Bisphosphonate-associated osteonecrosis: a long-term complication of bisphosphonate treatment

We present current knowledge of bisphosphonate-associated osteonecrosis, a new oral complication in oncology. It was first described in 2003, and hundreds of cases have been reported worldwide. The disorder affects patients with cancer on bisphosphonate treatment for multiple myeloma or bone metastasis from breast, prostate, or lung cancer. Bisphosphonate-associated osteonecrosis is characterised by the unexpected appearance of necrotic bone in the oral cavity. Osteonecrosis can develop spontaneously or after an invasive surgical procedure such as dental extraction. Patients might have severe pain or be asymptomatic. Symptoms can mimic routine dental problems such as decay or periodontal disease. Intravenous use of pamidronate and zoledronic acid is associated with most cases. Other risk factors include duration of bisphosphonate treatment (ie, 36 months and longer), old age in patients with multiple myeloma, and a history of recent dental extraction. We also discuss pathobiology, clinical features, management, and future directions for the disorder.

Anthracycline-Induced Cardiotoxicity in Adult Hematologic Malignancies

Anthracyclines are a highly efficacious treatment for adult hematologic malignancies, including acute myeloid leukemia, acute lymphoblastic leukemia, multiple myeloma, Hodgkin's disease, and non-Hodgkin's lymphoma. The consequences of anthracycline-induced cardiotoxicity have obliged hematologists to set empirical dose limits, above which the cardiotoxic risk is deemed unacceptable. However, subclinical (and also clinical) cardiotoxicity occurs below these empirical doses and may begin to induce cardiac damage in an unpredictable and progressive manner after the first dose of treatment. As a result, treatment with anthracyclines may be withdrawn from patients prematurely or substituted with less efficacious alternative therapies. Through discontinuing further use of anthracyclines, relapsed patients previously treated with these agents may consequently be treated with second-line therapy that is less effective and possibly less well tolerated. Anthracycline-induced cardiotoxicity is potentially fatal and can significantly impair patients' quality of life, while also substantially increasing health care costs.

Bisphosphonates Are Associated With Increased Risk for Jaw Surgery in Medical Claims Data: Is it Osteonecrosis?

PURPOSE

Bisphosphonates (BPs) have recently been associated with increased risk of osteonecrosis of the jaw. Using a large automated insurance database, we searched the medical claims for common procedure codes (CPT codes) denoting major surgery to the mandible or the maxilla. The primary aim of this pilot study was to alert readers to clinically relevant but preliminary information regarding the risk of jaw surgery among patients who received BPs, as compared with patients who did not.

METHODS

The study utilized 2001-2004 claims data from a large nationwide medical insurer. Medical claims from 255,757 cancer patients with breast, lung, or prostate malignancies, or multiple myeloma were analyzed for CPT codes 21015, 21025, 21026, 21034, 21040, 21045, 21046, and 21047.

RESULTS

We identified 224 cases of jaw surgery; of those, 39 cases were found among 26,288 BP users and 185 cases were found among 229,469 never-users. The odds ratio of jaw surgery for intravenous BP users was 4.24 (P<.05). Breast cancer patients experienced a 6-fold increase in risk as compared with nonusers. A trend of increased risk was noted for those on orally administered BPs, but the association was not significant.

CONCLUSION

A significant association was noted between the administration of IV BPs and oral surgery in cancer patients. More studies are needed to understand the role of BPs in bone biology and necrosis along with the associated biologic pathways.

