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Engelhardt M, Kortüm KM, Goldschmidt H, Merz M. Functional cure and long-term survival in multiple myeloma: how to challenge the previously impossible. Haematologica 2024; 109:2420-2435. [PMID: 38356448 PMCID: PMC11290544 DOI: 10.3324/haematol.2023.283058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 02/06/2024] [Indexed: 02/16/2024] Open
Abstract
Multiple myeloma (MM) is a heterogeneous disease with survival ranging from months to decades. The goal of 'cure' remains elusive for most patients, but has been shown to be possible, with durable remission and a transition to a plateau phase (analogous to monoclonal gammopathy of uncertain significance/smoldering myeloma). In this review, two representative cases set the stage to illustrate how this might be possible and what still needs to be determined to achieve functional disease control over a prolonged period. Several developments have emerged, such as improved diagnostics including the definitions and use of SLiM-CRAB criteria and measurable residual disease (MRD) with whole-genome/single-cell sequencing as well as other correlates to better understand disease biology. These advances enable earlier detection, more accurate risk stratification and improved personalized treatment strategies by facilitating analysis of genetic alterations and clonal heterogeneity. Whole-genome sequencing may also identify driver mutations and modes of resistance to immunotherapies as well as other targeted therapies. Today, induction with a CD38 antibody, proteasome inhibitor, immunomodulatory drug, and dexamethasone, potentially followed by autologous stem cell transplantation and lenalidomide maintenance, can be considered standard of care for transplant-eligible (TE) patients with newly diagnosed MM (NDMM). That prolonged disease control and functional cure can be achieved in non-transplant-eligible (NTE) patients is currently emerging as a distinct possibility: data from phase III trials that incorporate a CD38 antibody into the treatment of NTE NDMM patients demonstrate impressive MRD negativity rates that appear sustained over several years. While the long-term durability of chimeric antigen receptor T cells, bi-specific antibodies and other immunotherapies are being evaluated, several clinical trials are now investigating their role in frontline treatment for TE and NTE patients. These trials will address whether chimeric antigen receptor T-cell therapy will replace autologous stem cell transplantation and whether such immunotherapies will represent a truly curative option. We conclude that while cure remains elusive, the concept of operational or functional cure provides a new benchmark to strive for and is an emerging area of active and potentially achievable clinical research for MM.
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Affiliation(s)
- Monika Engelhardt
- Department of Medicine I Hematology and Oncology, Medical Center University of Freiburg, Faculty of Medicine, Comprehensive Cancer Center Freiburg (CCCF).
| | - K Martin Kortüm
- Department of Medicine II, University Hospital of Würzburg, Würzburg
| | - Hartmut Goldschmidt
- University Hospital Heidelberg and the National Center for Tumor Diseases, Heidelberg
| | - Maximilian Merz
- Department of Hematology, Cell therapy and Hemostaseology, University Hospital Leipzig, Leipzig.
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2
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Son AY, Chung HW. [Imaging for Multiple Myeloma according to the Recent International Myeloma Working Group Guidelines: Analysis of Image Acquisition Techniques and Response Evaluation in Whole-Body MRI according to MY-RADS]. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:150-169. [PMID: 36818702 PMCID: PMC9935955 DOI: 10.3348/jksr.2021.0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/16/2022] [Accepted: 02/12/2022] [Indexed: 11/15/2022]
Abstract
Multiple myeloma (MM) is a malignant hematologic disease caused by the proliferation of clonal plasma cells in the bone marrow, and its incidence is increasing in Korea. With the development of treatments for MM, the need for early diagnosis and treatment has emerged. In recent years, the International Myeloma Working Group (IMWG) has been constantly revising the laboratory and radiological diagnostic criteria for MM. In addition, as whole-body MRI (WBMR) has been increasing used in the diagnosis and treatment response evaluation of patients with MM, the Myeloma Response Assessment and Diagnosis System (MY-RADS) was created to standardize WBMR image acquisition techniques, image interpretation, and response evaluation methods. Radiologists need to have a detailed knowledge of the features of MM for accurate diagnosis. Thus, in this review article, we describe the imaging method for MM according to the latest IMWG guidelines as well as the image acquisition and response evaluation technique for WBMR according to MY-RADS.
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Affiliation(s)
- A Yeon Son
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye Won Chung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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3
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El Dirani M, Nagaratnam JM, Kholoki S. Factors Explaining the Coincidence of Smoldering Multiple Myeloma and Primary Biliary Cholangitis: A Case Report. Cureus 2022; 14:e26830. [PMID: 35974869 PMCID: PMC9375106 DOI: 10.7759/cureus.26830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2022] [Indexed: 11/05/2022] Open
Abstract
To date, there have been nine reported instances of coinciding smoldering multiple myeloma (SMM) and primary biliary cholangitis (PBC). The term SMM was coined in 1980 to describe low-severity multiple myeloma cases, a hematologic neoplasia that involves the malignant proliferation of plasma cells. PBC is an autoimmune disorder targeting the intrahepatic bile ducts and is characterized by elevated anti-mitochondrial antibodies and often resulting in autoimmune liver cirrhosis. Currently, there is no plausible rationale for the coincidence of SMM and PBC in patients. This report investigates the relationship between SMM and PBC in a Hispanic 49-year-old female residing in the United States and attempts to determine the possible genetic and biochemical causes of this coincidence.
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Goldsmith SR, Stockerl-Goldstein K. What Do the Elevated Protein Levels Mean in My Patients with Myeloma, Amyloidosis, and Related Disorders? Am J Med 2022; 135 Suppl 1:S24-S29. [PMID: 35081383 DOI: 10.1016/j.amjmed.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/14/2022] [Indexed: 11/26/2022]
Abstract
Multiple myeloma, light chain amyloidosis, and other plasma cell dyscrasias are characterized, in part, by abnormal production of paraproteins that are often responsible for the sequelae of those diseases. These paraproteins are whole or fragmented immunoglobulins produced by clonal antibody-secreting cells (usually plasma cells, but occasionally, B lymphocytes). Significant heterogeneity exists in the presentation of these diseases, ranging from incidental detection of a monoclonal protein in an asymptomatic patient, to life-threatening manifestations that require urgent diagnostic confirmation and intervention. Successful management of such scenarios requires a fundamental understanding of the laboratory assays at one's disposal, their role in the workup of paraproteinemias, and the interpretation thereof. This review broadly covers these assays and their roles in the diagnosis, prognosis, and management of these diseases.
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Affiliation(s)
- Scott R Goldsmith
- Division of Oncology, Washington University School of Medicine, St. Louis, Mo; The Judy and Bernard Briskin Center for Multiple Myeloma Research, City of Hope National Medical Center, Duarte, Calif.
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Gengenbach L, Graziani G, Reinhardt H, Rösner A, Braun M, Möller MD, Greil C, Wäsch R, Engelhardt M. Choosing the Right Therapy for Patients with Relapsed/Refractory Multiple Myeloma (RRMM) in Consideration of Patient-, Disease- and Treatment-Related Factors. Cancers (Basel) 2021; 13:4320. [PMID: 34503130 PMCID: PMC8430818 DOI: 10.3390/cancers13174320] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/13/2021] [Accepted: 08/24/2021] [Indexed: 02/02/2023] Open
Abstract
Treatment of relapsed/refractory multiple myeloma (RRMM) is more complex today due to the availability of novel therapeutic options, mostly applied as combination regimens. immunotherapy options have especially increased substantially, likewise the understanding that patient-, disease- and treatment-related factors should be considered at all stages of the disease. RRMM is based on definitions of the international myeloma working group (IMWG) and includes biochemical progression, such as paraprotein increase, or symptomatic relapse with CRAB criteria (hypercalcemia, renal impairment, anemia, bone lesions). When choosing RRMM-treatment, the biochemical markers for progression and severity of the disease, dynamic of disease relapse, type and number of prior therapy lines, including toxicity and underlying health status, need to be considered, and shared decision making should be pursued. Objectively characterizing health status via geriatric assessment (GA) at each multiple myeloma (MM) treatment decision point has been shown to be a better estimate than via age and comorbidities alone. The well-established national comprehensive cancer network, IMWG, European myeloma network and other national treatment algorithms consider these issues. Ideally, GA-based clinical trials should be supported in the future to choose wisely and efficaciously from available intervention and treatment options in often-older MM adults in order to further improve morbidity and mortality.
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Testing Mayo Clinic's New 20/20/20 Risk Model in Another Cohort of Smoldering Myeloma Patients: A Retrospective Study. ACTA ACUST UNITED AC 2021; 28:2029-2039. [PMID: 34073289 PMCID: PMC8161809 DOI: 10.3390/curroncol28030188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/20/2021] [Accepted: 05/21/2021] [Indexed: 11/22/2022]
Abstract
Background—smoldering multiple myeloma (SMM) risk of progression to multiple myeloma (MM) is highly heterogeneous and several models have been suggested to predict this risk. Lakshman et al. recently proposed a model based on three biomarkers: bone marrow plasma cell (BMPC) percentage > 20%, free light chain ratio (FLCr) > 20 and serum M protein > 20 g/L. The goal of our study was to test this “20/20/20” model in our population and to determine if similar results could be obtained in another cohort of SMM patients. Method—we conducted a retrospective, single center study with 89 patients diagnosed with SMM between January 2008 and December 2019. Results—all three tested biomarkers were associated with an increased risk of progression: BMPC percentage ≥ 20% (hazard ratio [HR]: 4.28 [95%C.I., 1.90–9.61]; p < 0.001), serum M protein ≥ 20 g/L (HR: 4.20 [95%C.I., 1.90–15.53]; p = 0.032) and FLCr ≥ 20 (HR: 3.25 [95%C.I., 1.09–9.71]; p = 0.035). The estimated median time to progression (TTP) was not reached for the low and intermediate risk groups and was 29.1 months (95%C.I., 3.9–54.4) in the high-risk group (p = 0.006). Conclusions—the 20/20/20 risk stratification model adequately predicted progression in our population and is easy to use in various clinical settings.
