Low molecular weight heparins for thromboprophylaxis during induction chemotherapy in patients with multiple myeloma

BACKGROUNDS

Patients with multiple myeloma have a high risk of venous thromboembolism (VTE), especially during the induction chemotherapy. The aim of our observational study was to determine the impact of prophylaxis with low molecular weight heparin (LMWH) on the incidence of thromboembolic complications.

PATIENTS AND METHODS

We analyzed the incidence of thromboembolic events in 258 patients treated with induction chemotherapy containing vincristin, doxorubicin or idarubicin, and dexamethasone, followed by stimulation chemotherapy with cyclophosphamide and G-CSF, and high-dose chemotherapy with melphalan. Two groups of these patients were compared based on the practice of thromboprophylaxis. Patients in the first group (Control, n = 140) were either not treated or treated with a short duration of anticoagulation therapy while the patients in the second group (Prophylactic, n = 118) underwent standard prophylaxis with LMWH throughout the entire period of induction chemotherapy. A total of 102 patients were selected for a close monitoring of the prophylactic effect of different LMWH doses and to be compared to patients without treatment.

RESULTS

Standard prophylaxis with LMWH significantly (p < 0.007) lowered a risk of VTE when compared to patients without such prophylaxis (3.4% versus 12.9%, respectively). Furthermore, analysis of the subgroup of 102 patients revealed that higher LMWH doses (> 70 IU/kg per day) achieved full prophylaxis in 28 patients while lower doses were less effective leading to DVT in 3 (7.7%) out of 39 patients. In contrast, VTE was diagnosed in 5 (14.3%) out of 35 patients without any LMWH prophylaxis.

CONCLUSION

Prophylaxis with LMWH leads to a significant reduction of the risk of thromboembolic complications during the induction chemotherapy in patients suffering from MM. The prophylactic effect of LMWH is dose-dependent.

Expression of RAN, ZHX-2, and CHC1L genes in multiple myeloma patients and in myeloma cell lines treated with HDAC and Dnmts inhibitors

Real time PCR is a powerful tool for studying the expression of genes involved in the pathophysiology of human diseases. Recent studies of the RAN (6p21), ZHX-2 (8q24.3), CHC1L (13q14.3) loci highlight the importance of these genes in multiple myeloma (MM) prognosis and therapeutic applications. Here, we described a detailed Real-Time PCR method for the detection of RAN, ZHX-2, and CHC1L expression, which could be applied in clinical situations. The expression profiles of these genes were studied in peripheral blood lymphocytes of healthy individuals, patients suffering from MM, and in the myeloma cell line, MOLP-8. Low expression levels of RAN, ZHX-2, and CHC1L were observed in myeloma patients, compared with peripheral blood lymphocytes and MOLP-8 cells. An inhibitor of histone deacetylases (TSA) had the ability to decrease expression of CHC1L and ZHX-2 in MOLP-8 cells, while expression of RAN was relatively stable in peripheral blood lymphocytes, control MOLP-8, and TSA- or 5-azacytidine treated MOLP-8 cells. In myeloma patients, we observed significant decreases in the expression of selected genes, but it was patient-specific. Our experiments illustrate new methodological approaches and troubleshooting for conducting gene expression studies in clinical laboratories.

Generation of myeloma-specific T cells using dendritic cells loaded with MUC1- and hTERT- drived nonapeptides or myeloma cell apoptotic bodies

Dendritic cells are able to induce anti-tumor immune responses by presenting tumor-specific antigens to T-lymphocytes. Various tumor-associated antigens have been studied in multiple myeloma in an effort to find a strong antigen capable of generating clinically meaningful responses in vaccinated patients. The aim of our study was to generate myeloma-specific cytotoxic T lymphocytes in vitro using dendritic cells loaded with peptide antigens or apoptotic bodies. Peripheral blood mononuclear cells from HLA-A2+ healthy donors were used for isolation and culture of dendritic cells (DCs) and T lymphocytes. DCs were loaded with hTERT- and MUC1-derived nonapeptides or apoptotic bodies from myeloma cells. Repeated stimulation of T lymphocytes led to their activation characterized by interferon-gamma production. Activated T lymphocytes were separated immunomagnetically and expanded in vitro. Specific cytotoxicity of the expanded T lymphocytes was tested against a myeloma cell line. There was evidence of cytotoxicity for all three types of antigens used for T lymphocyte priming and expansion. No statistically significant differences were observed in T lymphocyte cytotoxicity for any of the antigens. We present a method for the priming and expansion of myeloma-specific T lymphocytes using dendritic cells loaded with different types of tumor antigens. Cytotoxic T lymphocytes and/or activated dendritic cells generated by the described methods can be applied for cellular immunotherapy against multiple myeloma and other malignancies.

