloproteinases, which are directly secreted by the tumor cells. In fact, the presence in the bone marrow microenvironment of cytokines, in particular interleukin-6, as a consequence of plasma cell-stromal cell interactions, induces the production and secretion of angiogenic factors by other cells present in the bone microenvironment, thus contributing to the angiogenic switch during the progression of the disease. Near angiogenesis vasculogenesis occur in the bone marrow of myeloma patients and contribute to the vascular three formation. In the bone marrow of myeloma patients haematopoietic stem cells are recruited and induced to differentiate into endothelial cells by the angiogenic cytokines present in the microenvironment. Myeloma plasma cells also induce angiogenesis indirectly via recruitment and activation of stromal inflammatory cells (i.e.: macrophages and mast cells) to secrete their own angiogenic factors. They are recruited and activated by tumor plasma cells through the secretion of fibroblast growth factor-2, interleukin-8, and other chemokines, such as ITAC, Mig, IP-10. When macrophages and mast cells are activated they secrete their angiogenic factors: fibroblast growth factor-2, vascular endothelial growth factor, granulocyte-colony stimulating factor, granulocyte macrophage-colony stimulating factor, which contribute to enhance the tumor neovascularization. Finally, myeloma macrophages when exposed to vascular endothelial growth factor and fibroblast growth factor-2 secreted by plasma cells shows vasculogenic ability and acquire endothelial cell markers and transform into cells functionally and phenotypically similar to paired bone marrow endothelial cells. So they participate to the formation of the bone marrow capillary network (vasculogenic mimicry).
Objective: Several new drugs are used nowadays to treat multiple myeloma (MM). Some drugs are loa... more Objective: Several new drugs are used nowadays to treat multiple myeloma (MM). Some drugs are loaded with an increased risk of developing cardiovascular diseases. Carfilzomib (K), a proteasome inhibitor, is well recognized to cause cardiovascular side effects. Also, arterial hypertension is a main factor leading to LV dysfunction. Purpose is to evaluate if patients who underwent the carfilzomib treatment may present an increased incidence of arterial hypertension. Design and method: We evaluated 34 patients (group K, 20M, 14F, aged 65.87±5.98) treated with carfilzomib: 25 patients were given 56 mg/m2 (group 1, 14M, 9F, aged 67.30±5.98) while 9 27 mg/m2 (group 2, 6M, 3F, aged 63.00±5.39). As controls, we recruited 34 patients (16M, 18F, aged 69.80±9.13) who underwent in the same period the MM treatment without carfilzomib. Hypertension was identified as new onset of disease or worsening of disease (need double the dose used, add a new drug, or no pressure control in at least 3 drugs treatments). Results: At baseline, the controls presented an increased arterial hypertension rate (76.47% vs group K 47.06%, p = 0.07). There was no difference in any other CVD risk factor. There was no difference in LV mass, volumes and ejection fraction. The group K experienced an increased incidence of arterial hypertension compared to controls (controls 0% vs group K 41.17 %, p = 0.001). This result was not related to the drug dose. Finally, there was no difference in mortality between the two groups also by analysing the CV death. Conclusions: Carfilzomib is a potent and effective drug in MM. Its cardiovascular toxicity relates to a vascular and endothelial damage leading to a new onset of arterial hypertension. This observation may be useful in preventing evolution of the CV dysfunction in survivors and long survivors MM patients. Also, it may be important for studies of vascular damage in arterial hypertension pathophysiology.
