|Year : 2014 | Volume
| Issue : 3 | Page : 177-181
CD200 is an independent prognostic factor in multiple myeloma
Amany A Osman1, Doaa G Eissa MD 1, Mohamed M Moussa2
1 Department of Clinical Pathology, Ain-Shams University, Cairo, Egypt
2 Department of Internal Medicine and Hematology, Ain-Shams University, Cairo, Egypt
|Date of Submission||06-Nov-2014|
|Date of Acceptance||07-Oct-2014|
|Date of Web Publication||31-Dec-2014|
Doaa G Eissa
20 Nagaty Sarag Street, 8th District, Nasr City, Cairo 11471
Source of Support: None, Conflict of Interest: None
Background CD200 is a membrane glycoprotein belonging to the immunoglobulin superfamily and seems to play an immunosuppressive and protumor role. However, the diagnostic and prognostic role of its expression in multiple myeloma is not fully examined.
Aim of work The aim of this study was to detect the expression of CD200 in patients with plasma cell myeloma (PCM) and correlate its expression with other known clinical and laboratory prognostic factors.
Patients and methods A total of 68 PCM patients were enrolled and divided into 50 newly diagnosed and 18 treated patients with residual disease. Flow cytometry was applied on bone marrow samples from all patients to detect CD200 expression using monoclonal anti-CD200.
Results Our results showed CD200-positive expression in 76.5% of the studied PCM patients. A significant relation was found between CD200 expression and many prognostic factors such as advanced age, lytic bone lesions, advanced clinical staging, hematopoietic dysfunction, low level of residual polyclonal g-globulins, and elevated serum creatinine. Moreover, CD200 expression was strongly related to factors associated with tumor burden and activity, such as low serum albumin, high lactate dehydrogenase, high β2 microglobulin level, and elevated bone marrow plasma cell count. Follow-up of patients revealed a significantly shorter event-free survival of CD200-positive patients. Receiver operating characteristic curve showed that 78% is the best prognostic cutoff for CD200 expression, with 92% specificity and 66.7% sensitivity.
Conclusion CD200 is an independent prognostic factor that should be measured to determine PCM patients who are at risk of developing residual disease after standard treatment and thus must be subjected to intensified chemotherapy regimens from the start.
Keywords: CD200, multiple myeloma, prognosis
|How to cite this article:|
Osman AA, Eissa DG, Moussa MM. CD200 is an independent prognostic factor in multiple myeloma. Egypt J Haematol 2014;39:177-81
| Introduction|| |
Multiple myeloma (MM) is a malignant disorder characterized by uncontrolled proliferation of clonal plasma cells causing a wide variety of complications leading to organ dysfunction and eventually death  . The diagnosis of MM usually requires identification of increased plasma cells (>10% of marrow cells), demonstration of an abnormal phenotype and/or clonality, and further classification using a combination of morphologic, laboratory, radiologic, and other clinical findings  .
CD200 is a membrane glycoprotein with relatively frequent expression on B and T lymphocytes, endothelial cells, dendritic cells, and neurons. It has also been implicated in a variety of human cancer cells and is thought to play a protumor role  . CD200 has been reported to be expressed in chronic lymphocytic leukemia/small lymphocytic lymphoma  , in acute myeloid leukemias  , in MM  , and in a number of carcinomas and other malignant neoplasms, including malignant melanoma , .
The biological effect of CD200 expression is solely imparted by the interaction of its extracellular domain with CD200R1 present on myeloid cells and specific T-cell subsets  . CD200-CD200R1 interaction results in the activation of the intracellular inhibitory pathway with RasGAP recruitment and thus contributes to effector cell inhibition. It was confirmed that the CD200R activation induces the differentiation of T cells to the T reg subset and modulates cytokine environment from a Thl to a Th2 pattern resulting in suppression of antitumor T-cell responses  . The altered immune response to the tumor results in tumor cells that are resistant and free to proliferate in an immunocompromised tumor microenvironment  .
There is a paucity of literature data on CD200 in plasma cell myeloma (PCM), and because it potentially represents a useful prognostic indicator, we aimed to study the expression of CD200 in PCM patients by means of flow cytometry (FCM) and correlate it with other known clinical and laboratory prognostic factors to evaluate its role in the prognosis of this disease.
