51
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Asrar MM, Lad DP, Bansal D, Prinja S, Khadwal A, Prakash G, Jain A, Jandial A, Malhotra P. Health-related quality of life in transplant eligible multiple myeloma patients with or without early ASCT in the real-world setting. Leuk Lymphoma 2021; 62:3271-3277. [PMID: 34269156 DOI: 10.1080/10428194.2021.1953011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
There is no comparative health-related quality of life (HR-QoL) data of transplant eligible (TE) multiple myeloma (MM) patients undergoing early autologous stem cell transplantation (ASCT) and those without in the era of novel drugs. This study prospectively evaluated the serial HR-QoL in TE-MM using the EORTC QLQ-C30 and MY20 questionnaires. Barring the transient worsening in QoL one-month after ASCT, there was a comparable improvement in most QoL domains in both early-ASCT and no-early ASCT cohorts. Post-early-ASCT patients had higher global health scores (71.9 vs. 60.8, p < .05) than no-early ASCT at 12-months. Patients belonging to lower socioeconomic status (SES) were more likely not to undergo ASCT than middle-high SES patients (38.6% vs. 74.5%, p < .05). While age, gender had no impact on QoL, performance status, staging, and induction therapy impacted QoL. This study shows that early ASCT maintains QoL and should be encouraged in all TE-MM patients.
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Affiliation(s)
- Mir M Asrar
- Clinical Research Unit, National Institute of Pharmaceutical Education and Research (NIPER), S.A.S. Nagar, India
| | - Deepesh P Lad
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Dipika Bansal
- Clinical Research Unit, National Institute of Pharmaceutical Education and Research (NIPER), S.A.S. Nagar, India
| | - Shankar Prinja
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Alka Khadwal
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gaurav Prakash
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arihant Jain
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aditya Jandial
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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52
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Parrondo RD, Ailawadhi S, Sher T, Chanan-Khan AA, Roy V. Autologous Stem-Cell Transplantation for Multiple Myeloma in the Era of Novel Therapies. JCO Oncol Pract 2021; 16:56-66. [PMID: 32045556 DOI: 10.1200/jop.19.00335] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Despite the evolution of the therapeutic arsenal for the treatment of multiple myeloma (MM) over the past decade, autologous stem-cell transplantation (ASCT) remains an integral part of the treatment of patients with both newly diagnosed and relapsed MM. The advent of novel therapies, such as immunomodulatory agents, proteasome inhibitors, and monoclonal antibodies, has led to unprecedented levels of deep hematologic responses. Nonetheless, studies show that ASCT has an additive effect leading to additional deepening of responses. As the therapeutic agents for MM continue to evolve, the timing, duration, and sequence of their use in combination with ASCT will be crucial to understand to obtain the deepest response and survival benefit for patients with MM. This review aims to discuss the role of ASCT for the management of MM, with a particular focus on the role of ASCT in the context of novel therapies and minimal residual disease.
