Key Points First prospective US cooperative trial group in preneoplastic gammopathies. Prospective demonstration that genomic features of preneoplastic cells predict disease risk.

Background Exercise may improve fatigue in multiple myeloma survivors, but trial evidence is limited, and exercise may be perceived as risky in this older patient group with osteolytic bone destruction. Methods In this Phase 2 Zelen trial, multiple myeloma survivors who had completed treatment at least 6 weeks ago, or were on maintenance only, were enrolled in a cohort study and randomly assigned to usual care or a 6-month exercise programme of tailored aerobic and resistance training. Outcome assessors and usual care participants were masked. The primary outcome was the FACIT-F fatigue score with higher scores denoting less fatigue. Results During 2014–2016, 131 participants were randomised 3:1 to intervention ( n = 89) or usual care ( n = 42) to allow for patients declining allocation to the exercise arm. There was no difference between groups in fatigue at 3 months (between-group mean difference: 1.6 [95% CI: −1.1–4.3]) or 6 months (0.3 [95% CI: −2.6–3.1]). Muscle strength improved at 3 months (8.4 kg [95% CI: 0.5–16.3]) and 6 months (10.8 kg [95% CI: 1.2–20.5]). Using per-protocol analysis, cardiovascular fitness improved at 3 months (+1.2 ml/kg/min [95% CI: 0.3–3.7]). In participants with clinical fatigue ( n = 17), there was a trend towards less fatigue with exercise over 6 months (6.3 [95% CI: −0.6–13.3]). There were no serious adverse events. Conclusions Exercise appeared safe and improved muscle strength and cardiovascular fitness, but benefits in fatigue appeared limited to participants with clinical fatigue at baseline. Future studies should focus on patients with clinical fatigue. Clinical trial registration The study was registered with ISRCTN (38480455) and is completed.

Carfilzomib, the next generation of proteasome inhibitor, may increase osteoblast-related markers in patients with multiple myeloma, but the molecular mechanism of its effect on mesenchymal stem cell differentiation to osteoblasts remains unknown. Herein, we demonstrated that carfilzomib significantly promoted mesenchymal stem cell differentiation into osteoblasts. In osteoprogenitor cells and primary mesenchymal stem cells from patients with myeloma, carfilzomib induced increases in alkaline phosphatase activity, matrix mineralization, and calcium deposition via Wnt-independent activation of β-catenin/TCF signaling. Using affinity pull-down assays with immunoblotting analysis and immunofluorescence, we found that carfilzomib induced stabilization of both free and active forms of β-catenin in a time- and dose-dependent manner that was not associated with β-catenin transcriptional regulation. Nuclear translocation of β-catenin protein was associated with TCF transcriptional activity that was independent of the effects of GSK3β-activation and of signaling induced by 19 Wnt ligands, 10 Frizzled receptors, and LRP5/6 co-receptors. Blocking activation of β-catenin/TCF signaling by dominant negative TCF1 or TCF4 attenuated carfilzomib-induced matrix mineralization. Thus, carfilzomib induced osteoblast differentiation via Wnt-independent activation of the β-catenin/TCF pathway. These results provide a novel molecular mechanism critical to understanding the anabolic role of carfilzomib on myeloma-induced bone disease.

© F e r r a t a S t o r t i F o u n d a t i o nGenomics of high-risk SMM haematologica | 2015; 100(9) 1215 Methods Eligibility criteria and study designPatients with SMM seen at the Myeloma Institute for Research and Therapy were included in a prospective, observational clinical trial (SWOG S0120) as part of a national cooperative group trial to identify biological correlates that may relate to progression to symptomatic disease. Other eligibility criteria included no prior therapy for the plasma cell disorder and willingness to submit samples for research. Diagnostic criteria for SMM were based on the International Myeloma Working Group convention.3 All patients signed informed consent, in keeping with the Declaration of Helsinki and federal and institutional guidelines. The protocol was approved by the National Cancer Institute and all participating centers' internal review boards.All patients underwent detailed clinical staging at initial registration, including full blood count, analysis of blood chemistry, and standard MM-related serological and urinary measurements. Nephelometric analysis was performed to determine serum immunoglobulin levels. Immunofixation analyses of serum and urine were performed to define the nature of the monoclonal protein present in serum and/or urine. Bone marrow aspirates and biopsies were obtained for cytological and histopathological evaluation of the degree of plasma cell infiltration, including immunohistochemical clonality assessment. Metaphase karyotyping was performed on at least 20 Giemsa-stained metaphases. 23 In most patients, serum FLC assays were used to quantify k and l light chains. Imaging studies involved standard metastatic bone surveys by X-ray examination, and, when possible, MRI of the entire spine was used to identify focal lesions. The minimum follow-up of patients involved MM-related laboratory studies at 3, 6, and 12 months in the first year, and then every 6 to 12 months. Gene expression profiling and statistical methodsA sample of bone marrow aspirate was collected to isolate CD138 + plasma cells with immunomagnetic bead selection (autoMACS; Miltenyi Biotec) as described elsewhere. 24 The purity of the plasma cells was monitored by flow cytometry and >85% purity was used as a criterion for inclusion of GEP data. Total RNA from these plasma cells was used for the GEP with Affymetrix U133 Plus 2.0 microarrays. We identified patients with SMM and baseline GEP data who were cared for at this institution. We evaluated 54,675 Affymetrix gene probes for their potential to predict time to myeloma therapy (TTT). Probes were ranked by their qvalues; 25 we used 10-fold cross validation to identify the number of genes at the top of this list, which collectively maximized the concordance between risk score and survival. Gene scores were computed by subtracting the sum of the expressions of the up-regulated probes from the sum of the expressions of the down-regulated probes, then dividing by the total number of probes. A running log-rank test was used to iden...