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Evaluation of Cardiac Repolarization in the Randomized Phase 2 Study of Intermediate- or High-Risk Smoldering Multiple Myeloma Patients Treated with Daratumumab Monotherapy. Adv Ther 2021; 38:1328-1341. [PMID: 33474705 PMCID: PMC7889563 DOI: 10.1007/s12325-020-01601-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/09/2020] [Indexed: 12/22/2022]
Abstract
Introduction Daratumumab is a CD38-targeting monoclonal antibody that has demonstrated clinical benefit for multiple myeloma. Daratumumab inhibition of CD38, which is expressed on immune cell populations and cardiomyocytes, could potentially affect cardiac function. This QTc substudy of the phase 2 CENTAURUS study investigated the potential effect of intravenous daratumumab monotherapy on QTc prolongation and other electrocardiogram (ECG) parameters, including concentration-QTc effect modeling. Methods Patients had intermediate- or high-risk smoldering multiple myeloma. Patients with QT interval corrected by Fridericia’s formula (QTcF) > 470 ms, QRS interval ≥ 110 ms, or PR interval ≥ 200 ms were excluded. Triplicate ECGs were collected at screening, Dose 1, and Dose 8. Analyses of on-treatment ECGs were conducted with a time-matched baseline (primary analysis). By time-point, pharmacokinetic-pharmacodynamic (PK/PD), and outlier analyses were conducted. Results Of 123 patients in CENTAURUS, 31 were enrolled in the QTc substudy. Daratumumab produced a small increase in heart rate (5–12 beats per minute) of unclear significance. There was a small but clinically insignificant effect on QTc, as measured by both time-matched time-point and PK/PD analyses. The primary analysis demonstrated a maximum mean increase in QTcF of 9.1 ms (90% 2-sided upper confidence interval [CI], 14.1 ms). The primary PK/PD analysis predicted a maximum QTcF increase of 8.5 ms (90% 2-sided upper CI, 13.5 ms). No patient had an abnormal U wave, a new QTcF > 500 ms, or > 60 ms change from baseline for QTcF. Conclusion Analysis of ECG intervals and concentration-QTc relationships showed a small but clinically insignificant effect of daratumumab. Trial Registration ClinicalTrials.gov Identifier: NCT02316106. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-020-01601-w.
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Abstract
Until recently, treatment for multiple myeloma was only initiated in symptomatic disease. Greater understanding of the underlying biology and the development of new biomarkers, however, has led to changes in diagnosis, and with the help of improved imaging techniques, clinicians are increasingly identifying patients with early myeloma who may benefit from treatment. One major development in diagnostic imaging is the replacement of radiography with CT. PET/CT imaging is also useful for treatment response assessment, because the disappearance of focal lesions is an important prognostic factor. Finally, the Revised International Staging System for multiple myeloma has incorporated additional prognostic markers of aggressive disease, and risk-adapted treatment has been shown to improve survival.
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9
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Maura F, Bolli N, Rustad EH, Hultcrantz M, Munshi N, Landgren O. Moving From Cancer Burden to Cancer Genomics for Smoldering Myeloma: A Review. JAMA Oncol 2020; 6:425-432. [PMID: 31830214 DOI: 10.1001/jamaoncol.2019.4659] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Importance All patients who develop multiple myeloma have a preceding asymptomatic expansion of clonal plasma cells, clinically recognized as monoclonal gammopathy of undetermined significance or smoldering multiple myeloma (SMM). During the past decade, significant progress has been made in the classification and risk stratification of SMM. Observations This review summarizes current clinical challenges and discusses available models for risk stratification in the context of SMM. Owing to several novel, more effective, and less toxic drugs, these aspects are becoming increasingly important to identify patients eligible for early treatment. However, all proposed criteria were built around indirect markers of disease burden and therefore are generally able to identify a fraction of patients with SMM in whom transformation to multiple myeloma and genomic subclonal diversification are already happening. In contrast, next-generation sequencing approaches have the potential to identify myeloma precursor disease that will progress even before the major clonal expansion and progression, providing a potential base for more effective treatment and better precision regarding the optimal timing of treatment initiation. Conclusions and Relevance Owing to modern technologies, in the near future, prognostic models derived from genomic signatures independent of the disease burden will allow better identification of the optimal timing to treat a plasma cell clonal disorder at the very early stages, when the chances of eradication are higher.
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Affiliation(s)
- Francesco Maura
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Cancer Genome Project, Wellcome Trust Sanger Institute, Cambridgeshire, United Kingdom
| | - Niccolò Bolli
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.,Department of Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Even H Rustad
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Malin Hultcrantz
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nikhil Munshi
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Veterans Administration Boston Healthcare System, West Roxbury, Massachusetts
| | - Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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Gonsalves WI, Jang JS, Jessen E, Hitosugi T, Evans LA, Jevremovic D, Pettersson XM, Bush AG, Gransee J, Anderson EI, Kumar SK, Nair KS. In vivo assessment of glutamine anaplerosis into the TCA cycle in human pre-malignant and malignant clonal plasma cells. Cancer Metab 2020; 8:29. [PMID: 33308307 PMCID: PMC7731537 DOI: 10.1186/s40170-020-00235-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 11/30/2020] [Indexed: 01/16/2023] Open
Abstract
Background Overexpression of c-Myc is required for the progression of pre-malignant plasma cells in monoclonal gammopathy of undetermined significance (MGUS) to malignant plasma cells in multiple myeloma (MM). c-Myc also increases glutamine anaplerosis into the tricarboxylic acid (TCA) cycle within cancer cells. Whether increased glutamine anaplerosis is associated with the progression of pre-malignant to malignant plasma cells is unknown. Methods Human volunteers (N = 7) and patients with MGUS (N = 11) and MM (N = 12) were prospectively recruited to undergo an intravenous infusion of 13C-labeled glutamine followed by a bone marrow aspiration to obtain bone marrow cells and plasma. Results Despite notable heterogeneity, stable isotope-resolved metabolomics (SIRM) revealed that the mean 13C-labeled glutamine anaplerosis into the TCA cycle was higher in malignant compared to pre-malignant bone marrow plasma cells relative to the remainder of their paired bone marrow mononuclear cells. RNA sequencing demonstrated a higher relative mRNA expression of c-Myc and glutamine transporters such as ASCT2 and SN2 in malignant compared to pre-malignant bone marrow plasma cells. Finally, higher quantitative levels of TCA cycle intermediates in the bone marrow plasma differentiated MM from MGUS patients. Conclusion Measurement of the in vivo activity of glutamine anaplerosis into the TCA cycle provides novel insight into the metabolic changes associated with the transformation of pre-malignant plasma cells in MGUS to malignant plasma cells in MM. Trial registration NCT03384108 and NCT03119883
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Affiliation(s)
- Wilson I Gonsalves
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Jin Sung Jang
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Erik Jessen
- Department of Health Service Research, Mayo Clinic, Rochester, MN, USA
| | - Taro Hitosugi
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | - Laura A Evans
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Dragan Jevremovic
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Jaimee Gransee
- Mayo Clinic Metabolomics Core, Mayo Clinic, Rochester, MN, USA
| | - Emilie I Anderson
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Shaji K Kumar
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Changing paradigms in diagnosis and treatment of monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM). Leukemia 2020; 34:3111-3125. [PMID: 33046818 DOI: 10.1038/s41375-020-01051-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/18/2020] [Accepted: 09/29/2020] [Indexed: 12/13/2022]
Abstract
Multiple myeloma (MM) is a highly heterogenous disease that exists along a continuous disease spectrum starting with premalignant conditions monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM) that inevitably precede MM. Over the past two decades, significant progress has been made in the genetic characterization and risk stratification of precursor plasma cell disorders. Indeed, the clinical introduction of highly effective and well-tolerated drugs begs the question: would earlier therapeutic intervention with novel therapies in MGUS and SMM patients alter natural history, providing a potential curative option? In this review, we discuss the epidemiology of MGUS and SMM and current models for risk stratification that predict MGUS and SMM progression to MM. We further discuss genetic heterogeneity and clonal evolution in MM and the interplay between tumor cells and the bone marrow (BM) microenvironment. Finally, we provide an overview of the current recommendations for the management of MGUS and SMM and discuss the open controversies in the field in light of promising results from early intervention clinical trials.
