Multiple Myeloma Risk and Outcomes Are Associated with Pathogenic Germline Variants in DNA Repair Genes

Risk of lymphoid malignancy associated with cancer predisposition genes

We investigated the prevalence of rare inherited pathogenic variants (PV) in 19 cancer predisposition genes regularly included on multi-gene panel testing based on NCCN guidelines and their association with the risk of lymphoid malignancies (LM) overall and by common lymphoma subtypes and multiple myeloma. The study population included newly diagnosed LM cases (N = 6990) and unrelated controls (N = 42,632), excluding individuals with a history of hematologic malignancy. Whole exome sequencing was performed on DNA from whole blood. PV were defined as loss-of-function (i.e., nonsense, frameshift, consensus splice sites) or identified as "pathogenic" or "likely pathogenic" in the ClinVar database. A total of 1816 (3.7%) individuals had a PV across the 19 genes, higher in cases (4.7%) than controls (3.5%). In controls, CHEK2 (1.0%), ATM (0.4%), BRCA2 (0.4%), and BRCA1 (0.3%) had the highest prevalence. ATM (odds ratio [OR] = 1.86, 95% confidence interval [CI]: 1.36-2.49), CHEK2 (OR = 1.74, 95% CI: 1.42-2.13) and TP53 (OR = 9.07, 95% CI: 4.51-18.87) were associated with increased risk of LM overall and were further validated in the UK Biobank. We observed heterogeneity in associations by LM subtype. These results demonstrate that several commonly tested cancer predisposition genes are associated with an increased risk of LM.

Genetic variants in NHEJ1 and related DNA repair disorders: insights into phenotypic heterogeneity and links to hypoplastic myelodysplastic syndromes and familial hematological malignancies susceptibility

This study investigates the burden, phenotypes, progression, and outcomes of familial hematological malignancies (FHM) through clinical evaluation, gene panel testing, and whole exome sequencing, highlighting the significance of identifying genetic causes for personalized treatment. Over six years, 357 patients initially diagnosed with bone marrow failure (BMF) were evaluated, with 152 patients lacking identifiable causes undergoing further analysis. Among these, 53 (34.9%) exhibited features of inherited BMF syndromes, and 13 (24.5%) developed FHM. In a separate cohort of 27 patients with inherited immunodeficiency disorders, 8 (29.6%) developed FHM associated with NHEJ1 or LYST variants, underscoring the familial clustering of hematologic disorders. Notably, 6 of 7 patients from the same family (family-1) with homozygous NHEJ1 variants progressed to secondary myelodysplastic syndrome (sMDS), acute myeloid leukemia (AML), or lymphoma. Among 780 patients diagnosed with hematological malignancies during the study period, 45 (5.8%) were confirmed to have FHM, with 33 patients enrolled for detailed analysis. Of these, 16 (48.5%) had DNA-repair deficiencies (DNA-RD), including eight with Fanconi anemia, six with NHEJ1 variants, and two with BRCA2 mutations. The remaining 17 patients presented conditions such as familial myeloproliferative neoplasms, dyskeratosis congenita (DC) [TERT, DKC1 variants], and Chediak-Higashi syndrome. Two siblings (family-3) with a rare TERT variant and a unique DC phenotype developed sMDS after prolonged BMF. Patients with DNA-RD were younger and exhibited higher rates of growth failure, recurrent infections, and endocrinopathies. These cases frequently progressed to sMDS or AML. A comparative analysis of 319 individuals with DNA double-strand break repair deficiencies revealed a 45% frequency of hematological malignancies. Lymphoma was most common in Nijmegen breakage syndrome (79.4%) while MDS/AML was prevalent in Cernunnos deficiency (66.6%). The findings emphasize the importance of early diagnosis, genetic testing, and personalized management, including timely transplantation, to improve outcomes in FHM. This research underscores the need for clinical awareness and surveillance to facilitate timely interventions and mitigate disease progression.

FaMMily Affairs: Dissecting inherited contributions to multiple myeloma risk

Etiological links to multiple myeloma (MM) remain poorly understood, though emerging evidence suggests a significant hereditary component. This review integrates current literature on inherited factors contributing to MM risk, synthesizing both epidemiologic and genomic data. We examine familial clustering patterns, assess genome-wide association studies (GWAS) that reveal common genetic variants linked to MM, and explore rare, high-penetrance variants in key susceptibility genes. Additionally, we advocate for routine germline screening in high-risk MM populations, particularly those with a strong family history of cancer, a personal history of cancer, or early-onset disease. By elucidating the inherited influences on MM predisposition, this review seeks to inform future research and refine risk assessment strategies in this population.