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53
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Dhakal B, Thapa B, Dong H, Tarima S, Chhabra S, D'Souza A, Drobyski W, Abid M, Shah N, Fenske T, Longo W, Hari P, Hamadani M. Budesonide Prophylaxis Reduces the Risk of Engraftment Syndrome After Autologous Hematopoietic Cell Transplantation in Multiple Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:e775-e781. [PMID: 34257042 DOI: 10.1016/j.clml.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Engraftment syndrome (ES) after autologous hematopoietic cell transplantation (AHCT) in multiple myeloma (MM) encompasses a continuum of periengraftment complications characterized by noninfectious fever, rash, diarrhea, and capillary leak features. PATIENTS AND METHODS We analyzed the ES outcomes in 257 consecutive patients MM patients who underwent AHCT at our institution from 12/2017 to 11/2019 with budesonide prophylaxis (3 mg PO daily at day +5 post-AHCT till the time of discharge) (N = 109) and no prophylaxis (N = 148). RESULTS The rates of ES were significantly higher in the no prophylaxis group versus prophylaxis group [69 (46%) vs. 23 (21%); P< .001]. There was no significant difference in length of stay (LOS) [mean 15 (±3.2) vs. 16 (±2.8); P = .27] and 30-day readmission [9 (6%) vs. 8 (7%); P = .81] between the no prophylaxis and prophylaxis groups, respectively. On adjusted analysis, budesonide prophylaxis was associated with a significantly lower risk of developing ES [odds ratio (OR) 0.29 (95% confidence interval [CI], 0.16-0.51); P< .0001]. There was no difference in the 30-day readmission rates [OR 1.12 (95% CI, 0.41-3.03); P = .81], but a trend for shorter LOS in the prophylaxis group [7.3% reduction in LOS (95% CI, -14.4% to 0%); P = .06]. CONCLUSION Budesonide prophylaxis significantly reduces the risk of ES in MM patients undergoing AHCT. These promising results suggest the need for a randomized study investigate the role of budesonide for ES prophylaxis.
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Affiliation(s)
- Binod Dhakal
- Division of BMT & Cellular Therapy, Medical College of Wisconsin, Milwaukee, WI.
| | - Bicky Thapa
- Division of BMT & Cellular Therapy, Medical College of Wisconsin, Milwaukee, WI
| | - Huaying Dong
- Institute of Health and Sciences, Medical College of Wisconsin, Milwaukee, WI
| | - Sergey Tarima
- Institute of Health and Sciences, Medical College of Wisconsin, Milwaukee, WI
| | - Saurabh Chhabra
- Division of BMT & Cellular Therapy, Medical College of Wisconsin, Milwaukee, WI
| | - Anita D'Souza
- Division of BMT & Cellular Therapy, Medical College of Wisconsin, Milwaukee, WI
| | - William Drobyski
- Division of BMT & Cellular Therapy, Medical College of Wisconsin, Milwaukee, WI
| | - Muhammad Abid
- Division of BMT & Cellular Therapy, Medical College of Wisconsin, Milwaukee, WI
| | - Nirav Shah
- Division of BMT & Cellular Therapy, Medical College of Wisconsin, Milwaukee, WI
| | - Timothy Fenske
- Division of BMT & Cellular Therapy, Medical College of Wisconsin, Milwaukee, WI
| | - Walter Longo
- Division of BMT & Cellular Therapy, Medical College of Wisconsin, Milwaukee, WI
| | - Parameswaran Hari
- Division of BMT & Cellular Therapy, Medical College of Wisconsin, Milwaukee, WI
| | - Mehdi Hamadani
- Division of BMT & Cellular Therapy, Medical College of Wisconsin, Milwaukee, WI
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54
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Nair CK. Pretransplant Determinants of Outcome in Patients with Myeloma Undergoing Autologous Transplantation in Lower Resource Settings. EUROPEAN MEDICAL JOURNAL 2021. [DOI: 10.33590/emj/20-00263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The treatment landscape in multiple myeloma has significantly changed since the introduction of high-dose melphalan with autologous stem cell rescue in the 1980s. Many randomised controlled trials have clearly demonstrated the superiority of autologous stem cell transplantation in improving survival compared to conventional chemotherapy. However, outcomes in myeloma are highly variable with median survival as short as 2 years and as long as 10 years or more. The main adverse factor predicting shorter survival is presence of high-risk cytogenetics. However, there are many other potential factors that can contribute to the treatment outcomes. This review looks at the various pretransplant variables that are associated with post-transplant outcomes in myeloma.