Bortezomib: new indication. Second-line treatment of myeloma: limited efficacy, major risks

(1) When multiple myeloma relapses more than one year after initial treatment, the median survival time is only 12 to 15 months. (2) Bortezomib is a cytotoxic agent that inhibits the 26S proteasome, a complex involved in intracellular protein breakdown in mammals. Bortezomib was initially licensed for the treatment of myeloma after multiple treatment failure; its indications were subsequently modified to include second-line treatment. (3) Second-line bortezomib therapy has not been compared with haematopoietic stem cell grafting, a treatment with documented efficacy. (4) An unblinded comparative trial involving 54 patients requiring second-line treatment showed that bortezomib at a dose of 1.3 mg/m to the 2nd power (twice a week for two weeks, followed by a 10 day rest period) was significantly more effective than a dose of 1 mg/m to the 2nd power in terms of the median survival time (not determined in the 1.3 mg group, versus 26.7 months in the 1 mg group) and the median time to disease progression (11.7 versus 4.2 months). (5) Among 251 patients in whom first-line treatment had failed, bortezomib was significantly more effective than dexamethasone: the one-year survival rate was 80% versus 66% on dexamethasone, and the progression-free survival time was 6.2 months versus 3.5 months. (6) Adverse effects occurred in 30% to 60% of patients enrolled in clinical trials, and were severe in about 10% to 20% of patients. They mainly included fatigue, nausea and vomiting, diarrhoea, anaemia, thrombocytopenia, and peripheral neuropathy. Animal studies indicated a possible risk of cardiotoxicity, and cases of cardiac arrhythmias and conduction disorders were observed in clinical trials. (7) Bortezomib is metabolised by the cytochrome P450 isoenzyme CYP3A4, with a high risk of interactions. (8) The vials contain an excessive amount of this costly drug, creating a risk of inadvertent overdose and leading to unnecessary waste. (9) In practice, bortezomib is an alternative to steroid therapy for patients with multiple myeloma in whom first-line treatment has failed and who do not qualify for stem cell grafting. The choice of treatment must be discussed with the patient, after providing thorough information on the likely benefits and risks

Bortezomib with or without dexamethasone in relapsed multiple myeloma following allogeneic hematopoietic cell transplantation

We retrospectively evaluated the efficacy of bortezomib in 23 patients with multiple myeloma who had relapsed after allografting. Bortezomib was given as single agent to 9 patients (39%) and in combination with steroids in the other 14 (61%). Major toxicities were thrombocytopenia (10/23, 43%) and peripheral neuropathy (12/23, 52%). The overall response rate was 61% (14/23), including 22% (5/23) immunofixation-negative complete remissions. No significant differences in toxicity and response rates were seen between patients treated with bortezomib plus steroids and bortezomib alone. After a median follow-up of 6 months, progression free survival was 6 months. Twenty-one patients are alive, two and five in continuous very good partial and complete remissions, respectively.

Sustained activation of c-jun-N-terminal kinase plays a critical role in arsenic trioxide-induced cell apoptosis in multiple myeloma cell lines

Multiple myeloma (MM) is a presently incurable B-cell malignancy, and newer biologically based therapies are needed. Arsenic trioxide (ATO) has been established as a therapeutic agent for relapsed acute promyelocytic leukemia patients, and has been used for MM patients in clinical trials. In this study, we investigated the role of c-jun-N-terminal kinase (JNK) in ATO-induced apoptosis in MM lines. The exogenous interleukin (IL)-6 dependent MM line, ILKM-3, and independent MM lines, U266 and XG-7, were treated with a therapeutic concentration of ATO with or without JNK inhibitor 1 (a JNK-specific inhibitor) and anisomycin (a JNK activator). Their cell growth, cell cycle, JNK activation and NF-kappaB activation were investigated. ATO induced apoptosis in U266 and ILKM-3 regardless of their exogenous IL-6 dependency. This apoptosis, accompanied with decreased mitochondrial transmembrane potential, sustained activation of JNK but not cell cycle arrest. Pretreatment of JNK inhibitor prevented ATO-induced apoptosis in ATO-sensitive lines. Combined treatment with ATO and anisomycin induced sustained activation of JNK and apoptosis in the ATO-insensitive MM line, XG-7. Results of various time period treatments of ATO showed that sustained activation of JNK was needed in ATO-induced apoptosis in MM. IkBalpha phosphorylation was not associated with ATO-sensitivity of MM lines. These findings suggest that sustained activation of JNK plays a critical role in ATO-induced apoptosis in MM cell lines. Cotreatment with ATO and the agent, which can induce sustained activation of JNK, might improve the outcome in MM therapy.