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Gavriatopoulou M, Βoultadaki A, Koutoulidis V, Ntanasis-Stathopoulos I, Bourgioti C, Malandrakis P, Fotiou D, Migkou M, Kanellias N, Eleutherakis-Papaiakovou E, Kastritis E, Terpos E, Dimopoulos MA, Moulopoulos LA. The Role of Low Dose Whole Body CT in the Detection of Progression of Patients with Smoldering Multiple Myeloma. Blood Cancer J 2020; 10:93. [PMID: 32978365 PMCID: PMC7519647 DOI: 10.1038/s41408-020-00360-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/11/2020] [Accepted: 09/07/2020] [Indexed: 12/27/2022] Open
Abstract
Multiple myeloma (MM) is the second most common hematological malignancy, characterized by plasma cell bone marrow infiltration and end-organ involvement. Smoldering MM (SMM) is an intermediate clinical entity between MGUS and MM, with a risk of progression to symptomatic disease 10% per year. Bone disease is the most frequent symptom of MM, with ~90% of patients developing bone lesions throughout their disease course. Therefore, imaging plays a crucial role in diagnosis and management. Whole-body low-dose CT (WBLDCT) is widely available and has been incorporated in the latest diagnostic criteria of the IMWG. The purpose of this study was to evaluate the role of WBLDCT in the early identification of lesions in patients with SMM who progress solely with bone disease. In total, 100 asymptomatic patients were consecutively assessed with WBLDCT from July 2013 until March 2020 at baseline, 1-year after diagnosis and every 1 year thereafter. Ten percent of patients were identified as progressors with this single imaging modality. This is the first study to evaluate prospectively patients with SMM at different time points to identify early bone lesions related to MM evolution. Serial WBLDCT studies can identify early myeloma evolution and optimize disease monitoring and therapeutic strategies.
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Affiliation(s)
- Maria Gavriatopoulou
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, School of Medicine, General Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Andriani Βoultadaki
- 1st Department of Radiology, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vassilis Koutoulidis
- 1st Department of Radiology, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Ntanasis-Stathopoulos
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, School of Medicine, General Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Charis Bourgioti
- 1st Department of Radiology, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Malandrakis
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, School of Medicine, General Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Despina Fotiou
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, School of Medicine, General Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Magdalini Migkou
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, School of Medicine, General Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Kanellias
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, School of Medicine, General Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Eleutherakis-Papaiakovou
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, School of Medicine, General Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Kastritis
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, School of Medicine, General Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Terpos
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, School of Medicine, General Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Meletios A Dimopoulos
- Plasma Cell Dyscrasias Unit, Department of Clinical Therapeutics, School of Medicine, General Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Lia-Angela Moulopoulos
- 1st Department of Radiology, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
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13
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Landgren CO, Chari A, Cohen YC, Spencer A, Voorhees P, Estell JA, Sandhu I, Jenner MW, Williams C, Cavo M, van de Donk NWCJ, Beksac M, Moreau P, Goldschmidt H, Kuppens S, Bandekar R, Clemens PL, Neff T, Heuck C, Qi M, Hofmeister CC. Daratumumab monotherapy for patients with intermediate-risk or high-risk smoldering multiple myeloma: a randomized, open-label, multicenter, phase 2 study (CENTAURUS). Leukemia 2020; 34:1840-1852. [PMID: 32024950 PMCID: PMC7326703 DOI: 10.1038/s41375-020-0718-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 12/05/2019] [Accepted: 01/15/2020] [Indexed: 01/03/2023]
Abstract
Current guidelines for smoldering multiple myeloma (SMM) recommend active monitoring until the onset of multiple myeloma (MM) before initiating treatment or enrollment in a clinical trial. Earlier intervention may delay progression to MM. In CENTAURUS, 123 patients with intermediate-risk or high-risk SMM were randomly assigned to daratumumab 16 mg/kg intravenously on extended intense (intense), extended intermediate (intermediate), or short dosing schedules. At the prespecified primary analysis (15.8-month median follow-up), the complete response (CR) rates (co-primary endpoint) were 2.4%, 4.9%, and 0% for intense, intermediate, and short dosing, respectively; the co-primary endpoint of CR rate >15% was not met. Progressive disease (PD)/death rates (number of patients who progressed or died divided by total duration of progression-free survival [PFS] in patient-years; co-primary endpoint) for intense, intermediate, and short dosing were 0.055 (80% confidence interval [CI], 0.014-0.096), 0.102 (80% CI, 0.044-0.160), and 0.206 (80% CI, 0.118-0.295), respectively, translating to a median PFS ≥24 months in all arms (P < 0.0001, <0.0001, and =0.0213, respectively). With longer follow-up (median follow-up, 25.9 months), CR rates were 4.9%, 9.8%, and 0% for intense, intermediate, and short dosing, respectively. PD/death rates for intense, intermediate, and short dosing were 0.059 (80% CI, 0.025-0.092), 0.107 (80% CI, 0.058-0.155), and 0.150 (80% CI, 0.089-0.211), respectively, again translating to a median PFS ≥ 24 months in all arms (P < 0.0001 for all arms). Twenty-four-month PFS rates were 89.9% (90% CI, 78.5-95.4%), 82.0% (90% CI, 69.0-89.9%), and 75.3% (90% CI, 61.1-85.0%) for intense, intermediate, and short dosing, respectively. Pharmacokinetic analyses indicated that intense dosing maintained target-saturating trough concentrations in most patients throughout weekly, every-2-week, and every-4-week dosing periods. No new safety signals were observed. These data provide the basis for an ongoing phase 3 study of daratumumab in SMM.
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Affiliation(s)
- C Ola Landgren
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Ajai Chari
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yael C Cohen
- Department of Hematology, Tel-Aviv Sourasky (Ichilov) Medical Center, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Andrew Spencer
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Health-Monash University, Melbourne, VIC, Australia
| | - Peter Voorhees
- Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | - Jane A Estell
- Haematology Department, Concord Cancer Centre, Concord Hospital, University of Sydney, Concord, NSW, Australia
| | - Irwindeep Sandhu
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | | | - Catherine Williams
- Department of Clinical Haematology, Nottingham University Hospitals, Nottinghamshire, UK
| | - Michele Cavo
- Department of Experimental, Diagnostic and Specialty Medicine, "Seràgnoli" Institute of Hematology, University of Bologna, Bologna, Italy
| | | | - Meral Beksac
- Department of Hematology, Ankara University, Ankara, Turkey
| | | | - Hartmut Goldschmidt
- University Hospital Heidelberg and National Center of Tumor Diseases (NCT), Heidelberg, Germany
| | | | | | | | - Tobias Neff
- Janssen Research & Development, LLC, Spring House, PA, USA
| | | | - Ming Qi
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - Craig C Hofmeister
- Department of Hematology & Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA.
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14
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Graziani G, Herget GW, Ihorst G, Zeissig M, Chaidos A, Auner HW, Duyster J, Wäsch R, Engelhardt M. Time from first symptom onset to the final diagnosis of multiple myeloma (MM) - possible risks and future solutions: retrospective and prospective 'Deutsche Studiengruppe MM' (DSMM) and 'European Myeloma Network' (EMN) analysis .. Leuk Lymphoma 2020; 61:875-886. [PMID: 31779510 DOI: 10.1080/10428194.2019.1695051] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/30/2019] [Accepted: 11/06/2019] [Indexed: 01/10/2023]
Abstract
Multiple myeloma (MM) often presents with unspecific symptoms and is challenging to diagnose. We performed this DSMM/EMN-analysis via test-(retro-) and validation (prospective) study to determine the time interval from the onset of first symptoms to the diagnosis of MM. The retrospective and prospective analyses were performed in 101 and 176 patients, respectively. The median time from first symptoms to the MM diagnosis in both cohorts was 4 and 6 months, respectively. Frequencies of MM-related pathologic bone fractures, renal, and infectious complications at diagnosis occurred in 41%, 35%, and 16% of patients, respectively. Our MM-questionnaire determined that 39% of patients were dissatisfied with the diagnostic process. PFS and OS proved insignificantly different with shorter (≤6) and longer (>6 months) latency periods. In conclusion, our in depth studies demonstrate that delays in diagnosis do not decrease PFS or OS, but induce MM-related complications and influence patients' satisfaction with their medical care.
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Affiliation(s)
- Giulia Graziani
- Department of Medicine, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Georg W Herget
- Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mara Zeissig
- Myeloma Research Laboratory, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | | | - Holger W Auner
- Centre for Hematology, Imperial College London, London, UK
| | - Justus Duyster
- Department of Medicine, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Department of Medicine, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Monika Engelhardt
- Department of Medicine, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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15
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Abstract
Smoldering multiple myeloma (SMM) is an asymptomatic, intermediate stage positioned between the plasma cell disorders of monoclonal gammopathy of undermined significance and overt multiple myeloma (MM). Although the patients with SMM have a higher risk of progression to MM in comparison to their counterparts with monoclonal gammopathy of undermined significance, their clinical course can be highly variable. The standard of care for SMM, irrespective of the risk status, continues to be observation due to paucity of high-level evidence demonstrating survival or quality-of-life benefit with early intervention. With the expanded 2014 criteria for MM utilizing biomarkers, the subset of SMM patients with 70% to 80% risk of progression at 2 years (ultra-high risk SMM) is now categorized as active MM and treated prior to the development of end-organ damage. After exclusion of this group, patients with approximately 50% risk of progression in 2 years are now considered high-risk SMM, and the value of early treatment in this subset can be established only through clinical trials. Despite its limitations, a recent phase III trial (QuiRedex) has shown survival advantage to using lenalidomide and dexamethasone doublet over observation in high-risk SMM. In this article, we review the evolving concepts in the diagnosis, risk stratification, and management of SMM.