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Affiliation(s)
- Chandran K Nair
- Department of Clinical Haematology and Medical Oncology, Malabar Cancer Centre, Thalassery, Kerala, India
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55
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Naithani R, Dayal N, Rai R. Tandem Autologous Hematopoietic Stem Cell Transplantation in Very Young Patients with Multiple Myeloma. South Asian J Cancer 2021; 9:233-235. [PMID: 34136425 PMCID: PMC8203327 DOI: 10.1055/s-0041-1727068] [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] [Indexed: 11/29/2022] Open
Abstract
Introduction
Multiple myeloma (MM) in very young patients is uncommon, and no treatment guidelines exist for these patients.
Patients and Methods
We performed a retrospective analysis of five very young myeloma patients who underwent tandem autologous hematopoietic stem cell transplantation (HSCT).
Results
The median age was 37 years (range = 34–40 years). A median of two leukapheresis was performed (range = 1–4). The median number of hematopoietic stem cells collected was 5.4 × 10
6
/kg (4.4–8.2 × 10
6
/kg). During first transplant, four patients received melphalan of 200 mg/m
2
and one patient received melphalan of 140 mg/m
2
(due to renal failure) as conditioning regimen. Second transplant conditioning was melphalan of 200 mg/m
2
for one patient and melphalan of 140 mg/m
2
for remaining four patients. Two patients were in complete remission, and two were in very good partial remission and one patient progressed to active disease at the time of tandem autologous bone marrow transplant. All patients developed significant mucositis. Neutrophil and platelet recovery was longer in tandem autologous hematopoietic stem cell transplant. More viral infections were seen in tandem transplant. Day 30 and day 100 mortality was nil.
Conclusion
We present data on tandem autologous HSCTs in very young patients with MM in India. Responses continued to improve in this small series.
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Affiliation(s)
- Rahul Naithani
- Division of Hematology & Bone Marrow Transplantation, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Nitin Dayal
- Department of Lab Medicine, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Reeta Rai
- Department of Transfusion Medicine, Max Super Specialty Hospital, Saket, New Delhi, India
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56
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Future Directions in Maintenance Therapy in Multiple Myeloma. J Clin Med 2021; 10:jcm10112261. [PMID: 34073689 PMCID: PMC8197068 DOI: 10.3390/jcm10112261] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 05/17/2021] [Accepted: 05/20/2021] [Indexed: 12/23/2022] Open
Abstract
Autologous stem cell transplantation (ASCT) has been a backbone of therapy for newly diagnosed patients with multiple myeloma eligible for high-dose therapy for decades. Survival outcomes have continued to improve over time, in part because of the incorporation of highly effective induction regimens prior to ASCT as well as post-ASCT maintenance therapy. Randomized phase III clinical trials have helped establish lenalidomide maintenance as a standard of care. However, as nearly all patients will eventually experience disease relapse, there continues to be significant interest in developing novel maintenance strategies to improve upon lenalidomide maintenance. In this review, we summarize the available evidence for the use of immunomodulatory drugs, proteasome inhibitors, and monoclonal antibodies as post-ASCT maintenance therapies as well as discuss future directions and unanswered questions in the field.
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57
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Turunen A, Silvennoinen R, Partanen A, Valtola J, Siitonen T, Putkonen M, Sankelo M, Pyörälä M, Kuittinen T, Penttilä K, Sikiö A, Savolainen ER, Mäntymaa P, Pelkonen J, Varmavuo V, Jantunen E. Autograft cellular composition and outcome in myeloma patients: Results of the prospective multicenter GOA study. Transfusion 2021; 61:1830-1844. [PMID: 33955591 DOI: 10.1111/trf.16424] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/24/2021] [Accepted: 03/06/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Autologous stem cell transplantation (auto-SCT) is a widely used treatment option in multiple myeloma (MM) patients. The optimal graft cellular composition is not known. STUDY DESIGN AND METHODS Autograft cellular composition was analyzed after freezing by flow cytometry in 127 MM patients participating in a prospective multicenter study. The impact of graft cellular composition on hematologic recovery and outcome after auto-SCT was evaluated. RESULTS A higher graft CD34+ cell content predicted faster platelet recovery after auto-SCT in both the short and long term. In patients with standard-risk cytogenetics, a higher graft CD34+ count (>2.5 × 106 /kg) was linked with shorter progression-free survival (PFS; 28 vs. 46 months, p = 0.04), but there was no difference in overall survival (OS) (p = 0.53). In a multivariate model, a higher graft CD34+ CD133+ CD38- (>0.065 × 106 /kg, p = 0.009) and NK cell count (>2.5 × 106 /kg, p = 0.026), lenalidomide maintenance and standard-risk cytogenetics predicted better PFS. In contrast, a higher CD34+ count (>2.5 × 106 /kg, p = 0.015) predicted worse PFS. A very low CD3+ cell count (≤20 × 106 /kg, p = 0.001) in the infused graft and high-risk cytogenetics remained predictive of worse OS. CONCLUSIONS Autograft cellular composition may impact outcome in MM patients after auto-SCT. More studies are needed to define optimal graft composition.