| Patients and methods|| |
The present study was conducted on 68 PCM patients who attended the Hematology Oncology Unit of Ain-Shams University Hospitals from January 2011 to October 2013. All patients were followed-up during the period of the study. Informed consent for inclusion in the study was obtained from all patients. The procedures applied in this study were approved by the Ethical Committee of Human Experimentation of Ain-Shams University and are in accordance with the Helsinki Declaration of 1975. The patients were divided into two groups: 50 newly diagnosed PCM patients who were analyzed before the initiation of therapy and 18 treated PCM patients with residual disease and not responding to melphalan standard dose chemotherapy. Patients were diagnosed on the basis of the IMWG diagnostic criteria  , and staging of the disease was carried out on the basis of the Durie-Salmon (DS) system  and the International Staging System (ISS)  . All clinical and laboratory data of the patients were obtained from review of patients' records and included the following details: full history of weakness, fatigue, bone pain, easy bruising, bleeding, recurrent infections, or weight loss. Thorough clinical examination laying stress on manifestations of anemia, hypercalcemia, hyperviscosity, thrombocytopenia, and hypogammaglobulinemia was performed. Radiological investigations for lytic bone lesions, osteoporosis, and pathological fractures were performed. All patients were subjected to the following laboratory investigations: complete blood counts with examination of Leishman-stained peripheral blood films, bone marrow aspiration and examination of Leishman-stained bone marrow, serum protein electrophoresis, immunofixation to assess the type of abnormal protein, analysis of Bence-Jones' protein in urine, measurement of serum β2 microglobulin (β2 M), serum calcium, serum creatinine, and lactate dehydrogenase (LDH), together with measurement of CD200 using FCM on bone marrow samples.
Measurement of CD200 in multiple myeloma cells
CD200 expression was performed on the Coulter EPICS XL using a double labeling of plasma cells with anti-CD138 monoclonal antibody (MoAb) and anti-CD200 MoAb together with the routine panel of antibodies for MM (anti-CD38, CD56, CD19, CD45, cytoplasmic k, and λ light chains). All MoAbs were supplied by Beckman Coulter (Fullerton, California, USA), except CD200 MoAb, which was supplied by R&D Systems (Minneapolis, Minnesota, USA). All antibodies were fluorescein isothiocyanate-labeled except CD19 and CD38, which were labeled with phycoerythrin. Negative isotype-matched controls were used to determine the nonspecific binding  .
Cells were considered positive for a certain marker when 20% of cells or greater were expressing it ([Figure 1]).
|Figure 1 Flow cytometric histogram showing gating of plasma cells (a) and CD200 express ion (b).|
Click here to view
The data were analyzed using the IBM SPSS statistical software package (V. 21.0; IBM Corp., Armonk, New York, USA). Quantitative data were presented as mean ± SD or median and percentiles. Both number and percentage were used for categorized data. Student's t-test and Wilcoxon rank-sum test (Z) were used for comparison between two independent mean groups in parametric and nonparametric data, respectively. Quantitative data were compared using the χ2 -test. Correlation studies were carried out using Spearman's rank correlation test (r). P values less than 0.05 and less than 0.01 were considered significant and highly significant, respectively.
| Results|| |
On comparing newly diagnosed patients with patients with residual disease, a statistically significant difference was found as regards their outcome (P = 0.052): 16 of the 50 newly diagnosed patients (32%) died, whereas all patients with residual disease survived until the end of the study. No statistically significant difference was found between the two groups with respect to age, sex, lytic bone lesions, and clinical staging (P<0.05). As regards laboratory data, platelet count, and serum albumin were significantly decreased in newly diagnosed patients compared with residual disease patients (P = 0.007 and 0.002, respectively). In addition, a significant difference was found between the two groups with respect to the presence of monoclonal (M) band (P = 0.000) as 46 of the 50 newly diagnosed patients (92%) had M band, whereas 12/18 (66.7%) patients with residual disease had no M band. Moreover, serum creatinine, serum calcium, and percentage of bone marrow plasma cells (BMPCs%) were significantly elevated in newly diagnosed compared with residual disease patients (P = 0.000, 0.002, and 0.026, respectively). No statistically significant difference was detected between the two groups as regards CD200 expression and other laboratory data (P > 0.05) (data not shown).
Of the 68 studied PCM patients, 52 (76.5%) were CD200 + , whereas 16 (23.5%) were CD200 - . The comparative study of CD200 + and CD200 - PCMs are summarized in [Table 1]. A significantly higher number of patients with CD200 + were 65 years or older (P = 0.001) with a significant lytic bone lesions (P = 0.000) and significantly higher clinical staging (P = 0.000): 48/52 (92.3%) and 40/52 (76.9%) of CD200 + patients were classified as stage III by the DS and ISS, respectively. Hemoglobin level, serum albumin, and residual g were significantly decreased in CD200 + compared with CD200 - patients (P = 0, 0.037, and 0.001, respectively). A higher proportion of patients with CD200 + had a monoclonal band (P = 0.044). Moreover, total proteins, serum calcium, serum creatinine, LDH, β2 M, and BMPCS% were significantly elevated in CD200 + patients (P = 0.007, 0.002, 0.017, 0, 0.001, and 0.002, respectively). In a multivariate analysis using Cox regression, CD200 expression was tested with classical prognostic factors such as serum albumin and serum β2 M. It was proven that CD200 expression and serum β2 M are independent prognostic factors (P = 0.003 and 0.000, respectively), whereas serum albumin failed to be significant (P = 0.11).
Follow-up of the patients was conducted during the period of the study; it revealed a significantly shorter median EFS of CD200 + patients than the CD200 - ones, 7.5 versus 22 months (P = 0.001).