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16
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Therapeutic Advances in the Management of Smoldering Myeloma. Am J Ther 2019; 27:e194-e203. [PMID: 31842112 DOI: 10.1097/mjt.0000000000001034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The International Myeloma Working Group has defined smoldering multiple myeloma (SMM) as the presence of 10%-60% plasma cells in the bone marrow and M-protein (IgG, IgA) ≥3 g/dL without end-organ damage (an increased calcium level, renal failure, anemia, and destructive bone lesions). AREAS OF UNCERTAINTY Patients considered to have SMM should not have any myeloma-defining events or amyloidosis. Different risks factors classify SMM into low-, intermediate-, or high-risk categories. The rate of progression from SMM to symptomatic myeloma is ∼10% per year during the first 5 years of diagnosis. SMM requires frequent follow-up ∼every 3 months during the first 5 years as compared to monoclonal gammopathy of undermined significance, which usually requires follow-up every 6-12 months after the first year of diagnosis. DATA SOURCES A literature search was performed from electronic bibliographic databases: MEDLINE (Ovid SP/PubMed), EMBASE, the Cochrane Library (Cochrane Database of Systematic Reviews), and Cochrane Central Register of Controlled Trials and from annual meeting abstracts from inception to May 2017. THERAPEUTIC ADVANCES This review presents the literature and available data that support or do not support early treatment of high-risk SMM (HR-SMM) and provides evidence-based recommendations for management of SMM patients. Despite emerging data recommending early treatment of HR-SMM, we predict the SMM category may disappear in the near future and patients will be diagnosed with either multiple myeloma or monoclonal gammopathy of undermined significance. CONCLUSIONS Success with early therapy trials for HR-SMM is largely due to patients meeting current criteria for multiple myeloma that may have been classified as SMM and, therefore, benefitted from therapy. Based on current practices and the literature, SMM should be managed with close follow-up. Based on available data, we suggest SMM to only be treated in clinical trial settings.
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17
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Manasanch EE, Han G, Mathur R, Qing Y, Zhang Z, Lee H, Weber DM, Amini B, Berkova Z, Eterovic K, Zhang S, Zhang J, Song X, Mao X, Morgan M, Feng L, Baladandayuthapani V, Futreal A, Wang L, Neelapu SS, Orlowski RZ. A pilot study of pembrolizumab in smoldering myeloma: report of the clinical, immune, and genomic analysis. Blood Adv 2019; 3:2400-2408. [PMID: 31405950 PMCID: PMC6693011 DOI: 10.1182/bloodadvances.2019000300] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/01/2019] [Indexed: 12/22/2022] Open
Abstract
Multiple myeloma is, in most patients, an incurable cancer. Its precursors can be identified with routine tests setting the stage for early intervention to prevent active myeloma. We investigated the efficacy and safety of pembrolizumab, an antiprogrammed cell death 1 antibody, in smoldering myeloma patients with intermediate/high risk of progression to symptomatic myeloma. Thirteen patients were treated with a median number of 8 cycles. One patient achieved a stringent complete response with bone marrow next-generation sequencing negativity at 10-4 that is ongoing at 27 months (8%); 11 had stable disease (85%), and 1 progressed (8%). Three patients discontinued therapy due to immune-related adverse events: 2 with transaminitis and 1 due to tubulointerstitial nephritis. Immune profiling of bone marrow samples at baseline showed markers associated with a preexisting immune response in the responder compared with nonresponders and features of increased T-cell exhaustion in nonresponders. Consistent with this, transcriptome sequencing of bone marrow samples at baseline revealed an increased interferon-γ signature in the responder compared with the nonresponders. In summary, our results suggest that smoldering myeloma may be immunogenic in a subset of patients, and therapies that enhance antitumor T-cell responses may be effective in preventing its progression. This trial was registered at www.clinicaltrials.gov as #NCT02603887.
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Affiliation(s)
| | | | | | | | | | | | | | - Behrang Amini
- Department of Diagnostic Radiology, Division of Diagnostic Imaging
| | | | | | | | | | | | | | | | | | | | | | | | | | - Robert Z Orlowski
- Department of Lymphoma/Myeloma
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX
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18
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Cocito F, Mangiacavalli S, Ferretti VV, Cartia CS, Ganzetti M, Benveuti P, Pompa A, Catalano M, Fugazza E, Landini B, Arcaini L, Corso A. Smoldering multiple myeloma: the role of different scoring systems in identifying high-risk patients in real-life practice. Leuk Lymphoma 2019; 60:2968-2974. [PMID: 31169049 DOI: 10.1080/10428194.2019.1620948] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We explore the predictive role of 2014-updated International Myeloma Working Group (IMWG) diagnostic criteria and of some of currently available risk models for progression to symptomatic myeloma when applied in our unselected population of 75 smoldering multiple myeloma (SMM) patients observed between 2000 and 2015. Risk scores including routinely used clinical parameters such as bone marrow plasmacell infiltration rate, immunoparesis, serum monoclonal component (sMC) value, and altered free light chain ratio (FLCr), were clinically useful to identify SMM patients at higher risk of progression. Time to myeloma progression in our ultra-high risk SMM according to IMWG diagnostic update criteria was very short (12.4 months). Our analysis identified as independent reliable predictors of progression altered FLCr as well as increasing plasma cell infiltration which are part of most commonly applied risk models. Waiting for new scoring systems, bone marrow evaluation and complete laboratory screening are still milestones for SMM management.
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Affiliation(s)
- Federica Cocito
- Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Virginia Valeria Ferretti
- Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,University of Pavia, Pavia, Italy
| | | | - Maya Ganzetti
- Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,University of Pavia, Pavia, Italy
| | - Pietro Benveuti
- Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,University of Pavia, Pavia, Italy
| | - Alessandra Pompa
- Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore di Milano Policlinico, Milano, Italy
| | | | - Elena Fugazza
- Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Luca Arcaini
- Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,University of Pavia, Pavia, Italy
| | - Alessandro Corso
- Ospedale Nuovo di Legnano, Division of Hematology, Legnano, Italy
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19
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Gonsalves WI, Ramakrishnan V, Hitosugi T, Ghosh T, Jevremovic D, Dutta T, Sakrikar D, Petterson XM, Wellik L, Kumar SK, Nair KS. Glutamine-derived 2-hydroxyglutarate is associated with disease progression in plasma cell malignancies. JCI Insight 2018; 3:94543. [PMID: 29321378 DOI: 10.1172/jci.insight.94543] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 11/30/2017] [Indexed: 12/13/2022] Open
Abstract
The production of the oncometabolite 2-hydroxyglutarate (2-HG) has been associated with c-MYC overexpression. c-MYC also regulates glutamine metabolism and drives progression of asymptomatic precursor plasma cell (PC) malignancies to symptomatic multiple myeloma (MM). However, the presence of 2-HG and its clinical significance in PC malignancies is unknown. By performing 13C stable isotope resolved metabolomics (SIRM) using U[13C6]Glucose and U[13C5]Glutamine in human myeloma cell lines (HMCLs), we show that 2-HG is produced in clonal PCs and is derived predominantly from glutamine anaplerosis into the TCA cycle. Furthermore, the 13C SIRM studies in HMCLs also demonstrate that glutamine is preferentially utilized by the TCA cycle compared with glucose. Finally, measuring the levels of 2-HG in the BM supernatant and peripheral blood plasma from patients with precursor PC malignancies such as smoldering MM (SMM) demonstrates that relatively elevated levels of 2-HG are associated with higher levels of c-MYC expression in the BM clonal PCs and with a subsequent shorter time to progression (TTP) to MM. Thus, measuring 2-HG levels in BM supernatant or peripheral blood plasma of SMM patients offers potential early identification of those patients at high risk of progression to MM, who could benefit from early therapeutic intervention.
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Affiliation(s)
| | | | | | - Toshi Ghosh
- Department of Laboratory Medicine and Pathology
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20
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Genzen JR, Murray DL, Abel G, Meng QH, Baltaro RJ, Rhoads DD, Delgado JC, Souers RJ, Bashleben C, Keren DF, Ansari MQ. Screening and Diagnosis of Monoclonal Gammopathies: An International Survey of Laboratory Practice. Arch Pathol Lab Med 2017; 142:507-515. [DOI: 10.5858/arpa.2017-0128-cp] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Serum tests used for the screening and diagnosis of monoclonal gammopathies include serum protein electrophoresis (SPE; agarose gel or capillary zone), immunofixation (IFE) and immunosubtraction capillary electrophoresis, serum free light chains, quantitative immunoglobulins, and heavy/light–chain combinations. Urine protein electrophoresis and urine IFE may also be used to identify Bence-Jones proteinuria.
Objective.—
To assess current laboratory practice for monoclonal gammopathy testing.
Design.—
In April 2016, a voluntary questionnaire was distributed to 923 laboratories participating in a protein electrophoresis proficiency testing survey.
Results.—
Seven hundred seventy-four laboratories from 38 countries and regions completed the questionnaire (83.9% response rate; 774 of 923). The majority of participants (68.6%; 520 of 758) used agarose gel electrophoresis as their SPE method, whereas 31.4% (238 of 758) used capillary zone electrophoresis. The most common test approaches used in screening were SPE with reflex to IFE/immunosubtraction capillary electrophoresis (39.3%; 299 of 760); SPE only (19.1%; 145 of 760); SPE and IFE or immunosubtraction capillary electrophoresis (13.9%; 106 of 760); and SPE with IFE, serum free light chain, and quantitative immunoglobulins (11.8%; 90 of 760). Only 39.8% (305 of 767) of laboratories offered panel testing for ordering convenience. Although SPE was used by most laboratories in diagnosing new cases of myeloma, when laboratories reported the primary test used to follow patients with monoclonal gammopathy, only 55.7% (403 of 724) chose SPE, with the next most common selections being IFE (18.9%; 137 of 724), serum free light chain (11.7%; 85 of 724), and immunosubtraction capillary electrophoresis (2.1%; 15 of 724).