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Affiliation(s)
- Antti Turunen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland.,Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Raija Silvennoinen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland.,Department of Hematology, Comprehensive Cancer Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anu Partanen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Jaakko Valtola
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Timo Siitonen
- Department of Medicine, Oulu University Hospital, Oulu, Finland
| | - Mervi Putkonen
- Department of Medicine, Turku University Hospital, Turku, Finland
| | - Marja Sankelo
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Marja Pyörälä
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Taru Kuittinen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Karri Penttilä
- Finnish Medicines Agency, Kuopio, Finland.,Department of Medicine, Savonlinna Central Hospital, Savonlinna, Finland
| | - Anu Sikiö
- Department of Medicine, Central Hospital of Central Finland, Jyväskylä, Finland
| | | | | | - Jukka Pelkonen
- Laboratory Centre of Eastern Finland, Kuopio, Finland.,Department of Clinical Microbiology, University of Eastern Finland, Kuopio, Finland
| | - Ville Varmavuo
- Department of Medicine, Kymenlaakso Central Hospital, Kotka, Finland
| | - Esa Jantunen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland.,Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Department of Medicine, North Carelia Hospital District, Joensuu, Finland
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58
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Cost-Effectiveness of Post-Autotransplant Lenalidomide in Persons with Multiple Myeloma. Mediterr J Hematol Infect Dis 2021; 13:e2021034. [PMID: 34007422 PMCID: PMC8114895 DOI: 10.4084/mjhid.2021.034] [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: 01/20/2021] [Accepted: 04/12/2021] [Indexed: 11/08/2022] Open
Abstract
Considerable data indicate post-transplant lenalidomide prolongs progression-free survival and probably survival after an autotransplant for multiple myeloma (MM). However, optimal therapy duration is unknown, controversial and differs in the EU and US. We compared outcomes and cost-effectiveness of 3 post-transplant lenalidomide strategies in EU and US settings: (1) none; (2) until failure; and (3) 2-year fixed duration. We used a Markov decision model, which included six health states and informed by published data. The model estimated the lenalidomide strategy given to failure achieved 1.06 quality-adjusted life years (QALYs) at costs per QALY gained of €29,232 in the EU and $133,401 in the US settings. Two-year fixed-duration lenalidomide averted €7,286 per QALY gained in the EU setting and saved 0.84 QALYs at $60,835 per QALY gained in the US setting. These highly divergent costs per QALY in the EU and US settings resulted from significant differences in post-transplant lenalidomide costs and 2nd-line therapies driven by whether post-transplant failure was on or off-lenalidomide. In Monte Carlo simulation analyses which allowed us to account for the variability of inputs, 2-year fixedduration lenalidomide remained the preferred strategy for improving healthcare sustainability in the EU and US settings.