Negative prognostic significance of two or more cytogenetic abnormalities in multiple myeloma patients treated with autologous stem cell transplantation

Malignant plasma cells in multiple myeloma (MM) are frequently characterized by complex karyotypes and chromosome instability. These cytogenetic changes are considered important prognostic indicators in MM patients. We have studied samples from 68 patients with newly diagnosed MM who were treated with high-dose chemotherapy and autologous stem cell transplantation. G-banding revealed abnormal karyotypes in 14 of 55 patients (25%) who had informative conventional cytogenetics. The combination of cytoplasmic immunoglobulin light chain labeling and interphase fluorescent in situ hybridization (cIg-FISH) revealed the presence of genetic aberrations in 53 of 68 patients (78%). Chromosome 13 abnormalities were found in 33 patients (50%) and IgH rearrangements in 36 patients (56.25%). In IgH positive patients we performed subsequent examinations of IgH affecting translocations t(4;14) and t(11;14) and we found translocation t(11;14) in 8 patients (12.5%) and t(4;14) in 10 patients (15.5%). The occurrences of others chromosomal abnormalities with known prognostic impact in MM were as follows: del(17)(p13) was present in 5 patients (9.8%) and gain 1q21 in 14 patients (36%). Analysis of survival of patients with different cytogenetic abnormalities revealed shorter overall survival (OS) in patients with IgH rearrangements (p=0.020) and trend to shorter OS in patients with gain 1q21 (p=0.064), respectively. Remarkably, patients with two or more aberrations had significantly shorter overall survival (p=0.001), time to progression (p=0.036) and progression free survival (p=0.008). Our results show a high incidence of chromosomal abnormalities in MM patients and confirm the prognostic impact of selected chromosomal aberrations as well as cumulative effect of multiple cytogenetic changes occurring simultaneously.

Pretreatment hepatocyte growth factor and thrombospondin-1 levels predict response to high-dose chemotherapy for multiple myeloma

Our aim was to establish whether the pretreatment levels of angiogenesis activators and inhibitors can be used to predict clinical responses to treatment that included high-dose chemotherapy with peripheral stem cell support.<br />We analyzed samples and treatment outcomes of 96 patients with MM enrolled in the CMG 2002 randomized clinical trial and treated with induction chemotherapy and high-dose chemotherapy with stem cell support. Concentrations of vascular endothelial growth factor (VEGF), hepatocytar growth factor (HGF), basic fibroblastic growth factor (bFGF), thrombospondin-1 (TSP-1), endostatin, and angiostatin were measured in the peripheral blood plasma and in the bone marrow plasma at diagnosis. <br />Pretreatment HGF concentrations in the peripheral blood plasma as well as in the bone marrow plasma of patients who achieved complete or very good partial response were significantly lower than those in patients who had partial or worse response. Patients with complete or very good partial response had higher TSP-1 levels in the bone marrow plasma than the partial or insufficient response subgroups. There were no correlations between the pretreatment levels of VEGF, bFGF, endostatin, or angiostatin and the treatment response. <br />Pretreatment concentrations of HGF and TSP-1 were predictive factors for treatment response. Patients with low angiogenesis rate as determined by the relative HGF and TSP-1 concentrations were more likely to achieve complete or very good partial response after high-dose chemotherapy.

KEYWORDS

Angiogenesis, cytokines, high-dose chemotherapy, multiple myeloma, therapeutic response.