Conclusions.—
Ordering and testing practices for the screening and diagnosis of monoclonal gammopathy vary widely across laboratories. Improving utilization management and report content, as well as recognition and development of laboratory-directed testing guidelines, may serve to enhance the clinical value of testing.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Mohammad Q. Ansari
- From the Department of Pathology, University of Utah, Salt Lake City, and ARUP Laboratories, Salt Lake City, Utah (Drs Genzen and Delgado); the Department of Laboratory Medicine, Mayo Clinic, Rochester, Minnesota (Dr Murray); the Department of Laboratory Medicine, Lahey Hospital & Medical Center, Burlington, Massachusetts (Dr Abel); the Department of Laboratory Medicine, University of Texas MD An
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21
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Landgren O. Shall we treat smoldering multiple myeloma in the near future? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:194-204. [PMID: 29222256 PMCID: PMC6142564 DOI: 10.1182/asheducation-2017.1.194] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
In recent years, several new drugs have been approved for the treatment of multiple myeloma. Many of these newer drugs are highly efficacious and less toxic than older chemotherapy drugs. In 2014, the diagnostic criteria for multiple myeloma were revised. The intent with the new criteria was to identify patients who require therapy at an earlier stage than at manifestation of organ complications. A subset of patients who were previously defined as having high-risk smoldering multiple myeloma was redefined as having multiple myeloma. In this context, it is logical to raise questions regarding the optimal clinical management of patients who are diagnosed with smoldering multiple myeloma in the current era. When is the optimal time to start therapy? Do the clinical trajectories for patients suggest there are distinct sub-entities hidden in the current category of smoldering multiple myeloma? How can we move the field forward from here? This paper reviews and dissects data and models on the topics of clinical features, underlying biology, and early treatment trials in smoldering multiple myeloma. The text highlights assumptions, facts, and gaps in the literature. As indicated in the title of the paper, the recurrent theme of the text is this: shall we treat smoldering multiple myeloma in the near future?
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Affiliation(s)
- Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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22
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Greil C, Ihorst G, Gaiser F, Salzer U, Bisse E, Kastritis E, Ludwig H, Wäsch R, Engelhardt M. The serum heavy/light chain immunoassay: A valuable tool for sensitive paraprotein assessment, risk, and disease monitoring in monoclonal gammopathies. Eur J Haematol 2017; 99:449-458. [PMID: 28886228 DOI: 10.1111/ejh.12958] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The heavy/light chain (HLC)-immunoassay quantifies light chain types of each immunoglobulin class in patients with monoclonal gammopathies. METHODS We assessed 147 consecutive patients with different forms and stages of plasma cell dyscrasias (PCD) who received standard tests (serum and urine protein electrophoresis [SPEP, UPEP], immunofixation [IFE], serum-free light chain [SFLC]), and HLC-immunoassay. Patients with multiple myeloma (MM, n = 102), smoldering MM (SMM, n = 5), monoclonal gammopathy of undetermined significance (MGUS, n = 28), and Waldenström's macroglobulinemia (WM, n = 12) were included. RESULTS We verified a significant correlation between HLC- and standard monoclonal protein (mp)-parameters, and HLC-increases with higher disease stage and unfavorable remission status. In patients with difficult to quantify mp, more abnormal HLC- than SPEP-, immunoglobulin-, or SFLC-results were found. In WM, a pathological HLC κ/λ-ratio and M-component were observed in 95% and 58%, respectively. In 21/28 MGUS and 5/5 SMM patients, HLC κ/λ-ratios were abnormal. Testing different HLC cutoffs, patients with extreme HLC values showed impaired progression-free survival (PFS). CONCLUSIONS Despite the fact that different PCD patients were included, the assessment of the HLC-immunoassay in MGUS, SMM, MM, and WM, our comparison with standard mp-assays, and relevant PFS differences may excite future applications, which should be confirmed in prospective multicenter trials.
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Affiliation(s)
- Christine Greil
- Department of Medicine I, Hematology, Oncology & Stem Cell Transplantation, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Faculty of Medicine, Clinical Trials Unit, University of Freiburg, Freiburg, Germany
| | - Felix Gaiser
- Department of Medicine I, Hematology, Oncology & Stem Cell Transplantation, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Ulrich Salzer
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Emanuel Bisse
- Central Laboratory, Medical Center, University of Freiburg, Freiburg, Germany
| | | | - Heinz Ludwig
- Zentrum für Onkologie, Wihelminenkrebsforschungsinstitut, Beethovengasse, Österreich
| | - Ralph Wäsch
- Department of Medicine I, Hematology, Oncology & Stem Cell Transplantation, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Monika Engelhardt
- Department of Medicine I, Hematology, Oncology & Stem Cell Transplantation, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
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23
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Muchtar E, Kumar SK, Magen H, Gertz MA. Diagnosis and management of smoldering multiple myeloma: the razor's edge between clonality and cancer. Leuk Lymphoma 2017; 59:288-299. [PMID: 28592156 DOI: 10.1080/10428194.2017.1334124] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Smoldering multiple myeloma (SMM) is a rare plasma cell disorder, and as the disease is asymptomatic, diagnosis is often incidental. SMM is characterized by increased marrow infiltration by clonal plasma cells and/or elevated serum M-protein in the absence of a myeloma-defining event (MDE). In recent years, SMM has gained increased attention owing to a broadening of the criteria for MDE, which include apart from the CRAB criteria, three additional parameters. Survival advantage may be offered by early treatment in the high-risk subset, based on a single trial. In this review, we assess the risk factors and models for progression to multiple myeloma. A review of our diagnostic and management approaches to SMM is presented.
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Affiliation(s)
- Eli Muchtar
- a Division of Hematology , Mayo Clinic , Rochester , MN , USA
| | - Shaji K Kumar
- a Division of Hematology , Mayo Clinic , Rochester , MN , USA
| | - Hila Magen
- b Institute of Hematology, Davidoff cancer center, Beilinson Hospital, Rabin Medical Center, Petah-Tikva and Sackler School of Medicine , Tel-Aviv University , Tel-Aviv , Israel
| | - Morie A Gertz
- a Division of Hematology , Mayo Clinic , Rochester , MN , USA
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24
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Challenges and Promises of Genetic Stratification of Risk in Multiple Myeloma. Indian J Hematol Blood Transfus 2017; 33:1-2. [DOI: 10.1007/s12288-017-0778-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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25
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de Mel S, Chen Y, Gopalakrishnan SK, Ooi M, Teo C, Tan D, Teo MLC, Tso ACY, Lee LK, Nagarajan C, Goh YT, Chng WJ. The Singapore Myeloma Study Group Consensus Guidelines for the management of patients with multiple myeloma. Singapore Med J 2017; 58:55-71. [PMID: 27609508 PMCID: PMC5311886 DOI: 10.11622/smedj.2016150] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Multiple myeloma (MM) is an incurable plasma cell neoplasm with an incidence of 100 patients per year in Singapore. Major advances have been made in the diagnosis, risk stratification and treatment of MM in the recent past. The reclassification of a subset of patients with smouldering MM, based on high-risk biomarkers, and the development of the revised international staging system are among the key new developments in diagnosis and staging. The use of novel agent-based treatment has resulted in significant improvements in the survival and quality of life of many patients with MM. Determining the optimal use of proteasome inhibitors, immunomodulators and, more recently, monoclonal antibodies is an area of ongoing investigation. In this guideline, we aim to provide an overview of the management of MM, incorporating the latest developments in diagnosis and treatment.
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Affiliation(s)
- Sanjay de Mel
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore
| | - Yunxin Chen
- Department of Haematology, Singapore General Hospital, Singapore
| | | | - Melissa Ooi
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore
| | - Constance Teo
- Division of Oncology Pharmacy, National University Cancer Institute, National University Health System, Singapore
| | - Daryl Tan
- Raffles Cancer Centre, Raffles Hospital, Singapore
| | | | - Allison CY Tso
- Department of Haematology, Tan Tock Seng Hospital, Singapore
| | - Lian King Lee
- Department of Haematology, Tan Tock Seng Hospital, Singapore
| | | | - Yeow Tee Goh
- Department of Haematology, Singapore General Hospital, Singapore
| | - Wee Joo Chng
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore
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27
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Hong J, Lee JH. Recent advances in multiple myeloma: a Korean perspective. Korean J Intern Med 2016; 31:820-34. [PMID: 27604794 PMCID: PMC5016289 DOI: 10.3904/kjim.2015.408] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 08/22/2016] [Indexed: 12/22/2022] Open
Abstract
Epidemiologically, multiple myeloma (MM) is a malignant disorder of plasma cells with a higher incidence among Western populations than among Asians. However, there is growing evidence of a recent increase in the age-standardized incidence rate (ASR) of MM in Asian countries, particularly Korea. Application of novel agents has resulted in significant improvement of treatment outcomes, and the advances are ongoing with the recent introduction and U.S. Food and Drug Administration's approval of newer agents, including carfilzomib, ixazomib, elotuzumab, and daratumumab. In concert with the technical advances in the cytogenetic and molecular diagnostics of MM, modifications of its diagnosis and staging system have been attempted for better risk stratification. The modified diagnostic criteria from the International Myeloma Working Group in 2014 enabled a strategy of more active treatment for some patients with smoldering MM, with an ultra-high risk of progression, and fine-tuned the definition of end-organ damage, known as CRAB (hypercalcemia, renal insufficiency, anemia, and bone lesions). Considering Korea's trend of aging at an unprecedented rate, we can expect that the ASR of MM will maintain a gradual increase for many years to come; therefore, MM will be a cancer of critical importance from both medical and socioeconomic perspectives in Korea.