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59
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Johnsrud A, Ladha A, Muffly L, Shiraz P, Goldstein G, Osgood V, Shizuru JA, Johnston L, Arai S, Weng WK, Lowsky R, Rezvani AR, Meyer EH, Frank MJ, Negrin RS, Miklos DB, Sidana S. Stem Cell Mobilization in Multiple Myeloma: Comparing Safety and Efficacy of Cyclophosphamide +/- Plerixafor versus Granulocyte Colony-Stimulating Factor +/- Plerixafor in the Lenalidomide Era. Transplant Cell Ther 2021; 27:590.e1-590.e8. [PMID: 33915323 DOI: 10.1016/j.jtct.2021.04.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/05/2021] [Accepted: 04/18/2021] [Indexed: 11/17/2022]
Abstract
Growth factor and chemotherapy-based stem cell mobilization strategies are commonly used to treat patients with multiple myeloma. We retrospectively compared 398 patients mobilized between 2017 and 2020 using either cyclophosphamide (4 g/m2) plus granulocyte colony-stimulating factor (G-CSF) or G-CSF alone, with on demand plerixafor (PXF) in both groups. Although total CD34+ yield was higher after chemomobilization compared with G-CSF +/- PXF (median, 13.6 × 106/kg versus 4.4 × 106/kg; P < .01), achievement of ≥2 × 106 CD34+ cells (95% versus 93.7%; P = .61) and rates of mobilization failure (5% versus 6.3%; P = .61) were similar. Fewer patients required PXF with chemomobilization (12.3% versus 49.5%; P < .01), and apheresis sessions were fewer (median, 1 [range, 1 to 4] versus 2 [range, 1 to 5]). The rate of complications, including neutropenic fever, emergency department visits, and hospitalizations, was higher after chemomobilization (30% versus 7.4%; P < .01). Previous use of ≤6 cycles of lenalidomide did not impair cell yield in either group. The median cost of mobilization was 17.4% lower in the G-CSF +/- PXF group (P = .01). Between group differences in time to engraftment were not clinically significant. Given similar rates of successful mobilization, similar engraftment time, and less toxicity and lower costs compared with chemomobilization, G-CSF with on-demand PXF may be preferable in myeloma patients with adequate disease control and limited lenalidomide exposure.
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Affiliation(s)
- Andrew Johnsrud
- Stanford Cancer Institute, Stanford, California; Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University, Stanford, California
| | - Abdullah Ladha
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University, Stanford, California; Division of Hematology, University of Southern California, Los Angeles, California
| | - Lori Muffly
- Stanford Cancer Institute, Stanford, California; Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University, Stanford, California
| | - Parveen Shiraz
- Stanford Cancer Institute, Stanford, California; Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University, Stanford, California
| | - Gary Goldstein
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University, Stanford, California
| | - Victoria Osgood
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University, Stanford, California
| | - Judith A Shizuru
- Stanford Cancer Institute, Stanford, California; Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University, Stanford, California
| | - Laura Johnston
- Stanford Cancer Institute, Stanford, California; Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University, Stanford, California
| | - Sally Arai
- Stanford Cancer Institute, Stanford, California; Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University, Stanford, California
| | - Wen-Kai Weng
- Stanford Cancer Institute, Stanford, California; Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University, Stanford, California
| | - Robert Lowsky
- Stanford Cancer Institute, Stanford, California; Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University, Stanford, California
| | - Andrew R Rezvani
- Stanford Cancer Institute, Stanford, California; Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University, Stanford, California
| | - Everett H Meyer
- Stanford Cancer Institute, Stanford, California; Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University, Stanford, California
| | - Matthew J Frank
- Stanford Cancer Institute, Stanford, California; Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University, Stanford, California
| | - Robert S Negrin
- Stanford Cancer Institute, Stanford, California; Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University, Stanford, California
| | - David B Miklos
- Stanford Cancer Institute, Stanford, California; Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University, Stanford, California
| | - Surbhi Sidana
- Stanford Cancer Institute, Stanford, California; Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University, Stanford, California.