Centrosome amplification as a possible marker of mitotic disruptions and cellular carcinogenesis in multiple myeloma

Centrosome amplification (CA) as a potential marker of mitotic disruptions in multiple myeloma (MM) was investigated in two populations of B-cell lineage: B-cells and plasma cells (PCs). Using immunofluorescent staining, it was shown that CA in B-cells is present in 3.2+/-2.5% in healthy donors versus 9.9+/-7.9% in MM patients (p<0.0001). Based on the calculated threshold value of CA in B-cells, 37% (14/38) of MM patients were positive. There was no significant correlation between CA-positive MM cases (based on PC samples evaluation) and the occurrence of cytogenetic abnormalities in PCs, including del(13)(q14), del(17)(p13), gain(1)(q21) and hyperdiploidy.

Phenotype of plasma cells in multiple myeloma and monoclonal gammopathy of undetermined significance

Flow cytometry is a useful tool for the analysis of plasma cells in monoclonal gammopathies. The aim of this study was to find possibilities and limits of multicolour flow cytometry in diagnostics of monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma (MM) and to identify parameters that could be used to differentiate between these two disorders. Surface markers CD38 and CD138 were used for identification of plasma cells, CD19 and CD56 further distinguished normal and abnormal plasma cells, respectively. The percentage of circulating plasma cells in peripheral blood was lower in MGUS patients then in MM (p<0,001) In bone marrow, the percentage of residual polyclonal CD19 plasma cell was higher (p<0,001) and the percentage of malignant monoclonal CD56 plasma cell was lower (p<0,001) in MGUS than in MM. In conclusion, flow cytometry is relatively quick and effective method for analysis of plasma cells thus immunophenotyping can significantly contribute to the differential diagnosis of plasma cell proliferations.

Nuclear topography of the 1q21 genomic region and Mcl-1 protein levels associated with pathophysiology of multiple myeloma

Chromosomal rearrangements and copy number variation are frequently observed in cancer cells, including multiple myeloma (MM). Karyotypic abnormalities seen in MM cells correlate with the disease stage and drug responses. Here, we investigate the nuclear arrangement of the 1q21 region; amplification of this region is an important diagnostic and prognostic marker of MM. We examined the lymphoblastoid cell line CD138- ARH-77, multiple myeloma CD138+ MOLP-8 cells, and the CD138+ bone marrow fraction of patients diagnosed with MM. In this experimental system, we observed that gamma-radiation and selected cytostatic drugs such as melphalan and dexamethasone did not significantly alter the nuclear radial arrangement of the 1q21 region and other relevant regions of chromosome 1. Similarly, conserved nuclear radial positioning after cytostatic treatment was observed for the c-myc, TP53, CCND1, and IgH loci. When analyzed Mcl-1, a protein encoded by a gene mapped to the 1q21 region, we found that the variant Mcl1S is highly expressed in multiple myeloma MOLP-8 cells, but not in peripheral blood lymphocytes of healthy donors or lymphoblastoid ARH-77 cells; this is in contrast to the expression pattern of the Mcl-1L variant. On the basis of these observations we suggest that the 1q21 region is an important diagnostic marker of MM, particularly the gene encoding the Mcl-1S variant, which can be easily detected by western analysis.

International myeloma working group (IMWG) consensus statement and guidelines regarding the current status of stem cell collection and high-dose therapy for multiple myeloma and the role of plerixafor (AMD 3100)

Multiple myeloma is the most common indication for high-dose chemotherapy with autologous stem cell support (ASCT) in North America today. Stem cell procurement for ASCT has most commonly been performed with stem cell mobilization using colony-stimulating factors with or without prior chemotherapy. The target CD34+ cell dose to be collected as well as the number of apheresis performed varies throughout the country, but a minimum of 2 million CD34+ cells/kg has been traditionally used for the support of one cycle of high-dose therapy. With the advent of plerixafor (AMD3100) (a novel stem cell mobilization agent), it is pertinent to review the current status of stem cell mobilization for myeloma as well as the role of autologous stem cell transplantation in this disease. On June 1, 2008, a panel of experts was convened by the International Myeloma Foundation to address issues regarding stem cell mobilization and autologous transplantation in myeloma in the context of new therapies. The panel was asked to discuss a variety of issues regarding stem cell collection and transplantation in myeloma especially with the arrival of plerixafor. Herein, is a summary of their deliberations and conclusions.