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
Purpose: To determine a “gene/molecular fingerprint” of multiple myeloma endothelial cells and id... more Purpose: To determine a “gene/molecular fingerprint” of multiple myeloma endothelial cells and identify vascular mechanisms governing the malignant progression from quiescent monoclonal gammopathy of undetermined significance.Experimental Design: Comparative gene expression profiling of multiple myeloma endothelial cells and monoclonal gammopathy of undetermined significance endothelial cells with the Affymetrix U133A Arrays was carried out in patients at diagnosis; expression and function of selective vascular markers was validated by real-time reverse transcriptase-PCR, Western blot, and small interfering RNA analyses.Results: Twenty-two genes were found differentially expressed (14 down-regulated and eight up-regulated) at relatively high stringency in multiple myeloma endothelial cells compared with monoclonal gammopathy of undetermined significance endothelial cells. Functional annotation revealed a role of these genes in the regulation of extracellular matrix formation and bone remodeling, cell adhesion, chemotaxis, angiogenesis, resistance to apoptosis, and cell-cycle regulation. Validation was focused on six genes (DIRAS3, SERPINF1, SRPX, BNIP3, IER3, and SEPW1) not previously found to be functionally correlated to the overangiogenic phenotype of multiple myeloma endothelial cells in active disease. The small interfering RNA knockdown of BNIP3, IER3, and SEPW1 genes affected critical multiple myeloma endothelial cell functions correlated with the overangiogenic phenotype.Conclusions: The distinct endothelial cell gene expression profiles and vascular phenotypes detected in this study may influence remodeling of the bone marrow microenvironment in patients with active multiple myeloma. A better understanding of the linkage between plasma cells and endothelial cells in multiple myeloma could contribute to the molecular classification of the disease and thus pinpoint selective gene targets for more effective antiangiogenic treatments. (Clin Cancer Res 2009;15(17):5369–78)
We identified STAT1 gain of function (GOF) in a 32-year-old female with pallor, weakness, cough, ... more We identified STAT1 gain of function (GOF) in a 32-year-old female with pallor, weakness, cough, and dyspnea admitted to our Division of Medicine. She had severe oral ulcers (OU), type 1 diabetes (T1DM), and pancytopenia. Bone marrow (BM) biopsy showed the absence of erythroid precursors. Peripheral blood parameters such as neutrophils < 500/mL, reticulocytes < 2%, and BM hypo-cellularity allowed to diagnose severe aplastic anemia. A heterozygous variant (p.520T>C, p.Cys174Arg) of STAT1 was uncovered. Thus, p.Cys174Arg mutation was investigated as potentially responsible for the patient's inborn immunity error and aplastic anemia. Although STAT1 GOF is rare, aplastic anemia is a more common condition; therefore, we explored STAT1 functional role in the pathobiology of BM failure. Interestingly, in a cohort of six patients with idiopathic aplastic anemia, enhanced phospho-STAT1 levels were observed on BM immunostaining. Next, the most remarkable features associated with ...
Microarray was utilized to determine if a genetic signature associated with resistance to carfilz... more Microarray was utilized to determine if a genetic signature associated with resistance to carfilzomib (CFZ) could be identified. Twelve human myeloma (MM) cell lines (HMCLs) were treated with CFZ and a cell-viability profile was assessed categorizing HMCLs as sensitive or resistant to CFZ. The gene expression profiles (GEP) of untreated resistant versus sensitive HMCLs revealed 29 differentially expressed genes. TOP2A, an enzyme involved in cell cycle and proliferation, was overexpressed in carfilzomib-resistant HMCLs. TOP2A protein expression levels, evaluated utilizing trephine biopsy specimens acquired prior to treatment with proteasome inhibitors, were higher in patients failing to achieve a response when compared to responding patients. Logistic-regression analysis confirmed that TOP2A protein expression was a highly significant predictor of response to PIs (AUC 0.738). Further, the combination of CFZ with TOP2A inhibitors, demonstrated synergistic cytotoxic effects in vitro, providing a rationale for combining topoisomerase inhibitors with CFZ to overcome resistance in MM.
Interactions of malignant multiple myeloma (MM) plasma cells (MM-cells) with the microenvironment... more Interactions of malignant multiple myeloma (MM) plasma cells (MM-cells) with the microenvironment control MM-cell growth, survival, drug-resistance and dissemination. As in MM microvascular density increases in the bone marrow (BM), we investigated whether BM MM endothelial cells (MMECs) control disease progression via the junctional adhesion molecule A (JAM-A). Membrane and cytoplasmic JAM-A levels were upregulated in MMECs in 111 newly diagnosed (NDMM) and 201 relapsed-refractory (RRMM) patients compared to monoclonal gammopathy of undetermined significance (MGUS) and healthy controls. Elevated membrane expression of JAM-A on MMECs predicted poor clinical outcome. Mechanistically, addition of recombinant JAM-A to MMECs increased angiogenesis whereas its inhibition impaired angiogenesis and MM growth in 2D and 3D in vitro cell culture and chorioallantoic membrane-assays. To corroborate these findings, we treated MM bearing mice with JAM-A blocking mAb and demonstrated impaired MM p...
The proposed work describes preliminary results of a research project based on the realization of... more The proposed work describes preliminary results of a research project based on the realization of a Decision Support System -DSS- platform embedding medical and artificial intelligence -AI- algorithms. Specifically the telemedicine platform is suitable for the optimization of assistance processes of patients affected by Monoclonal Gammopaty. The results are related to the whole design of the platform implementing a DSS based on a multi-level decision making process. Starting from the main architecture specifications, is formulated a flowchart based on different alerting levels of patient risk including artificial intelligence -AI- decision supporting facilities. Finally, the perspectives of the performed research are discussed.