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60
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Elnair RA, Holstein SA. Evolution of Treatment Paradigms in Newly Diagnosed Multiple Myeloma. Drugs 2021; 81:825-840. [PMID: 33871818 DOI: 10.1007/s40265-021-01514-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 12/22/2022]
Abstract
The plasma cell neoplasm multiple myeloma (MM) is currently considered incurable. However, significant advances in treatment options over the past 20 years have led to unprecedented response rates to initial therapy as well as prolonged survival rates. Induction regimens have evolved from alkylator-based therapies to those consisting of immunomodulatory drugs and proteasome inhibitors. The combination of bortezomib/lenalidomide/dexamethasone (VRd) has emerged as a standard regimen for both transplant-eligible (TE) and transplant-ineligible (TI) patient populations. More recent efforts have focused on the incorporation of monoclonal antibody therapy into the newly diagnosed setting, particularly anti-CD38 monoclonal antibodies. In the TI patient population, the combination of daratumumab/lenalidomide/dexamethasone is now considered another standard therapy. In the TE setting, it remains to be determined whether the addition of daratumumab to the VRd backbone results in improved long-term outcomes. Recent studies have confirmed the progression-free survival benefit of upfront autologous stem cell transplant and have established lenalidomide maintenance as a standard of care. Multiple studies are evaluating whether inclusion of monoclonal antibody therapy in the maintenance setting will improve outcomes. The optimal management of newly diagnosed patients with high-risk cytogenetics remains to be determined. We discuss the emerging therapies that will likely shape management of newly diagnosed MM in the future.
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Affiliation(s)
- Radowan A Elnair
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Sarah A Holstein
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA.
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61
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Marneni N, Chakraborty R. Current Approach to Managing Patients with Newly Diagnosed High-Risk Multiple Myeloma. Curr Hematol Malig Rep 2021; 16:148-161. [PMID: 33876390 DOI: 10.1007/s11899-021-00631-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW With rapid advances in the therapeutic landscape and biological insights in multiple myeloma, it is critical to identify and strategically manage high-risk patients to achieve best outcomes with currently available drugs. The purpose of this review is to summarize the management of high-risk myeloma with a focus on recent advances in the field. RECENT FINDINGS The most widely accepted definition of "high-risk" is the Revised International Staging System (R-ISS) stage 3 disease, which includes high tumor burden (ISS stage 3) and high-risk FISH cytogenetics or an elevated lactate dehydrogenase level. A major advance in the management of high-risk patients is insight into the importance of achieving and sustaining minimal residual disease (MRD) negativity, which is an influential equalizer for long-term outcomes. Quadruplet pre-transplant induction regimens incorporating an anti-CD38 monoclonal antibody (mAb), proteasome inhibitor (PI: bortezomib or carfilzomib), lenalidomide, and dexamethasone should be strongly considered in high-risk patients given higher odds of getting to MRD negativity with these regimens compared to triplets. In transplant-eligible patients, upfront transplant does lead to a higher rate of sustained MRD negativity and superior PFS compared to delayed transplant. The role of tandem transplant in the context of bortezomib-lenalidomide-dexamethasone (VRD) induction therapy is unclear. Post-transplant maintenance therapy should include lenalidomide in combination with either bortezomib or carfilzomib until progression. For transplant-ineligible patients, VRD or daratumumab-lenalidomide-dexamethasone (DRD) until progressions are both reasonable and choice should be individualized based on patient-related factors. Outcomes of high-risk myeloma patients have improved in the last decade with the use of modern 3-drug induction regimens incorporating a PI and an immunomodulatory drug, with potential for further improvement as we bring anti-CD38 mAb upfront. MRD assessment will play a major role in treatment modification at several key time-points in the future such as pre-transplant, pre-maintenance, and yearly on maintenance therapy.
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Affiliation(s)
- Naimisha Marneni
- Department of Internal Medicine, St. Barnabas Hospital Program, Bronx, NY, USA
| | - Rajshekhar Chakraborty
- Division of Hematology/Oncology, Department of Medicine, Multiple Myeloma and Amyloidosis Program, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 161 Fort Washington Ave G, New York, NY, 10032, USA.