The Use of Thalidomide in Myeloma Therapy as an Effective Anticancer Drug

Thalidomide and its immunomodulatory derivatives have provided the most significant advance in the therapy of myeloma since the introduction of high dose chemotherapy followed by stem cell transplantation nearly 20 years ago. The mechanism of action of thalidomide is complex and involves many aspects of malignant plasma cell growth and bone marrow stromal cell microenvironment interaction. Thalidomide was first used because of its anti-angiogenic properties, however it is the immunomodulatory actions that involve increasing host tumour-specific immunosurveillance by both T cell and natural killer cells which may be the most important mode of action.

Gene expression profile of multiple myeloma cell line treated by realgar

In order to elucidate the molecular mechanism of Realgar treatment for multiple myeloma (MM), cDNA microaaray was used to compare the gene expression profiles of MM cell line RPMI8226 at 72 hrs pre- and post-Realgar treatment on three separate days. 54 up-regulated and 60 down-regulated genes were identified by cDNA microarray. Further analysis screened out 17 up-regulated and 3 down-regulated genes with Z-score greater than 2 or less than -2, which can be considered the significantly altered genes after Realgar treatment in this study. CCL2, CCL3, BTG1,TNFAIP3, TNFAIP8, SLC38A2, IGFBP4 were important up-regulated genes and they were associated with a variety of cell life functions such as cell growth, cell-cell signaling, regulation of apoptosis and cell homeostasis based on biological process of gene. There are only 3 significantly down-regulated genes (Z-score <-2.0) involved in muscle contract. Several of these genes have been previously identified in relation to MM in published papers. Subsequent validation of selected genes (CCL2, TNFAIP3 and BTG1) by reverse transcription polymerase chain reaction was consistent with our microarray analysis. CCL2 may be involved in MM pathobiology by tumor growth suppression. BTG1 could be used as a potential treatment-related biomarker for monitoring the therapy effect and the remission status of leukemia patients.

[Bisphosphonates and osteonecrosis of the jaws in patients with myelomatosis]

Osteonecrosis of the jaws in patients on chronic bisphosphonate therapy has been reported in small series since 2003. We present two patients with multiple myeloma who developed osteonecrosis of the jaws on intravenous treatment with zolendronic acid and pamidronate, respectively. The patients were treated with debridement of the involved bone and long-term antibiotic therapy.

United States Food and Drug Administration Approval Summary: Bortezomib for the Treatment of Progressive Multiple Myeloma after One Prior Therapy

PURPOSE

On March 25, 2005, bortezomib (Velcade for Injection; Millennium Pharmaceuticals, Inc., Cambridge, MA, and Johnson & Johnson Pharmaceutical Research & Development, L.L.C.) received regular approval from the U.S. Food and Drug Administration (U.S. FDA) for the treatment of multiple myeloma (MM) progressing after at least one prior therapy. This approval was based on bortezomib's efficacy and safety which was shown in a single, large, comparative international open-label phase 3 trial that randomized 669 patients with MM previously treated with at least one systemic regimen to receive single-agent bortezomib or high-dose dexamethasone. The FDA analysis of the trial data and bortezomib's regulatory development are summarized here.

EXPERIMENTAL DESIGN AND RESULTS

Following a preplanned interim analysis of time to disease progression (the primary end point), an independent data-monitoring committee advised the sponsor to halt the study and offer bortezomib to all dexamethasone-treated study patients. Time to progression was significantly prolonged in the bortezomib treatment arm (median, 6.2 months) compared with the dexamethasone arm (median, 3.5 months; log-rank test, P < 0.0001; hazard ratio, 0.55; 95% confidence interval, 0.44-0.69). Analysis of overall survival done on the interim database (with 20% of events) showed the superiority of bortezomib for patients (log-rank test, P < 0.05; hazard ratio, 0.57; 95% confidence interval, 0.40-0.81). Using criteria from the European Group for Blood and Marrow Transplantation, the response rate (complete plus partial response) with bortezomib was also superior to dexamethasone (38% versus 18%; P < 0.0001). Adverse events on the bortezomib arm were similar to those previously observed in phase 2 studies; some notable adverse events included asthenia, peripheral neuropathy, thrombocytopenia, and neutropenia.