Endoscopic versus minimally invasive vein harvesting. Impact on leg-related morbidity in coronary artery bypass surgery: one-year follow-up of a prospective trial

AIM

We sought to compare the impact of endoscopic and minimally invasive great saphenous vein harvesting on leg-related patient morbidity after coronary artery bypass grafting.

METHODS

From February 2004 to July 2006, 120 patients underwent minimally invasive vein harvesting, and 180 patients underwent endoscopic vein harvesting for coronary artery bypass grafting. Patients were evaluated prospectively for wound-healing disturbances, residual leg edema, pain intensity and saphenous neuropathy at seven days, three months and one year after surgery.

RESULTS

Both harvesting techniques were associated with a low incidence of wound-healing disturbances; nevertheless, endoscopic vein harvesting was associated with a significantly lower incidence of residual edema (12% vs 28%, P<0.05 seven days postoperative; 6% vs 19%, P<0.001 three months postoperative), pain (9% vs 20%, P<0.05; 6% vs 10%, P<0.05) and saphenous neuropathy (6% vs 23%, P<0.001; 3% vs 14%, P<0.05) during follow-ups. Endoscopic vein harvesting was also associated with a significantly lower incidence of neurological disturbances at one-year follow-up (2% vs 8%, P<0.05). Mean harvesting time (43.9+/-10.2 vs 40.6+/-15.5 min, P=0.09), conversion rate (2% vs 3%, P=0.71) and injury per conduit (0.3+/-0.1 vs 0.3+/-0.2, P=0.91) were comparable for both groups.

CONCLUSION

EVH is superior to MIVH in terms of reduction in pain intensity, residual leg edema and saphenous neuropathy at seven days and again at three months postoperative. A significantly lower incidence of neurological disturbances is still presented one year after surgery.

The Czech National External Quality Assessment of monoclonal immunoglobulin in the period of 1996 - 2005

The aim of the presented study was to evaluate the results of SEKK "Gammopathy" (GP) control cycle (Czech National External Quality Assessment) that assessed the success rate of monoclonal immunoglobulin determination by clinical laboratories for the 1996 - 2005 period. The study summarizes the results of 20 "Gammopathy" control cycles during the ten-year period. Control cycles were repeated every 6 months. Patients who provided samples for individual SEKK "Gammopathy" control cycles were selected during routine diagnostic process in the University Hospital Hradec Kralove. Correct paraprotein typing in both A and B control samples (plasma, serum or urine) is required prior to certification. Assessment of paraprotein concentration is optional. The number of participating laboratories was gradually increasing from 26 in 1996 to 79 in 2005 (including 6 Slovak laboratories). The majority of laboratories used immunofixation electrophoresis as the method of paraprotein typing. In 2005, only one laboratory was still using immunoelectrophoresis. Typing was successful in approximately 70% of cases during the first 3 cycles and the success rate gradually increased to almost 96% by 2005. The only exception was GP 1/02 cycle with a sample of relatively rare IgD-lambda paraprotein and the success rate of 38% only. A sample of plasma without paraprotein was distributed 4 times. Several laboratories falsely identified fibrinogen as paraprotein each time. Results of "Gammopathy" control cycle for the past 10 years confirmed the value and legitimacy of this control cycle in the system of external quality control of SEKK laboratories.

Capillary immunotyping electrophoresis and high resolution two-dimensional electrophoresis for the detection of mu-heavy chain disease

Heavy chain disease with monoclonal incomplete mu-heavy chains (mu-HCD) is a rare disorder usually associated with an underlying lymphoproliferative malignancy. Laboratory diagnosis of patients with mu-HCD is usually challenging and the monoclonal protein is not detected by electrophoresis in up to 75% of mu-HCD cases. We describe a patient with multiple malignancies in whom we detected and characterized monoclonal mu-heavy chains using immunofixation electrophoresis, capillary zone electrophoresis with immunotyping, and high resolution two-dimensional electrophoresis. The high resolution 2D electrophoresis enabled us to determine the molecular weight of the mu-heavy chains. The abnormal protein concentration in the serum was unusually high, 38 g/l measured in our patient is the highest reported value in the literature so far.

