23Multiple myeloma is a malignancy of antibody-secreting plasma cells. Most patients benefit from current 24 therapies, however, 20% of patients relapse or die within two years and are deemed 'high-risk'. To better 25 understand and identify high-risk myeloma, we analyzed the translocation landscape of 826 newly-26 diagnosed patients by whole genome sequencing as part of the CoMMpass study. Translocations at the 27 IgL locus were present in 10% of myeloma patients, and corresponded with poor prognosis. Importantly, 28 70% of IgL translocations co-occurred with hyperdiploid disease, a marker of standard risk, which is 29 routinely diagnosed clinically whereas IgL-translocations are not. Thus, it is likely that the majority of IgL-30 translocated myeloma is being misclassified. The IgL enhancer is among the strongest in myeloma cells, 31indicating it can robustly drive oncogene expression when translocated. Consistent with this, IgL-32 translocated patients failed to benefit from immunomodulatory imide drugs (IMiDs), which target the 33 lymphocyte-specific transcription factor Ikaros. These data implicate the IgL enhancer as resistant to 34IMiD-inhibition, and when translocated, as a driver of poor prognosis. 35 36
The breakpoint of IgH translocations indicate multiple mechanisms 110The pathologic significance of translocations was studied starting with the most frequent region, the IgH 111 locus. The most common IgH translocations included t(11;14), t(4;14), t(8;14), and t(14;16), which 112 accounted for 283 of 342 (82.7%) IgH-translocated patients ( Fig. 2a). These translocations resulted in 113 aberrant upregulation of the transposed gene (Fig. S1a). IgH translocations preferentially occurred near 114 the class switch recombination (CSR) regions located at the 5' edge of the constant heavy chains (M), 115 1 (G1), 1 (A1), 2 (G2), 2 (A2), and 3 (G3) (Fig. 2b; top). However, there were distinct differences between 116 the IgH translocation species. For instance, t(11;14), t(4;14), and t(14;16) translocations were primarily 117 located at CSR regions, with t(11;14) translocations more likely to occur at the G1, A1, G2, A2, G3 CSR 118 regions, and t(4;14) almost exclusively at the M switch region. In contrast, t(8;14) and other IgH 119 translocations preferentially occurred at extragenic regions (Fig. 2b). To determine if there were 120 differences in breakpoint location between the IgH translocation species, translocations arising from the 121 CSR, VD, and extragenic regions were quantified and biases in location were expressed as an odds ratio 122 of overlap for each region and translocation (Fig. S1b). These data further indicated that t(11;14), t(4;14), 123 and t(14;16) translocations preferentially occurred at the CSR regions, with t(4;14) showing the strongest 124 bias. Conversely, t(8;14) and other IgH translocations preferentially occurred at extragenic regions ( Fig. 125 S1b, right). These data suggest that the majority of IgH translocations occurred during germinal center B 126 cell CSR, consistent...