CONCLUSIONS

The U.S. FDA had earlier (May 2003) granted bortezomib accelerated approval for the treatment of patients with MM progressing after two prior therapies. The results of the phase 3 trial and the FDA analysis of the data, along with the sponsor's completion of other postmarketing commitments, confirm bortezomib's benefit and support regular approval.

[The plasma cell myeloma--molecular pathogenesis and target therapies]

The cells of the malignant clone of plasmacell myeloma have cytogenetic aberrations in a substantial number of cases. Many of these abnormal karyotypes are predictive for an unfavorable outcome. Gene mutations and abnormal gene expression, particularly of oncogenes and tumor suppressor genes, are often observed in myeloma cells. The cross talk between the myeloma cells and the bone marrow microenvironment plays an important role for growth and survival of the tumor cells. As a consequence of this cell-to-cell-interaction, several cytokines are secreted. The intracellular signaling, evoked by these cytokines, leads to continuous growth and proliferation and inhibition of apoptosis. Since these molecular pathways have been defined, many new targets for therapeutical interventions become obvious. Some molecules, directed against cytokines, are under early clinical investigation. Medicaments intervening in the cross talk between the myeloma cell and the bone marrow stroma as Thalidomide, Lenalidomide or Bortezomib are already available. Many of the myeloma patients suffer from bone disease. Some new drugs inhibiting the differentiation and activation of osteoclasts are evaluated in clinical trials. These molecules will be an important contribution against the painful bone disease of plasmacell myeloma.

Type III hyperlipoproteinemia with xanthomas and multiple myeloma

BACKGROUND

Type III hyperlipoproteinemia usually results from an inherited defect in the composition of apolipoprotein E and is associated with atherosclerosis. An acquired form of the type III phenotype may rarely be associated with myeloma and immunoglobulin-lipoprotein complexes.

OBSERVATION

We present the case of a 72-year-old man with a history of well-controlled, unclassified hypercholesterolemia and hypertriglyceridemia, without evidence of atherosclerotic disease. He subsequently developed refractory dyslipidemia, palmar crease, and tuberous xanthomas. Type III hyperlipoproteinemia was confirmed, and nonclassic defective apolipoprotein E. Common secondary causes of hyperlipidemia were ruled out. A workup for malignancy revealed monoclonal IgA gammopathy. Immunostaining confirmed IgA antibodies complexed to the patient's very low-density lipoprotein (VLDL) fraction, causing gross impairment of VLDL metabolism. Conventional therapy for type III hyperlipoproteinemia was attempted but ineffective. Thus, chemotherapy was initiated for his myeloma, with subsequent lowering of his IgA, cholesterol, and triglyceride levels, and improvement of his xanthomas.

CONCLUSION

There are several unusual features to this case. Planar xanthomas can be associated with myelomas, but usually in the setting of normal lipids. Type III hyperlipoproteinemias are not usually refractory to standard therapy and are only rarely associated with IgA myeloma. IgA antibodies complexed to the patient's VLDL caused gross impairment of VLDL metabolism. The patient's apolipoprotein E genotype (heterozygote E2/E3) is not typical for expression of the heritable type III phenotype (homozygote E2/E2). These features support a causal relationship between this patient's multiple myeloma and type III hyperlipoproteinemia rather than two independent, coexistent conditions.

Extended follow-up of a phase II trial in relapsed, refractory multiple myeloma:: final time-to-event results from the SUMMIT trial

BACKGROUND

Bortezomib, a first-in-class proteasome inhibitor, has shown clinical activity in relapsed, refractory multiple myeloma in a pivotal Phase II trial, SUMMIT.