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62
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Low-Dose Cyclophosphamide versus Intermediate-High-Dose Cyclophosphamide versus Granulocyte Colony-Stimulating Factor Alone for Stem Cell Mobilization in Multiple Myeloma in the Era of Novel Agents: A Multicenter Retrospective Study. Transplant Cell Ther 2021; 27:244.e1-244.e8. [PMID: 33781522 DOI: 10.1016/j.jtct.2020.12.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/13/2020] [Accepted: 12/06/2020] [Indexed: 12/11/2022]
Abstract
The optimal stem cell (SC) mobilization strategy for patients with multiple myeloma (MM) remains a matter of debate. Possible approaches include low or high doses of cyclophosphamide (Cy), other chemotherapeutic agents, or granulocyte colony-stimulating factor (G-CSF) alone. The scope of the study was to compare low-dose Cy plus G-CSF versus intermediate-high-dose Cy plus G-CSF versus G-CSF alone for SC mobilization in MM, in terms of efficacy and safety. We retrospectively analyzed 422 MM patients undergoing SC mobilization in 6 Italian centers, including 188 patients who received low-dose Cy (LD-Cy group, defined as 2 g/m2), 163 patients who received intermediate-high-dose Cy (HD-Cy group, defined as ≥ 3 g/m2), and 71 patients who received G-CSF alone (G-CSF group). The median peak of circulating CD34+ cells was 77/µL in the LD-Cy group, 92/µL in the HD-Cy group, and 55/µL in the G-CSF group (P = .0001). The median amount of SCs collected was 9.1 × 106/kg, 9.7 × 106/kg, and 5.6 × 106/kg in the 3 groups, respectively (P = .0001). The rate of mobilization failure (defined as failure to collect ≥2 × 106/kg) was 3.7% in the LD-Cy group, 3.4% in the HD-Cy group, and 4.3% in the G-CSF group (P = .9). The target SC dose of at least 4 × 106/kg was reached in 90.4%, 91.1%, and 78.6% of the patients in these 3 groups, respectively (P = .014). The "on demand" use of plerixafor was higher in the G-CSF group (76%) compared with the LD-Cy group (19%) and the HD-Cy group (6%). In multivariate analysis, G-CSF mobilization and previous use of melphalan or radiotherapy were independently associated with failure to collect the target SC dose of ≥4 × 106/kg. No impacts of age, blood counts, or previous treatment with lenalidomide, bortezomib, or carfilzomib were observed. Our results suggest that LD-Cy may be considered for successful SC mobilization in patients with MM.
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Effect of autologous hematopoietic stem cell transplant on the development of second primary malignancies in multiple myeloma patients. Blood Cancer J 2021; 11:5. [PMID: 33414400 PMCID: PMC7791054 DOI: 10.1038/s41408-020-00400-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/16/2020] [Accepted: 12/07/2020] [Indexed: 02/06/2023] Open
Abstract
Autologous stem cell transplant (aHSCT) is associated with improved survival for multiple myeloma (MM) patients but may be associated with second primary malignancy (SPM) development. Using the California Cancer Registry linked to statewide hospitalization data, we determined the cumulative incidence (CMI) of SPMs more than 1 year after MM diagnosis, accounting for the competing risk of death. AHSCT recipients were matched 1:2 to non-aHSCT patients. Adjusted hazard ratios (aHR) were estimated using the Fine and Gray method. Among 16,331 patients, 933 (5.7%) developed a SPM more than 1 year after diagnosis. The 10-year CMI of developing any SPM was 6.6%, 5.7% for solid tumor SPM and 0.9% for hematologic malignancies. The 10-year CMI of developing any SPM was similar among aHSCT [9.1% (7.7-10.7%)] and non-aHSCT [7.5% (6.5-8.6%)] (P = 0.26) recipients and there was no difference in solid-tumor SPMs (P = 0.98). The 10-year CMI of hematologic SPMs was higher among aHSCT recipients [2.1% (1.4-2.9%) vs. 0.8% (0.5-1.2%); P = 0.005], corresponding to a 1.3% absolute increase and an aHR of 1.51 (1.01-2.27). Ten-year myeloma-specific and non-cancer mortality rates were 59% (58.2-60.0%) and 18.1% (17.4-18.8%), respectively. Although aHSCT was associated with a small increase in hematologic SPMs, mortality was driven by MM and non-cancer causes.