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Affiliation(s)
| | - Jae Hoon Lee
- Correspondence to Jae Hoon Lee, M.D. Department of Internal Medicine, Gachon University Gil Medical Center, 21 Namdong-daero 774beon-gil, Namdong-gu, Incheon 21565, Korea Tel: +82-32-460-2186 Fax: +82-32-460-3233 E-mail:
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28
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Ludwig H. Early treatment for high-risk smouldering myeloma: has the time come? Lancet Oncol 2016; 17:1030-1032. [PMID: 27402144 DOI: 10.1016/s1470-2045(16)30151-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 05/05/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Heinz Ludwig
- Wilhelminen Cancer Research Institute, Wilheminenspital, Vienna 1171, Austria.
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Lust JA, Lacy MQ, Zeldenrust SR, Witzig TE, Moon-Tasson LL, Dinarello CA, Donovan KA. Reduction in C-reactive protein indicates successful targeting of the IL-1/IL-6 axis resulting in improved survival in early stage multiple myeloma. Am J Hematol 2016; 91:571-4. [PMID: 26945843 DOI: 10.1002/ajh.24352] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/02/2016] [Indexed: 11/08/2022]
Abstract
We report the long-term follow-up results of a phase II trial of IL-1 receptor antagonist and low-dose dexamethasone for early stage multiple myeloma (MM). Patients were eligible if they had smoldering multiple myeloma (SMM) or indolent multiple myeloma (IMM) without the need for immediate therapy. Forty seven patients were enrolled and subsequently treated with IL-1Ra; in 25/47 low-dose dexamethasone (20 mg weekly) was added. The primary endpoint was progression-free survival (PFS). In the clinical trial, three patients achieved a minor response (MR) to IL-1Ra alone; five patients a partial response (PR) and four patients an MR after addition of dexamethasone. Seven patients showed a decrease in the plasma cell labeling index (PCLI) which paralleled a decrease in the high sensitivity C-reactive protein (hs-CRP). The median PFS for the 47 patients was 1116 days (37.2 months). The median PFS for patients without (n = 22) and with (n = 25) a decrease in their baseline hs-CRP was 326 days (11 months) vs. 3139 days (104 months) respectively (P <0.0001). The median overall survival (OS) for the 47 patients was 3482 days (9.5 years). The median OS for patients without and with a decrease in their baseline hs-CRP was 2885 days (7.9 years) vs. median not reached, respectively (P = 0.001). In SMM/IMM patients at risk for progression to active myeloma, reduction in the hs-CRP indicates successful targeting of the IL-1/IL-6 axis resulting in improved PFS and OS. (Clinical Trials.gov Identifier: NCT00635154) Am. J. Hematol. 91:571-574, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- John A. Lust
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | - Martha Q. Lacy
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | | | | | | | - Charles A. Dinarello
- Department of Medicine; University of Colorado; 12700 East 19 Ave, B168 Aurora Colorado 80045
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Hillengass J, Ritsch J, Merz M, Wagner B, Kunz C, Hielscher T, Laue H, Bäuerle T, Zechmann CM, Ho AD, Schlemmer HP, Goldschmidt H, Moehler TM, Delorme S. Increased microcirculation detected by dynamic contrast-enhanced magnetic resonance imaging is of prognostic significance in asymptomatic myeloma. Br J Haematol 2016; 174:127-35. [PMID: 26991959 DOI: 10.1111/bjh.14038] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 01/15/2016] [Indexed: 02/06/2023]
Abstract
This prospective study aimed to investigate the prognostic significance of dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) as a non-invasive imaging technique delivering the quantitative parameters amplitude A (reflecting blood volume) and exchange rate constant kep (reflecting vascular permeability) in patients with asymptomatic monoclonal plasma cell diseases. We analysed DCE-MRI parameters in 33 healthy controls and 148 patients with monoclonal gammopathy of undetermined significance (MGUS) or smouldering multiple myeloma (SMM) according to the 2003 IMWG guidelines. All individuals underwent standardized DCE-MRI of the lumbar spine. Regions of interest were drawn manually on T1-weighted images encompassing the bone marrow of each of the 5 lumbar vertebrae sparing the vertebral vessel. Prognostic significance for median of amplitude A (univariate: P < 0·001, hazard ratio (HR) 2·42, multivariate P = 0·02, HR 2·7) and exchange rate constant kep (univariate P = 0·03, HR 1·92, multivariate P = 0·46, HR 1·5) for time to progression of 79 patients with SMM was found. Patients with amplitude A above the optimal cut-off point of 0·89 arbitrary units had a 2-year progression rate into symptomatic disease of 80%. In conclusion, DCE-MRI parameters are of prognostic significance for time to progression in patients with SMM but not in individuals with MGUS.
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Affiliation(s)
- Jens Hillengass
- Department of Haematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany.,Department of Radiology, German Cancer Research Centre, Heidelberg, Germany
| | - Judith Ritsch
- Department of Radiology, German Cancer Research Centre, Heidelberg, Germany
| | - Maximilian Merz
- Department of Haematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany.,Department of Radiology, German Cancer Research Centre, Heidelberg, Germany
| | - Barbara Wagner
- Department of Haematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Christina Kunz
- Department of Biostatistics, German Cancer Research Centre, Heidelberg, Germany
| | - Thomas Hielscher
- Department of Biostatistics, German Cancer Research Centre, Heidelberg, Germany
| | - Hendrik Laue
- Fraunhofer Institute for Medical Image Computing MEVIS, Bremen, Germany
| | - Tobias Bäuerle
- Institute of Radiology, University Medical Centre Erlangen, Erlangen, Germany
| | | | - Anthony D Ho
- Department of Haematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | | | - Hartmut Goldschmidt
- Department of Haematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany.,National Centre for Tumor Diseases, Heidelberg, Germany
| | | | - Stefan Delorme
- Department of Radiology, German Cancer Research Centre, Heidelberg, Germany
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Caers J, Fernández de Larrea C, Leleu X, Heusschen R, Zojer N, Decaux O, Kastritis E, Minnema M, Jurczyszyn A, Beguin Y, Wäsch R, Palumbo A, Dimopoulos M, Mateos MV, Ludwig H, Engelhardt M. The Changing Landscape of Smoldering Multiple Myeloma: A European Perspective. Oncologist 2016; 21:333-42. [PMID: 26921288 DOI: 10.1634/theoncologist.2015-0303] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 12/04/2015] [Indexed: 11/17/2022] Open
Abstract
Smoldering multiple myeloma (SMM) is an asymptomatic clonal plasma cell disorder and bridges monoclonal gammopathy of undetermined significance to multiple myeloma (MM), based on higher levels of circulating monoclonal immunoglobulin and bone marrow plasmocytosis without end-organ damage. Until a Spanish study reported fewer MM-related events and better overall survival among patients with high-risk SMM treated with lenalidomide and dexamethasone, prior studies had failed to show improved survival with earlier intervention, although a reduction in skeletal-related events (without any impact on disease progression) has been described with bisphosphonate use. Risk factors have now been defined, and a subset of ultra-high-risk patients have been reclassified by the International Myeloma Working Group as MM, and thus will require optimal MM treatment, based on biomarkers that identify patients with a >80% risk of progression. The number of these redefined patients is small (∼10%), but important to unravel, because their risk of progression to overt MM is substantial (≥80% within 2 years). Patients with a high-risk cytogenetic profile are not yet considered for early treatment, because groups are heterogeneous and risk factors other than cytogenetics are deemed to weight higher. Because patients with ultra-high-risk SMM are now considered as MM and may be treated as such, concerns exist that earlier therapy may increase the risk of selecting resistant clones and induce side effects and costs. Therefore, an even more accurate identification of patients who would benefit from interventions needs to be performed, and clinical judgment and careful discussion of pros and cons of treatment initiation need to be undertaken. For the majority of SMM patients, the standard of care remains observation until development of symptomatic MM occurs, encouraging participation in ongoing and upcoming SMM/early MM clinical trials, as well as consideration of bisphosphonate use in patients with early bone loss.
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Affiliation(s)
- Jo Caers
- Department of Hematology, University Hospital of Liège, Liège, Belgium
| | - Carlos Fernández de Larrea
- Amyloidosis and Myeloma Unit, Department of Hematology, Hospital Clínic and Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Xavier Leleu
- Hopital La Miletrie, CHU Poitiers, Poitiers, France
| | - Roy Heusschen
- Hematology Laboratory, Groupe Interdisciplinaire de Génoprotéomique Appliquée-I3, University of Liège, Liège, Belgium
| | - Niklas Zojer
- Department of Medicine I, Wilhelminen Hospital, Vienna, Austria
| | - Olivier Decaux
- Internal Medicine Department, Rennes University Hospitals, Hôpital Sud, Rennes, France
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Monique Minnema
- Department of Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Artur Jurczyszyn
- Department of Hematology Jagiellonian University, Cracow, Poland
| | - Yves Beguin
- Department of Hematology, University Hospital of Liège, Liège, Belgium
| | - Ralph Wäsch
- Department of Hematology and Oncology, University of Freiburg Medical Center, Freiburg, Germany
| | - Antonio Palumbo
- Myeloma Unit, Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliero-Universitaria Citta della Salute e della Scienza di Torino, Italy
| | - Meletios Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Maria Victoria Mateos
- Instituto de Investigación Biomédica de Salamanca-Hematology, Hospital Universitario de Salamanca, Salamanca, Spain
| | - Heinz Ludwig
- Department of Medicine I, Wilhelminen Hospital, Vienna, Austria
| | - Monika Engelhardt
- Department of Hematology and Oncology, University of Freiburg Medical Center, Freiburg, Germany
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Manier S, Salem KZ, Liu D, Ghobrial IM. Future Directions in the Evaluation and Treatment of Precursor Plasma Cell Disorders. Am Soc Clin Oncol Educ Book 2016; 35:e400-e406. [PMID: 27249747 DOI: 10.1200/edbk_159010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Multiple myeloma (MM) is an incurable disease that progresses from a premalignant stage termed monoclonal gammopathy of undetermined significance (MGUS) and an intermediate stage of smoldering multiple myeloma (SMM). Recent major advances in therapy with more effective and less toxic treatments have brought reconsideration of early therapeutic intervention in management of SMM, with the goal of reducing progression of the disease before the occurrence of end-organ damage to MM and improving survival. Key to this effort is accurate identification of patients at high risk of progression who would truly benefit from early intervention. In this review, we discuss the current definitions, risk factors, risk stratification, prognosis, and management of MGUS and SMM, as well as new emerging therapeutic options under active investigation.