METHODS

Patients received bortezomib 1.3 mg/m(2) on Days 1, 4, 8, and 11 followed by a 10-day rest period for up to 8 cycles. Dexamethasone 20 mg on the day of and the day after bortezomib was permitted for suboptimal response. Extended treatment beyond 8 cycles was offered to patients whose physicians felt they would benefit from additional therapy. Follow-up was conducted in all patients for a median of 23 months, an additional 13 months from the original report.

RESULTS

Of 202 patients enrolled in SUMMIT, 193 were evaluable for response. Seven (4%) patients achieved a complete response, 12 (6%) achieved a nearly complete response, 34 (18%) achieved a partial response, and 14 (7%) had a minimal response while on bortezomib. The updated median duration of response to bortezomib alone was 12.7 months. The median overall time to progression for all SUMMIT patients was 7 months. For responding patients, the median time to progression was 13.9 months, whereas for those with progressive disease (PD) or who were not evaluable, the median time to progression was 1.3 months. The median overall survival (OS) for all SUMMIT patients was 17.0 months. Whereas the median OS for patients with PD or who were not evaluable was 8 months, the median OS for responding patients was not reached at 23 months of follow-up.

CONCLUSIONS

These data demonstrate that treatment with bortezomib results in meaningful long-term benefit for patients with relapsed and refractory myeloma.

Intermediate-Dose Melphalan (100 mg/m2)/Bortezomib/Thalidomide/Dexamethasone and Stem Cell Support in Patients with Refractory or Relapsed Myeloma

BACKGROUND

Bortezomib and thalidomide have shown synergy with melphalan and dexamethasone. We used this 4-drug combination as conditioning before autologous hematopoietic cell infusions.

PATIENTS AND METHODS

Twenty-six patients with advanced-stage myeloma were treated with melphalan 50 mg/m(2) and bortezomib 1.3 mg/m(2) on days -6 and -3 in association with thalidomide 200 mg and dexamethasone 20 mg on days -6 through -3, followed by hematopoietic cell support on day 0.

RESULTS

Nonhematologic toxicities included pneumonia, febrile neutropenia, and peripheral neuropathy. All patients had undergone autologous transplantation at diagnosis, and 13 patients (50%) underwent an additional transplantation at relapse. Responses occurred in 17 of 26 patients (65%), including 1 complete remission, 3 near complete remissions (12%), and 2 very good partial remissions (8%). Response rate was higher than that induced by the previous line of treatment in 12 patients (46%).

CONCLUSION

Melphalan/bortezomib/thalidomide/dexamethasone showed encouraging antimyeloma activity in patients with advanced-stage myeloma.

Optimizing the efficacy and safety of bortezomib in relapsed multiple myeloma

Bortezomib (Velcade, Millennium) is the first proteasome inhibitor to be used in clinical practice and is indicated for the treatment of multiple myeloma patients who have received at least one prior therapy. Bortezomib inhibits the intracellular degradation of proteins necessary for normal cell cycling and function. This, in turn, results in cell-cycle arrest and apoptosis. Bortezomib has shown significant activity in trials of patients with relapsed or refractory multiple myeloma; approximately one third of patients have shown significant improvement with bortezomib monotherapy in phase II and III clinical trials. Early phase trials are also evaluating bortezomib in combination with other agents used in the treatment of multiple myeloma, including melphalan, prednisone, thalidomide, and lenalidomide. Preliminary data suggest that bortezomib may act synergistically with some agents, and improves response rates. Bortezomib is generally well tolerated, but common side effects include peripheral neuropathy and thrombocytopenia. Studies are underway to explore different dosing strategies as well as ways to maximize patient benefit while reducing toxicity. This review will discuss what is known thus far about the efficacy and safety profile of bortezomib, ways for optimizing treatment with bortezomib, and strategies for managing side effects and enhancing quality of life.