Negative pressure therapy as a treatment modality for surgical site infection in cardiac surgery

BACKGROUND

Negative pressure therapy (NPT), primarily introduced for the treatment of pressure ulcers or chronic debilitating wounds, has recently emerged as a novel treatment strategy in the field of cardiac surgery, providing superior results to the conventional therapeutic strategies.

PATIENTS AND METHODS

From November 2004 to October 2005, 25 patients underwent NPT (negative pressure therapy). Four patients (16%) were treated for extensive leg-wound infections, 10 (40%) were treated for superficial sternal wound infections and 11 (44%) for deep sternal wound infections. The median age was 67.9 years (range 48 to 79) and the median BMI was 34.2 kg/m2 (range 28 to 41). Because of wound infection complications, 11 patients (44%) were re-admitted to the department. In 13 patients (52%), NPT was employed after the failure of the conventional treatment strategy.

RESULTS

All 25 patients were successfully healed. In-hospital mortality was 0% and 30-day survival was 100%. The overall length of hospitalization reached 36.4 days (range 11 to 62). The median number of dressing changes was 4.9 (range 3 to 9). The median NPT treatment time until the surgical closure was 9.7 days (range 6 to 24 days). In 17 patients (68%), the excessive residual sternal defect required a local advancement flap transfer. One patient (4%) with a chronic wire-related fistula was re-admitted 6 months after NPT therapy.

CONCLUSION

NPT therapy can be considered as an effective treatment strategy associated with a low risk of procedure failure and wound infection recurrence, particularly in the management of sternal wound infection after cardiac surgery.

Effect of the combination of pegylated liposomal doxorubicin and bortezomib on time to progression (TTP) and overall survival of patients with relapsed/refractory multiple myeloma compared with bortezomib alone

8002

Background: Proteasome inhibition with bortezomib is a standard of care for patients with relapsed/refractory multiple myeloma (MM). Recently, we reported the results of an interim analysis for the DOXIL-MMY-3001 study, a large multi-national, phase III, randomized study of patients with previously treated MM demonstrating that the combination of pegylated liposomal doxorubicin (PLD) and bortezomib resulted in a 45% risk reduction of experiencing disease progression over bortezomib alone (Orlowski et al, 2006 ASH Meeting, Abstract #404). The improvement in TTP was associated with an overall survival (OS) trend favoring the combination therapy (P=0.113; hazard ratio[HR], 1.48, 95% Confidence Interval [CI], 0.91 to 2.41). We now present an updated survival analysis with a median follow up of 11 months. Methods: 646 patients at 123 centers in 18 countries received either intravenous bortezomib, 1.3 mg/m2, on days 1, 4, 8, and 11 of every 21-day cycle, or the same bortezomib regimen with PLD, 30 mg/m2, on day 4. Results: As previously reported, median TTP was improved from 6.5 months for bortezomib alone to 9.3 months for the PLD+bortezomib combination (P=0.000004; HR, 1.82; 95% CI, 1.41 to 2.35). The complete+partial response rate was 43% for bortezomib and 48% for PLD+bortezomib (P=0.251). Median duration of response was increased from 7.0 months (95% CI, 5.9 to 8.3) to 10.2 months (95% CI, 10.2 to 12.9) with combination therapy (p=0.0008). Updated OS analysis showed PLD+bortezomib significantly improved OS (p<0.05; HR, 1.41, 95% CI, 1.002 to1.97). Both groups received a median of 5 cycles of treatment. The safety profile of the combination was consistent with the known toxicities of the two agents. Grade 3/4 adverse events were more frequent in the combination group primarily due to increase in myelosuppression and GI toxicities. Conclusions: PLD with bortezomib is superior to bortezomib monotherapy for the treatment of patients with relapsed/refractory MM.