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Affiliation(s)
- Salomon Manier
- From the Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Karma Z Salem
- From the Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - David Liu
- From the Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Irene M Ghobrial
- From the Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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Wight J, Stillwell A, Morris E, Grant B, Lai HC, Irving I. Screening whole spine magnetic resonance imaging in multiple myeloma. Intern Med J 2015; 45:762-5. [DOI: 10.1111/imj.12789] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 04/07/2015] [Indexed: 11/28/2022]
Affiliation(s)
- J. Wight
- Department of Haematology; Austin Health Service; Townsville Queensland Australia
- School of Medicine and Dentistry; James Cook University; Townsville Queensland Australia
- Department of Haematology and Bone Marrow Transplantation; Townsville Hospital and Health Service; Townsville Queensland Australia
| | - A. Stillwell
- Department of Orthopaedic Surgery; The Gold Coast Hospital; Gold Coast Queensland Australia
| | - E. Morris
- Department of Haematology and Bone Marrow Transplantation; Townsville Hospital and Health Service; Townsville Queensland Australia
| | - B. Grant
- Department of Haematology and Bone Marrow Transplantation; Townsville Hospital and Health Service; Townsville Queensland Australia
| | - H. C. Lai
- Department of Haematology and Bone Marrow Transplantation; Townsville Hospital and Health Service; Townsville Queensland Australia
| | - I. Irving
- Department of Haematology and Bone Marrow Transplantation; Townsville Hospital and Health Service; Townsville Queensland Australia
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34
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Smoldering multiple myeloma. BIOMED RESEARCH INTERNATIONAL 2015; 2015:623254. [PMID: 26000300 PMCID: PMC4426782 DOI: 10.1155/2015/623254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 11/06/2014] [Indexed: 01/24/2023]
Abstract
Smoldering multiple myeloma (SMM) is an asymptomatic precursor stage of multiple myeloma (MM) characterized by clonal bone marrow plasma cells (BMPC) ≥ 10% and/or M protein level ≥ 30 g/L in the absence of end organ damage. It represents an intermediate stage between monoclonal gammopathy of undetermined significance (MGUS) and symptomatic MM. The risk of progression to symptomatic MM is not uniform, and several parameters have been reported to predict the risk of progression. These include the level of M protein and the percentage of BMPC, the proportion of immunophenotypically aberrant plasma cells, and the presence of immunoparesis, free light-chain (FLC) ratio, peripheral blood plasma cells (PBPC), pattern of serum M protein evolution, abnormal magnetic resonance imaging (MRI), cytogenetic abnormalities, IgA isotype, and Bence Jones proteinuria. So far treatment is still not recommended for SMM, because several trials suggested that patients with SMM do not benefit from early treatment. However, the Mateos et al. trial showed a survival benefit after early treatment with lenalidomide plus dexamethasone in patients with high-risk SMM. This trial has prompted a reevaluation of early treatment in an asymptomatic patient population.
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Abstract
INTRODUCTION Smoldering multiple myeloma (SMM) is a heterogeneous clinical entity that defines patients in the spectrum of disease progression from monoclonal gammopathy of undetermined significance to multiple myeloma (MM). Current standard of care is observation until end organ damage occurs. In spite of this, the scientific community has begun to question whether the strategy of watchful waiting should be replaced with earlier therapeutic intervention with the ultimate goal of preventing clonal heterogeneity and end organ damage. AREAS COVERED In this review, we challenge the concept of observation as the best option of therapy in SMM. We present current data on diagnosis, prognostic factors of disease progression and studies that have been conducted to date to determine whether earlier therapeutic interventions will lead to an improvement in overall survival of patients with MM. EXPERT OPINION If the recommendations of treatment of SMM were to change, the scientific body of evidence would have to overcome four major hurdles: to demonstrate that early intervention leads to prolonged survival and delay in development of end organ damage, that it does not have long-term toxicities, that it is implemented in patients with a high-likelihood of developing myeloma and that it does not lead to the outgrowth of more resistant clones. Only well-designed clinical trials will determine whether cure can be achieved with earlier interventions.
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Abstract
Smoldering multiple myeloma (SMM) is an asymptomatic clonal plasma cell disorder. SMM is distinguished from monoclonal gammopathy of undetermined significance by a much higher risk of progression to multiple myeloma (MM). There have been major advances in the diagnosis, prognosis, and management of SMM in the last few years. These include a revised disease definition, identification of several new prognostic factors, a classification based on underlying cytogenetic changes, and new treatment options. Importantly, a subset of patients previously considered SMM is now reclassified as MM on the basis of biomarkers identifying patients with an ≥80% risk of progression within 2 years. SMM has assumed greater significance on the basis of recent trials showing that early therapy can be potentially beneficial to patients. As a result, there is a need to accurately diagnose and risk-stratify patients with SMM, including routine incorporation of modern imaging and laboratory techniques. In this review, we outline current concepts in diagnosis and risk stratification of SMM, and provide specific recommendations on the management of SMM.
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37
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Dolscheid-Pommerich RC, Beinert S, Eichhorn L, Conrad R, Stoffel-Wagner B, Zur B. IgG subclass distribution in patients with monoclonal gammopathy. Clin Chim Acta 2015; 444:167-9. [DOI: 10.1016/j.cca.2015.02.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 02/11/2015] [Accepted: 02/11/2015] [Indexed: 11/25/2022]
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Imaging myeloma and related monoclonal plasma cell disorders using MRI, low-dose whole-body CT and FDG PET/CT. Clin Transl Imaging 2015. [DOI: 10.1007/s40336-015-0119-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gentile M, Offidani M, Vigna E, Corvatta L, Recchia AG, Morabito L, Martino M, Morabito F, Gentili S. Smoldering multiple myeloma: to treat or not to treat. Expert Opin Pharmacother 2015; 16:785-90. [DOI: 10.1517/14656566.2015.1007952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
CLINICAL ISSUE Emerging clinical trial data support treatment of high-risk smoldering multiple myeloma (SMM) upon diagnosis, and not only at the time of progression to symptomatic complications (multiple myeloma). Early detection of bone and/or bone marrow involvement by sensitive imaging modalities may help define SMM patients at a high risk of progression. STANDARD RADIOLOGICAL METHODS Current (2011) consensus guidelines recognize skeletal survey as a cornerstone modality for assessment of bone involvement at initial diagnosis and during follow-up of SMM. Skeletal survey has severe limitations related to underdetection of bone lesions and also provides no information on bone marrow abnormalities. METHODICAL INNOVATIONS Modern imaging strategies such as fluorodeoxyglucose positron-emission tomography/CT (FDG PET/CT) and MRI, in conjunction with functional innovations, provide improved estimates of global abnormalities in the bone marrow and bone compartments. These methods have the potential to objectively quantify early transformation from SMM to multiple myeloma. PERFORMANCE Although frequently used for staging and risk prognostication in multiple myeloma, modern imaging techniques have only been evaluated to a limited extent in SMM. Scant data in SMM indicate the prognostic value of two or more MRI-detected focal bone marrow abnormalities, which, if present, predict rapid progression to multiple myeloma. Data evaluating the role of FDG PET/CT in detecting early bone marrow abnormalities as an aid to predicting risk or directing treatment in SMM is currently lacking. ACHIEVEMENTS The superior specificity and sensitivity of modern imaging techniques compared to skeletal survey suggest that these should have a place in standard practice management of patients at a high risk of SMM progression. The model imaging of the future should be an all-in-one strategy offering high diagnostic performance for bone marrow abnormalities and low-volume bone lesions, as well as allowing monitoring by minimizing radiation exposure and the need for contrast agents. PRACTICAL RECOMMENDATIONS Newer imaging techniques need to be validated in prospective clinical trials assessing the SMM to multiple myeloma transition, with the aim of enabling appropriate management decisions. Efforts are also needed to improve the costs and availability of whole-body MRI and/or FDG PET/CT, in order to facilitate their widespread adoption as first-line detection modalities. Future clinical trials of therapeutic agents using earlier detection strategies will have to be carefully designed and take into consideration the risk of lead-time and length-time biases, which might falsely demonstrate longer overall survival. The English full text version of this article is available at SpringerLink (under "Supplemental").