Multiple myeloma plasma cells home and expand in the bone marrow where cause an unbalanced bone r... more Multiple myeloma plasma cells home and expand in the bone marrow where cause an unbalanced bone remodelling with increased bone resorption and low bone formation that represent the typical feature in the majority of patients. A clinically relevant aspect of the interactions of multiple myeloma plasma cells in the bone marrow microenvironment is neovascularization, a constant hallmark of disease progression. This process is only partially supported by factors such as vascular endothelial growth factor, fibroblast growth factor-2 and metalloproteinases, which are directly secreted by the tumor cells. In fact, the presence in the bone marrow microenvironment of cytokines, in particular interleukin-6, as a consequence of plasma cell-stromal cell interactions, induces the production and secretion of angiogenic factors by other cells present in the bone microenvironment, thus contributing to the angiogenic switch during the progression of the disease. Near angiogenesis vasculogenesis occur in the bone marrow of myeloma patients and contribute to the vascular three formation. In the bone marrow of myeloma patients haematopoietic stem cells are recruited and induced to differentiate into endothelial cells by the angiogenic cytokines present in the microenvironment. Myeloma plasma cells also induce angiogenesis indirectly via recruitment and activation of stromal inflammatory cells (i.e.: macrophages and mast cells) to secrete their own angiogenic factors. They are recruited and activated by tumor plasma cells through the secretion of fibroblast growth factor-2, interleukin-8, and other chemokines, such as ITAC, Mig, IP-10. When macrophages and mast cells are activated they secrete their angiogenic factors: fibroblast growth factor-2, vascular endothelial growth factor, granulocyte-colony stimulating factor, granulocyte macrophage-colony stimulating factor, which contribute to enhance the tumor neovascularization. Finally, myeloma macrophages when exposed to vascular endothelial growth factor and fibroblast growth factor-2 secreted by plasma cells shows vasculogenic ability and acquire endothelial cell markers and transform into cells functionally and phenotypically similar to paired bone marrow endothelial cells. So they participate to the formation of the bone marrow capillary network (vasculogenic mimicry).
Objective: Several new drugs are used nowadays to treat multiple myeloma (MM). Some drugs are loa... more Objective: Several new drugs are used nowadays to treat multiple myeloma (MM). Some drugs are loaded with an increased risk of developing cardiovascular diseases. Carfilzomib (K), a proteasome inhibitor, is well recognized to cause cardiovascular side effects. Also, arterial hypertension is a main factor leading to LV dysfunction. Purpose is to evaluate if patients who underwent the carfilzomib treatment may present an increased incidence of arterial hypertension. Design and method: We evaluated 34 patients (group K, 20M, 14F, aged 65.87±5.98) treated with carfilzomib: 25 patients were given 56 mg/m2 (group 1, 14M, 9F, aged 67.30±5.98) while 9 27 mg/m2 (group 2, 6M, 3F, aged 63.00±5.39). As controls, we recruited 34 patients (16M, 18F, aged 69.80±9.13) who underwent in the same period the MM treatment without carfilzomib. Hypertension was identified as new onset of disease or worsening of disease (need double the dose used, add a new drug, or no pressure control in at least 3 drugs treatments). Results: At baseline, the controls presented an increased arterial hypertension rate (76.47% vs group K 47.06%, p = 0.07). There was no difference in any other CVD risk factor. There was no difference in LV mass, volumes and ejection fraction. The group K experienced an increased incidence of arterial hypertension compared to controls (controls 0% vs group K 41.17 %, p = 0.001). This result was not related to the drug dose. Finally, there was no difference in mortality between the two groups also by analysing the CV death. Conclusions: Carfilzomib is a potent and effective drug in MM. Its cardiovascular toxicity relates to a vascular and endothelial damage leading to a new onset of arterial hypertension. This observation may be useful in preventing evolution of the CV dysfunction in survivors and long survivors MM patients. Also, it may be important for studies of vascular damage in arterial hypertension pathophysiology.