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Impact of prior thalidomide (T) therapy on the efficacy of pegylated liposomal doxorubicin (PLD) and bortezomib (B) in relapsed/refractory multiple myeloma (RRMM)

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Background: IMIDs and proteasome inhibitors offer novel therapeutic options for patients with RRMM. T+Dex is approved for the treatment of newly diagnosed MM (Rajkumar JCO 2006). Wang et al (ASCO 2006, ASH 2006) suggested prior T exposure resulted in partial cross resistance to subsequent treatment with lenalidomide (L). Our objectives were to determine 1) whether resistance also existed to PLD+B in patients receiving prior T vs no prior T and 2) if the efficacy and safety profile of PLD+B was comparable to that previously reported with L+Dex in T failures. Methods: We performed a post hoc analysis of a previously reported phase III trial comparing PLD+B vs B alone (Orlowski ASH 2006). RRMM patients receiving ≥1 prior therapy and randomized to receive PLD at 30 mg/m2 given on D4 of each cycle along with B at 1.3 mg/m2 on D1, 4, 8, and 11 of every 21-day cycle were analyzed based on prior T exposure or no prior T. Treatment was continued for up to 8 cycles or for at least 2 cycles beyond a CR unless disease progression was observed or unacceptable toxicity occurred. Results: 324 patients were randomized to PLD+B (n=194 [T naïve], n=130 [T exposed]) and included in this analysis. Baseline albumin was 3.8 g/dL, 3.8 g/dL and 4.8 g/dL for the PLD+B (T naïve), PLD+B (T exposed) and L+Dex (T exposed), respectively. Baseline β2 microglobulin was 5.2 g/dL, 5.4 g/dL and 3.7 g/dL for these groups, respectively. Conclusions: These results demonstrate that PLD+B provide a consistent efficacy benefit in both T exposed and T naïve patients with no evidence of cross resistance to prior T. Compared to L+Dex in a similar patient population with prior T exposure, PLD+B has comparable response rates and time to progression, but the risk of TVE is substantially reduced. These results should be considered when choosing treatment options for RRMM who have failed prior T treatment and confirmed in a prospective randomized study.

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An international field study of the reliability and validity of a disease-specific questionnaire module (the QLQ-MY20) in assessing the quality of life of patients with multiple myeloma

AIM

To test the reliability, validity and sensitivity of the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-MY24 questionnaire, designed to assess the quality of life of myeloma patients with the QLQ-C30.

METHODS

The study was carried out through the EORTC Quality of Life Group using clinical trials in seven countries. All trials used the QLQ-C30 and QLQ-MY24 at baseline and a follow-up timepoint.

RESULTS

Two hundred and forty patients participated. The questionnaires were acceptable to patients. The hypothesised scale structure (disease symptoms, side-effects, body image and future perspective) was confirmed by multi-trait scaling, internal consistency and correlation analysis. Most scales demonstrated sensitivity to change and discriminated between clinically different patients. The social support scale (4 items) was removed due to observed ceiling effects.

CONCLUSION

The final questionnaire contains 20 items, QLQ-MY20, and is a reliable and valid instrument recommended for use with the QLQ-C30 in myeloma patients.

Fluorodeoxyglucose positron emission tomography in multiple myeloma, solitary plasmocytoma and monoclonal gammapathy of unknown significance

The aim of our study was to evaluate the role of fluorine-18 fluorodeoxyglucose positron emission tomography (FDGPET) in 49 patients with plasma cell malignancies. FDG-PET results were verified by conventional imaging methods, including plain radiographs, magnetic resonance imaging (MRI) and computer tomography (CT). Focally increased FDG uptake was observed in three (23 %) of 11 newly diagnosed myeloma patients with negative bone radiographs. Focally increased tracer uptake was found in five of 26 patients with MM in remission but with suspected relapse. Of the 20 patients who had negative FDG-PET scans, only one relapsed 12 months after FDG-PET examination.. FDG-PET was positive in two of six patients with MGUS and with suspected progression to MM or with suspected other malignancy. In one case a thyroid carcinoma was later detected, in the other an intestinal tumor was found. We conclude that FDG PET might contribute to initial staging of MM patients with negative bone radiographs and is useful for the follow-up of patients in remission especially in non-secretory MM and in patients with large plasmocytoma (>5 cm) after radiochemotherapy.