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Gertz MA. Advanced skeletal imaging redefines the management of plasma cell disorders. J Clin Oncol 2015; 33:537-9. [PMID: 25605847 DOI: 10.1200/jco.2014.59.5066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Mikhael JR. A practical approach to relapsed multiple myeloma. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2014; 2014:262-267. [PMID: 25696865 DOI: 10.1182/asheducation-2014.1.262] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
There has been tremendous progress made in multiple myeloma in the last decade, resulting in improved overall survival for all patients, including those with high-risk disease and those ineligible for transplantation. However, despite the addition of several novel agents, unprecedented response rates, and our ability to achieve complete remission in the majority of patients, the disease remains incurable in nearly all and will require repeated therapies. With many options available to the clinician, there is no simple or ideal sequence of treatments that has been established, so the choice of relapsed therapy is based on a series of factors that include response and tolerability of prior therapies, risk status, available novel agents, aggressiveness of relapse, renal function, performance status, cost, etc. This chapter provides practical guidance in selecting relapsed therapies structured through a series of 5 questions that can inform the decision. Specific emphasis is placed on the 2 most recent novel agents, carfilzomib and pomalidomide, but agents in development are also included.
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Manasanch EE, Korde N, Mailankody S, Tageja N, Bhutani M, Roschewski M, Landgren O. Smoldering multiple myeloma: special considerations surrounding treatment on versus off clinical trials. Haematologica 2014; 99:1769-71. [PMID: 25472951 DOI: 10.3324/haematol.2014.107516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Elisabet E Manasanch
- Department of Lymphoma/Myeloma, University of Texas MD Anderson Cancer Center, Houston, TX;
| | - Neha Korde
- Myeloma Service, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Sham Mailankody
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, Bethesda, USA
| | - Nishant Tageja
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, Bethesda, USA
| | - Manisha Bhutani
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, Bethesda, USA
| | - Mark Roschewski
- Multiple Myeloma Section, Lymphoid Malignancies Branch, National Cancer Institute, National Institutes of Health, Bethesda, USA
| | - Ola Landgren
- Myeloma Service, Memorial Sloan-Kettering Cancer Center, New York, NY;
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Ghobrial IM, Landgren O. How I treat smoldering multiple myeloma. Blood 2014; 124:3380-8. [PMID: 25298034 PMCID: PMC4246036 DOI: 10.1182/blood-2014-08-551549] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Accepted: 09/23/2014] [Indexed: 11/20/2022] Open
Abstract
Smoldering myeloma is a heterogeneous clinical entity where a subset of patients has an indolent course of disease that mimics monoclonal gammopathy of undermined significance, whereas others have a more aggressive course that has been described as "early myeloma." It is defined as either serum M-protein ≥ 3 g/L or ≥ 10% monoclonal plasma cells in the bone marrow. There are currently no molecular factors to differentiate risks of progression for these patients. Current recommendations of therapy continue to be patient observation or patient enrollment in clinical trials. However, new definitions of active multiple myeloma recently agreed upon by the International Myeloma Working Group may alter the timing of therapy. On the basis of emerging data of therapy in these patients, it seems reasonable to believe that future recommendations for therapy of patients with smoldering myeloma will become an increasingly important topic. In this article, we review the current knowledge of this disease and risk factors associated with progression. We also examine biological insights and alterations that occur in the tumor clone and the surrounding bone marrow niche. Finally, we review clinical trials that have been performed in these patients and provide recommendations for follow-up of patients with this unique disease entity.
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Affiliation(s)
- Irene M Ghobrial
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; and
| | - Ola Landgren
- Memorial Sloan Kettering Cancer Center, New York, NY
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46
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Rajkumar SV, Dimopoulos MA, Palumbo A, Blade J, Merlini G, Mateos MV, Kumar S, Hillengass J, Kastritis E, Richardson P, Landgren O, Paiva B, Dispenzieri A, Weiss B, LeLeu X, Zweegman S, Lonial S, Rosinol L, Zamagni E, Jagannath S, Sezer O, Kristinsson SY, Caers J, Usmani SZ, Lahuerta JJ, Johnsen HE, Beksac M, Cavo M, Goldschmidt H, Terpos E, Kyle RA, Anderson KC, Durie BGM, Miguel JFS. International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. Lancet Oncol 2014; 15:e538-48. [PMID: 25439696 DOI: 10.1016/s1470-2045(14)70442-5] [Citation(s) in RCA: 2812] [Impact Index Per Article: 281.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This International Myeloma Working Group consensus updates the disease definition of multiple myeloma to include validated biomarkers in addition to existing requirements of attributable CRAB features (hypercalcaemia, renal failure, anaemia, and bone lesions). These changes are based on the identification of biomarkers associated with near inevitable development of CRAB features in patients who would otherwise be regarded as having smouldering multiple myeloma. A delay in application of the label of multiple myeloma and postponement of therapy could be detrimental to these patients. In addition to this change, we clarify and update the underlying laboratory and radiographic variables that fulfil the criteria for the presence of myeloma-defining CRAB features, and the histological and monoclonal protein requirements for the disease diagnosis. Finally, we provide specific metrics that new biomarkers should meet for inclusion in the disease definition. The International Myeloma Working Group recommends the implementation of these criteria in routine practice and in future clinical trials, and recommends that future studies analyse any differences in outcome that might occur as a result of the new disease definition.
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Affiliation(s)
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, University of Athens, School of Medicine, Athens, Greece
| | - Antonio Palumbo
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | | | - Giampaolo Merlini
- Amyloidosis Center, University Hospital Policlinico San Matteo, Pavia, Italy
| | | | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Jens Hillengass
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, University of Athens, School of Medicine, Athens, Greece
| | | | - Ola Landgren
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bruno Paiva
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), Pamplona, Spain
| | | | - Brendan Weiss
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Sonja Zweegman
- Department of Hematology, VU University Medical Center, Amsterdam, Netherlands
| | - Sagar Lonial
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | - Elena Zamagni
- Seràgnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
| | | | | | | | - Jo Caers
- Department of Hematology, CHU de Liege, Liege, Belgium
| | - Saad Z Usmani
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA
| | - Juan José Lahuerta
- Servicio de Hematología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Hans Erik Johnsen
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | - Meral Beksac
- Ankara University School of Medicine, Ankara, Turkey
| | - Michele Cavo
- Seràgnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
| | - Hartmut Goldschmidt
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Evangelos Terpos
- Department of Clinical Therapeutics, University of Athens, School of Medicine, Athens, Greece
| | - Robert A Kyle
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | - Brian G M Durie
- Cedars-Sinai Comprehensive Cancer Center, Los Angeles, CA, USA
| | - Jesus F San Miguel
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), Pamplona, Spain
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Identifying Professional Education Gaps and Barriers in Multiple Myeloma Patient Care: Findings of the Managing Myeloma Continuing Educational Initiative Advisory Committee. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 14:356-69. [DOI: 10.1016/j.clml.2014.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 03/26/2014] [Accepted: 04/03/2014] [Indexed: 12/31/2022]
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Monoclonal Gammopathy of Undetermined Significance and Smoldering Multiple Myeloma. Hematol Oncol Clin North Am 2014; 28:775-90. [DOI: 10.1016/j.hoc.2014.06.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Leleu X. Multiple myeloma: the puzzle is finally completed. Lancet Haematol 2014; 1:e4-e5. [PMID: 27030067 DOI: 10.1016/s2352-3026(14)70007-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Xavier Leleu
- Service des Maladies du Sang, Hôpital Claude Huriez, Lille 59037, France.
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Ludwig H, Sonneveld P, Davies F, Bladé J, Boccadoro M, Cavo M, Morgan G, de la Rubia J, Delforge M, Dimopoulos M, Einsele H, Facon T, Goldschmidt H, Moreau P, Nahi H, Plesner T, San-Miguel J, Hajek R, Sondergeld P, Palumbo A. European perspective on multiple myeloma treatment strategies in 2014. Oncologist 2014; 19:829-44. [PMID: 25063227 PMCID: PMC4122482 DOI: 10.1634/theoncologist.2014-0042] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
The treatment of multiple myeloma has undergone significant changes and has resulted in the achievement of molecular remissions, the prolongation of remission duration, and extended survival becoming realistic goals, with a cure being possible in a small but growing number of patients. In addition, nowadays it is possible to categorize patients more precisely into different risk groups, thus allowing the evaluation of therapies in different settings and enabling a better comparison of results across trials. Here, we review the evidence from clinical studies, which forms the basis for our recommendations for the management of patients with myeloma. Treatment approaches depend on "fitness," with chronological age still being an important discriminator for selecting therapy. In younger, fit patients, a short three drug-based induction treatment followed by autologous stem cell transplantation (ASCT) remains the preferred option. Consolidation and maintenance therapy are attractive strategies not yet approved by the European Medicines Agency, and a decision regarding post-ASCT therapy should only be made after detailed discussion of the pros and cons with the individual patient. Two- and three-drug combinations are recommended for patients not eligible for transplantation. Treatment should be administered for at least nine cycles, although different durations of initial therapy have only rarely been compared so far. Comorbidity and frailty should be thoroughly assessed in elderly patients, and treatment must be adapted to individual needs, carefully selecting appropriate drugs and doses. A substantial number of new drugs and novel drug classes in early clinical development have shown promising activity. Their introduction into clinical practice will most likely further improve treatment results.
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Affiliation(s)
- Heinz Ludwig
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Pieter Sonneveld
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Faith Davies
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Joan Bladé
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Mario Boccadoro
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Michele Cavo
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Gareth Morgan
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Javier de la Rubia
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Michel Delforge
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Meletios Dimopoulos
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Hermann Einsele
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Thierry Facon
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Hartmut Goldschmidt
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Philippe Moreau
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Hareth Nahi
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Torben Plesner
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Jesús San-Miguel
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Roman Hajek
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Pia Sondergeld
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Antonio Palumbo
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
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