[Home care of hematological malignancies]

Hematological malignancies such as leukemia or lymphoma are mainly treated by hospitalization or in outpatient clinics. Therefore, home care and home nursing are not so intensively done in the treatment of these malignancies. However, G-CSF administration against neutropenia after chemotherapy and administration of narcotics or opioids against severe pain have been performed sometimes during home care, and have been contributing to better QOL of the patients.

[The relationship between abnormal MDR gene expression and chemotherapy response in lymphoid malignancies]

OBJECTIVE

To investigate the expression of multidrug resistance-1 (MDR(1)), Topoisomerase II (Topo II), glucocorticoid receptor (GCR) and their correlation with relapse rate and chemotherapy response in lymphoid malignancies.

METHODS

The expression of MDR(1), Topo II and GCR in 189 patients with lymphoid neoplasms was examined by RT-PCR, slot blot and ligand-labelled methods.

RESULTS

(1) The expressions of MDR(1), Topo II, GCR in untreated and relapsed/refractory patients with ALL, NHL, NHL-L, MM were significantly abnormal at varying levels, especially in the relapsed/refractory group. (2) The complete remission (CR) rate of MDR(1) high expression group (MDR(1)(+)) was significantly lower than that of MDR(1) negative expression (MDR(1)(-)) group (P < 0.05), and the relapse rate of MDR(1)(+) group was significantly higher than that of MDR(1)(-) group (P < 0.05). In untreated patients, the relapse rate in the Topo II low expression (Topo II(-)) group was positively higher than Topo II high expression (Topo II(+)) group (P < 0.05), whereas in the relapsed/refractory patients, the CR rate of Topo II(-) group was significantly lower than that of Topo II(+) group (P < 0.05). In the untreated and relapsed/refractory patients, the CR rates of low GCR expression (GCR(-)) group was obviously lower than that in the normal GCR expression group (P < 0.05). (3) Considering mono-drug resistance mechanism, CR rate of MDR(1)(+) group was the lowest, Topo II(-) group took the second place and GCR(-) group was the highest. As multiple drug resistance mechanisms coexisted, the CR rate of MDR(1)(+) + Topo II(-) + GCR(-) group and MDR(1)(+) + Topo II(-) group (11.1% and 15.4%, respectively) were significantly lower than that of MDR(1)(+), Topo II(-) and GCR(-) group (36.7%, 48.0% and 53.8%, respectively; P < 0.05 - P < 0.001).

CONCLUSION

There are primary and acquired drug resistance in lymphoid neoplasms. The high expression of MDR(1), low expression of Topo II and GCR are positively related to low chemotherapy response rate and high 2-year relapse rate. Co-analysis of MDR(1), Topo II and GCR may play an important role on chemotherapy response and prognostic judgment in lymphoid neoplasms.

Case of multiple myeloma associated with extramedullary cutaneous plasmacytoma and pyoderma gangrenosum

A variety of cutaneous manifestations has been described in multiple myeloma including extramedullary cutaneous plasmacytomas, cutaneous amyloidosis, pyoderma gangrenosum, leukocytoclastic vasculitis, necrobiotic xanthogranuloma, scleromyxedema, Sweet's syndrome, subcorneal pustular dermatosis, scleredema, and plane xanthomas etc. An 89-year-old Korean man, who had been suffering from multiple myeloma 1 year previous, presented for evaluation of two nodules on the right side of the forehead, left side of the chest (7th rib area), and multiple ulcers with papulopustules on both the thigh and the left side of the chest (2nd rib area) during 15 days, which developed at the same time. A biopsy of a lesion which manifested as a cutaneous nodule on the right side of the forehead revealed dermal infiltration by well-differentiated plasma cells, similar to those found on a bone marrow biopsy, and a biopsy of the lesion manifested as a painful ulceration on the right thigh area showing dermal neutrophilic infiltration. Histologic findings were consistent with plasmacytoma and pyoderma gangrenosum, respectively. We present a case of multiple myeloma which developed extramedullary cutaneous plasmacytoma and pyoderma gangrenosum simultaneously, which is very rare. The patient was treated with a systemic steroid and conservative therapy.