A receiver operating characteristic curve was used to identify the best prognostic cutoff level that predicts PCM patients at risk of developing residual disease following standard treatment and who must be subjected to intensified chemotherapy. The best level of CD200% was 78%, which had specificity of 92%, sensitivity of 66.7%, positive predictive value of 75%, negative predictive value of 88.5%, and efficacy of 85.3%.
| Discussion|| |
MM is generally fatal and incurable disease, but the clinical properties, treatment responses, and survival vary considerably between individuals. This heterogeneity relates mainly to prognostic factors associated with specific characteristics of both the tumor itself and the host  . Variables, including patient's age, osteolytic bone lesions, clinical stage, hemoglobin level, serum albumin, LDH, serum β2 M, and BMPC infiltration have long been recognized to predict prognosis  .
In the current study, statistical comparison between newly diagnosed PCM patients and PCM patients with residual disease showed nonsignificant difference with respect to CD200 expression. This finding recommended their pooling together and their statistical analysis as one group. This was done by Olteanu et al.  , who studied 44 newly diagnosed and 32 treated PCM patients with residual disease collectively together as one group to detect CD200 expression. Another study by Spears et al.  found that CD200 expression in PCM patients determined by means of FCM is relatively stable over time and during the course of chemotherapy.
Another classification of PCM patients into CD200 + and CD200 - on the basis of the cutoff of positivity of the FCM was carried out. CD200 + expression was detected in 76.5% of the studied PCM patients. This was consistent with those of Moreaux et al.  , Olteanu et al.  , and Alapat et al.  , who reported that although CD200 is not expressed on normal plasma cells, CD200 + expression was demonstrated in 78, 61.8, and 71% of their studied PCM patients, respectively.
In the present study, 76.9% of CD200 positive PCM patients were 65 years or older. Our finding was in agreement with that of Olteanu et al.  , who found that a higher proportion of their CD200 positive studied patients were 65 years or older. In contrast, Moreaux et al.  reported that the characteristic of age 65 years or older appeared at a significantly higher frequency in patients with CD200-absent MM cells. All our CD200 + patients had bone lesions and their serum calcium level was significantly elevated in CD200 + compared with CD200 - patients. These findings denoted the significant relation between CD200 expression and skeletal disease as evidenced by lytic bone lesions and hypercalcemia. Furthermore, most of our studied CD200 + patients were classified as stage III by DS and ISS, being 92.3 and 76.9%, respectively. This finding revealed the presence of significant relation between CD200 expression and advanced clinical staging. In contrast, Olteanu et al.  reported no statistically significant difference between CD200 + and CD200 - studied groups as regards bone lesions and clinical staging.
The survival time was significantly decreased in CD200 + patients in our study. This was in agreement with the study by Moreau et al.  , who reported that patients with CD200 + PCM were shown to have inferior survival compared with those with CD200 - disease. Similarly, in the study by Olteanu et al.  , patients with CD200 + expression had shorter event-free survival after high-dose chemotherapy and autologous stem-cell transplantation than those with negative CD200 expression: 15 versus 37 months. In contrast, Alapat et al.  suggested that the absence of CD200 expression may serve as a predictor of poor clinical outcome.
In our study, a significant relation was found between CD200 expression and degree of hemotopoietic dysfunction as evidenced by anemia, as the hemoglobin level was significantly decreased in CD200 + patients. This was in agreement with the finding of Olteanu and his coworkers  , who reported the significant decrease in hemoglobin level in CD200 + compared with CD200 - PCM patients.
In MM, the decrease in the level of normal residual polyclonal g-globulins was correlated with more extensive disease  . In this study, the level of residual gamma globulins was significantly decreased in CD200 + compared with CD200 - patients. In contrast, serum creatinine was found to be significantly higher in CD200 + patients. At the same time, Dmoszynska  had found that impaired kidney function with high presenting serum creatinine was correlated with more aggressive disease. Hoffbrand et al.  reported that low serum albumin occurs with more advanced disease. Also, Dispenzieri et al.  found that β2 M was the most reliable prognostic factor in MM. Furthermore, BMPC count has been shown to be an independent prognostic indicator of overall survival in PCM patients  . In the current study, serum albumin was significantly decreased, whereas serum β2M and BMPCs% were significantly increased in CD200 + patients compared with negative ones. Unfortunately, Olteanu et al.  reported no statistically significant differences between CD200 positive and CD200 negative patients included in their study concerning factors associated with greater tumor burden, such as low serum albumin, high β2 M, and increased BMPCs.
CD200 expression was proven to be independent prognostic factor; therefore, an receiver operating characteristic curve was used in this study to detect the best prognostic cutoff level for CD200% expression. This cutoff level can predict PCM patients at risk of developing residual disease after standard treatment and who thus must be subjected to intensified chemotherapy regimens. However, the treatment strategy in PCM patients should be targeted against CD200 itself (anti-CD200 antibodies) as it could reduce the activity of the disease. This seems a reasonable achievement in the near future, either using anti-CD200 alone or in combination with other plasma cell cytotoxins, cancer vaccines, or other immunostimulatory agents.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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