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
Purpose: To determine a “gene/molecular fingerprint” of multiple myeloma endothelial cells and id... more Purpose: To determine a “gene/molecular fingerprint” of multiple myeloma endothelial cells and identify vascular mechanisms governing the malignant progression from quiescent monoclonal gammopathy of undetermined significance.Experimental Design: Comparative gene expression profiling of multiple myeloma endothelial cells and monoclonal gammopathy of undetermined significance endothelial cells with the Affymetrix U133A Arrays was carried out in patients at diagnosis; expression and function of selective vascular markers was validated by real-time reverse transcriptase-PCR, Western blot, and small interfering RNA analyses.Results: Twenty-two genes were found differentially expressed (14 down-regulated and eight up-regulated) at relatively high stringency in multiple myeloma endothelial cells compared with monoclonal gammopathy of undetermined significance endothelial cells. Functional annotation revealed a role of these genes in the regulation of extracellular matrix formation and bone remodeling, cell adhesion, chemotaxis, angiogenesis, resistance to apoptosis, and cell-cycle regulation. Validation was focused on six genes (DIRAS3, SERPINF1, SRPX, BNIP3, IER3, and SEPW1) not previously found to be functionally correlated to the overangiogenic phenotype of multiple myeloma endothelial cells in active disease. The small interfering RNA knockdown of BNIP3, IER3, and SEPW1 genes affected critical multiple myeloma endothelial cell functions correlated with the overangiogenic phenotype.Conclusions: The distinct endothelial cell gene expression profiles and vascular phenotypes detected in this study may influence remodeling of the bone marrow microenvironment in patients with active multiple myeloma. A better understanding of the linkage between plasma cells and endothelial cells in multiple myeloma could contribute to the molecular classification of the disease and thus pinpoint selective gene targets for more effective antiangiogenic treatments. (Clin Cancer Res 2009;15(17):5369–78)
We identified STAT1 gain of function (GOF) in a 32-year-old female with pallor, weakness, cough, ... more We identified STAT1 gain of function (GOF) in a 32-year-old female with pallor, weakness, cough, and dyspnea admitted to our Division of Medicine. She had severe oral ulcers (OU), type 1 diabetes (T1DM), and pancytopenia. Bone marrow (BM) biopsy showed the absence of erythroid precursors. Peripheral blood parameters such as neutrophils < 500/mL, reticulocytes < 2%, and BM hypo-cellularity allowed to diagnose severe aplastic anemia. A heterozygous variant (p.520T>C, p.Cys174Arg) of STAT1 was uncovered. Thus, p.Cys174Arg mutation was investigated as potentially responsible for the patient's inborn immunity error and aplastic anemia. Although STAT1 GOF is rare, aplastic anemia is a more common condition; therefore, we explored STAT1 functional role in the pathobiology of BM failure. Interestingly, in a cohort of six patients with idiopathic aplastic anemia, enhanced phospho-STAT1 levels were observed on BM immunostaining. Next, the most remarkable features associated with ...
Microarray was utilized to determine if a genetic signature associated with resistance to carfilz... more Microarray was utilized to determine if a genetic signature associated with resistance to carfilzomib (CFZ) could be identified. Twelve human myeloma (MM) cell lines (HMCLs) were treated with CFZ and a cell-viability profile was assessed categorizing HMCLs as sensitive or resistant to CFZ. The gene expression profiles (GEP) of untreated resistant versus sensitive HMCLs revealed 29 differentially expressed genes. TOP2A, an enzyme involved in cell cycle and proliferation, was overexpressed in carfilzomib-resistant HMCLs. TOP2A protein expression levels, evaluated utilizing trephine biopsy specimens acquired prior to treatment with proteasome inhibitors, were higher in patients failing to achieve a response when compared to responding patients. Logistic-regression analysis confirmed that TOP2A protein expression was a highly significant predictor of response to PIs (AUC 0.738). Further, the combination of CFZ with TOP2A inhibitors, demonstrated synergistic cytotoxic effects in vitro, providing a rationale for combining topoisomerase inhibitors with CFZ to overcome resistance in MM.
Interactions of malignant multiple myeloma (MM) plasma cells (MM-cells) with the microenvironment... more Interactions of malignant multiple myeloma (MM) plasma cells (MM-cells) with the microenvironment control MM-cell growth, survival, drug-resistance and dissemination. As in MM microvascular density increases in the bone marrow (BM), we investigated whether BM MM endothelial cells (MMECs) control disease progression via the junctional adhesion molecule A (JAM-A). Membrane and cytoplasmic JAM-A levels were upregulated in MMECs in 111 newly diagnosed (NDMM) and 201 relapsed-refractory (RRMM) patients compared to monoclonal gammopathy of undetermined significance (MGUS) and healthy controls. Elevated membrane expression of JAM-A on MMECs predicted poor clinical outcome. Mechanistically, addition of recombinant JAM-A to MMECs increased angiogenesis whereas its inhibition impaired angiogenesis and MM growth in 2D and 3D in vitro cell culture and chorioallantoic membrane-assays. To corroborate these findings, we treated MM bearing mice with JAM-A blocking mAb and demonstrated impaired MM p...
Uploads
Papers by Roberto Ria