Prognostic Value of PSMB5 and Correlations with LC3II and Reactive Oxygen Species Levels in the Bone Marrow Mononuclear Cells of Bortezomib-Resistant Multiple Myeloma Patients

Proteasome inhibitors (PIs) constitute the most common type of induction treatment for multiple myeloma. Interactions between the proteasome, autophagy, and reactive oxygen species (ROS) have been shown in the past, thus emphasizing the need for a better understanding of the underlying pathophysiology. For this study, bone marrow mononuclear cells from 110 myeloma patients were collected at different disease stages. PSMB5 and LC3I/II protein levels were determined using Western blot, proteasome proteolytic activity (PPA) with spectrofluorometry, and ROS with flow cytometry. PSMB5 accumulation was found to diminish after PI treatment (p-value = 0.014), and the same pattern was observed in PPA (p-value < 0.001). Conversely, LC3II protein levels were elevated at both remission and relapse compared to baseline levels (p-value = 0.041). Patients with a baseline PSMB5 accumulation lower than 1.06 units had longer disease-free survival compared to those with values above 1.06 units (12.0 ± 6.7 vs. 36 ± 12.1 months; p-value < 0.001). Median ROS levels in plasma cells were significantly higher at relapse compared to both baseline and remission levels (p-value < 0.001), implying poor prognosis. Overall, post-treatment PSMB5 reduction could indicate a shift from proteasomal to autophagic degradation as a main proteostatic mechanism, thus explaining resistance. The elevated oxidative stress in PI-treated patients could possibly serve as an additional compensatory mechanism.

The Genetic and Molecular Drivers of Multiple Myeloma: Current Insights, Clinical Implications, and the Path Forward

Background

Multiple myeloma (MM) is a hematological malignancy characterized by the clonal proliferation of malignant plasma cells within the bone marrow. The disease's complexity is underpinned by a variety of genetic and molecular abnormalities that drive its progression.

Methods

This review was conducted through a state-of-The-art literature search, primarily utilizing PubMed to gather peer-reviewed articles. We focused on the most comprehensive and cited studies to ensure a thorough understanding of the genetic and molecular landscapes of MM.

Results

We detail primary and secondary alterations such as translocations, hyperdiploidy, single nucleotide variants (SNVs), copy number alterations (CNAs), gene fusions, epigenetic modifications, non-coding RNAs, germline predisposing variants, and the influence of the tumor microenvironment (TME). Our analysis highlights the heterogeneity of MM and the challenges it poses in treatment and prognosis, emphasizing the distinction between driver mutations, which actively contribute to oncogenesis, and passenger mutations, which arise due to genomic instability and do not contribute to disease progression.

Conclusion & Future Perspectives

We report key controversies and challenges in defining the genetic drivers of MM, and examine their implications for future therapeutic strategies. We discuss the importance of systems biology approaches in understanding the dependencies and interactions among these alterations, particularly highlighting the impact of double and triple-hit scenarios on disease outcomes. By advancing our understanding of the molecular drivers and their interactions, this review sets the stage for novel therapeutic targets and strategies, ultimately aiming to improve clinical outcomes in MM patients.

Coexisting Thalassemia, Immune Thrombocytopenic Purpura, and Multiple Myeloma With Osteopenia: Complex Hematologic Case in an Adult Asian Male Patient

We report a rare case of a 45-year-old Asian male patient with concurrent multiple myeloma (MM), immune thrombocytopenic purpura (ITP), and thalassemia trait, presenting with severe thrombocytopenia, back pain, and bleeding manifestations. The diagnosis was established through a combination of laboratory findings, imaging, and bone marrow biopsy, revealing 90% plasma cell involvement and KRAS/BRCA2 mutations. Management focused on controlling ITP with corticosteroids, rituximab, and platelet transfusions while addressing immunosuppression risks. Due to logistical limitations, MM-specific therapy was deferred, and the patient was stabilized for transfer to continue treatment in his home country. This case highlights the challenges of managing overlapping hematologic disorders and underscores the importance of individualized care in complex presentations.

A Role for Germline Variants in Multiple Myeloma?

In Blood Cancer Discovery, Thibaud and colleagues report the incidence of pathogenic germline variants (PGV) in patients with multiple myeloma and that these PGVs are associated with DNA repair pathway genes, including BRCA1 and BRCA2. They find an association of patients with PGVs and previous family or personal history of cancer, and that these patients are diagnosed slightly earlier than those without PGVs. Patients with PGVs had a longer progression-free survival than those without PGVs when they received high-dose melphalan and autologous stem cell transplant, providing a therapeutic rationale for diagnostic germline testing in myeloma. See related article by Thibaud et al., p. 428.