Molecular Characteristics of High-Dose Melphalan Associated Oral Mucositis in Patients with Multiple Myeloma: A Gene Expression Study on Human Mucosa

PLoS One. 2017 Jan 4;12(1):e0169286. doi: 10.1371/journal.pone.0169286. eCollection 2017.


Background: Toxicity of the oral and gastrointestinal mucosa induced by high-dose melphalan is a clinical challenge with no documented prophylactic interventions or predictive tests. The aim of this study was to describe molecular changes in human oral mucosa and to identify biomarkers correlated with the grade of clinical mucositis.

Methods and findings: Ten patients with multiple myeloma (MM) were included. For each patient, we acquired three buccal biopsies, one before, one at 2 days, and one at 20 days after high-dose melphalan administration. We also acquired buccal biopsies from 10 healthy individuals that served as controls. We analyzed the biopsies for global gene expression and performed an immunohistochemical analysis to determine HLA-DRB5 expression. We evaluated associations between clinical mucositis and gene expression profiles. Compared to gene expression levels before and 20 days after therapy, at two days after melphalan treatment, we found gene regulation in the p53 and TNF pathways (MDM2, INPPD5, TIGAR), which favored anti-apoptotic defense, and upregulation of immunoregulatory genes (TREM2, LAMP3) in mucosal dendritic cells. This upregulation was independent of clinical mucositis. HLA-DRB1 and HLA-DRB5 (surface receptors on dendritic cells) were expressed at low levels in all patients with MM, in the subgroup of patients with ulcerative mucositis (UM), and in controls; in contrast, the subgroup with low-grade mucositis (NM) displayed 5-6 fold increases in HLA-DRB1 and HLA-DRB5 expression in the first two biopsies, independent of melphalan treatment. Moreover, different splice variants of HLA-DRB1 were expressed in the UM and NM subgroups.

Conclusions: Our results revealed that, among patients with MM, immunoregulatory genes and genes involved in defense against apoptosis were affected immediately after melphalan administration, independent of the presence of clinical mucositis. Furthermore, our results suggested that the expression levels of HLA-DRB1 and HLA-DRB5 may serve as potential predictive biomarkers for mucositis severity.

MeSH terms

  • Aged
  • Biopsy
  • Dose-Response Relationship, Drug
  • Female
  • Follow-Up Studies
  • Gene Expression Regulation*
  • HLA-DRB5 Chains / immunology
  • Hematopoietic Stem Cell Transplantation
  • Humans
  • Immunohistochemistry
  • Male
  • Melphalan / administration & dosage
  • Melphalan / adverse effects*
  • Middle Aged
  • Mouth Mucosa / immunology
  • Mouth Mucosa / metabolism
  • Mouth Mucosa / pathology
  • Multiple Myeloma / drug therapy*
  • Stomatitis / blood
  • Stomatitis / chemically induced*
  • Stomatitis / genetics*
  • Stomatitis / immunology


  • HLA-DRB5 Chains
  • Melphalan

Grant support

Support was provided by: Det Obelske Familiefond []; The Health Scientific Research Foundation of The North Denmark Region []; Herta Christensen Foundation []; Doctor Henrik Kopps Grant []. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.