Highly malignant myeloma cells up-regulate their Fas-ligand (Fas-L) to escape immune surveillance by Fas(+) cytotoxic cells. Here it is demonstrated that this abnormality is involved in the pathogenesis of the severe anemia associated with progression of multiple myeloma (MM). By measuring Fas and Fas-L in plasma cells and erythroblasts from 19 MM patients and 5 with monoclonal gammopathies of undetermined significance (MGUS), it was found that both Fas-L(+) myeloma cells and Fas(+) erythroid progenitors were significantly increased in patients with stage III MM whose erythroblasts, cultured in the presence of autologous plasma cells or their supernatant, underwent prompt apoptosis as evaluated by propidium iodide staining, the TUNEL assay, and detection of the APO2.7-reactive mitochondrial antigen. Flow cytometry of fresh erythroblasts revealed a considerable expression of the caspases CPP32 and FLICE in both their constitutive proenzymatic forms and in cleaved subunits. By contrast, their intracytoplasmic expression was defective in patients with inactive disease and MGUS controls. The evidence that Fas-L(+) myeloma clones directly prime erythroblast apoptosis in vivo was further supported by the occurrence of fluorescein isothiocyanate-TUNEL(+) erythroblasts juxtaposed to myeloma cells in bone marrow smears. These results strongly suggest that the deregulated apoptosis in myeloma clones plays an active role in the progressive destruction of the erythroid matrix by a cytotoxic mechanism based on up-regulation of Fas-L.