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We found that ME contained a higher percentage of cytotoxic T\u00a0cells, whereas PB contained a higher proportion of naive T cells. Malignant cells varied within and between sites and patients in their expression of signatures. We identified a gene module highly expressed in intramedullary and extramedullary plasma cell clusters and defined cell clusters expressing this gene set as extramedullary-initiating cells (EMICs). This gene set was associated with increased cellular proliferation, involved in p53 signaling, and related to poor prognosis in MM. The transcriptional regulators E2F1, YY1, and SMAD1 were activated in EMICs. Leukocyte immunoglobulin\u2013like receptor subfamily B4 (LILRB4) was upregulated in extramedullary EMICs. We confirmed that LILRB4 promoted MM cell migration in\u00a0vitro. This study provided insight into the evolutionary mechanisms of ME and defined EMICs and LILRB4 associated with extramedullary development.<\/jats:p>","DOI":"10.1182\/bloodadvances.2022009477","type":"journal-article","created":{"date-parts":[[2023,6,5]],"date-time":"2023-06-05T16:34:21Z","timestamp":1685982861000},"page":"4148-4159","update-policy":"https:\/\/doi.org\/10.1182\/blood.2019cm0000","source":"Crossref","is-referenced-by-count":11,"title":["Identification of evolutionary mechanisms of myelomatous effusion by single-cell RNA sequencing"],"prefix":"10.1182","volume":"7","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7869-6851","authenticated-orcid":false,"given":"Zhengxu","family":"Sun","sequence":"first","affiliation":[{"name":"1Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8991-7514","authenticated-orcid":false,"given":"Jiamei","family":"Ji","sequence":"additional","affiliation":[{"name":"1Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2134-0595","authenticated-orcid":false,"given":"Yating","family":"Li","sequence":"additional","affiliation":[{"name":"1Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0826-3660","authenticated-orcid":false,"given":"Yunqi","family":"Cui","sequence":"additional","affiliation":[{"name":"1Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lei","family":"Fan","sequence":"additional","affiliation":[{"name":"1Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jianyong","family":"Li","sequence":"additional","affiliation":[{"name":"1Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0863-5417","authenticated-orcid":false,"given":"Xiaoyan","family":"Qu","sequence":"additional","affiliation":[{"name":"1Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"234","published-online":{"date-parts":[[2023,8,1]]},"reference":[{"issue":"10272","key":"2023080717553752600_bib1","doi-asserted-by":"crossref","first-page":"410","DOI":"10.1016\/S0140-6736(21)00135-5","article-title":"Multiple myeloma","volume":"397","author":"van de Donk","year":"2021","journal-title":"Lancet"},{"issue":"5","key":"2023080717553752600_bib2","doi-asserted-by":"crossref","first-page":"497","DOI":"10.1001\/jama.2021.25306","article-title":"What is multiple myeloma?","volume":"327","author":"Silberstein","year":"2022","journal-title":"JAMA"},{"issue":"17","key":"2023080717553752600_bib3","doi-asserted-by":"crossref","first-page":"2360","DOI":"10.1182\/blood.2020005885","article-title":"Progression signature underlies clonal evolution and dissemination of multiple myeloma","volume":"137","author":"Shen","year":"2021","journal-title":"Blood"},{"issue":"2","key":"2023080717553752600_bib4","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1093\/annonc\/mdp329","article-title":"Incidence, presenting features and outcome of extramedullary disease in multiple myeloma: a longitudinal study on 1003 consecutive patients","volume":"21","author":"Varettoni","year":"2010","journal-title":"Ann Oncol"},{"issue":"2","key":"2023080717553752600_bib5","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1007\/s11899-020-00568-3","article-title":"Extramedullary disease in multiple myeloma","volume":"15","author":"Jagosky","year":"2020","journal-title":"Curr Hematol Malig Rep"},{"issue":"1","key":"2023080717553752600_bib6","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1038\/s41375-019-0660-0","article-title":"Extramedullary multiple myeloma","volume":"34","author":"Bhutani","year":"2020","journal-title":"Leukemia"},{"key":"2023080717553752600_bib7","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1016\/j.blre.2019.04.002","article-title":"Extramedullary disease in multiple myeloma - 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