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Influence of Overlapping Genetic Abnormalities on Treatment Outcomes of Multiple Myeloma. Transplant Cell Ther 2020; 27:243.e1-243.e6. [PMID: 33781521 DOI: 10.1016/j.jtct.2020.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/10/2020] [Accepted: 10/25/2020] [Indexed: 11/22/2022]
Abstract
Numerous genetic abnormalities affect treatment outcomes in multiple myeloma. The role of coexistent trisomy or hyperdiploidy and high-risk cytogenetic abnormalities (CGAs) is not well defined. We assessed the influence of overlapping genetic abnormalities in patients who received frontline autologous stem cell transplantation. A total of 491 consecutive patients between January 2009 and January 2016 were identified. High-risk CGAs included del(17p), t(4;14), t(14;16), and gain 1q21 by fluorescence in situ hybridization and del(13) by conventional cytogenetics. Thirty-two percent had a trisomy, 27% had a high-risk CGA, and 11% had both. Among patients with any trisomy, 3-year progression-free survival (PFS) and overall survival (OS) were 60% and 90%, respectively, compared to 25% and 65%, respectively, for patients with any high-risk CGA. Patients with co-existent trisomy and high-risk CGAs had 3-year PFS and OS of 43% and 89%, respectively, whereas those with isolated high-risk CGAs without trisomy had 3-year PFS and OS of 13% and 49%, respectively. The PFS (hazard ratio [HR], 1.9; 95% confidence interval [CI], 1.1 to 3.3; P = .02) and OS (HR, 4.5; 95% CI, 1.5 to 13; P = .006) were worse for high-risk CGAs without versus those with concurrent trisomies. Our findings suggest a protective impact of trisomies in patients with high-risk CGAs and a potential need for revised risk stratification assessments to account for overlapping genetic abnormalities.
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Kazandjian D, Mo CC, Landgren O, Richardson PG. The role of high-dose melphalan with autologous stem-cell transplant in multiple myeloma: is it time for a paradigm shift? Br J Haematol 2020; 191:692-703. [PMID: 32501533 PMCID: PMC8505046 DOI: 10.1111/bjh.16764] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/29/2020] [Indexed: 02/06/2023]
Abstract
Recent advances in multiple myeloma include numerous approvals of novel therapies with unprecedented efficacy, a rapid and sustained tempo of new drug development, and further refinements to prognostication to include minimal residual disease (MRD) testing and improved risk stratification. The upfront use of immunomodulatory drug and proteasome inhibitor combinations followed by maintenance has resulted in transformative clinical benefit. Four-drug regimens incorporating monoclonal antibodies are reporting unprecedented rates of complete response and MRD negativity in the absence of intensification. In the context of these advances, the added value of high-dose melphalan with autologous stem-cell transplant (HDM-ASCT) is a key question. From a safety standpoint, HDM-ASCT is associated with both acute toxicities that reduce quality of life and long-term toxicities that may limit life expectancy for some patients. The present review discusses the recent advances in induction therapy, the impact of these advances on HDM-ASCT, the evolving role of MRD testing and the short- and long-term risks of HDM-ASCT. Recognising that prospective data remains limited, we suggest that HDM-ASCT not be considered mandatory for eligible newly diagnosed patients who are treated with highly efficacious regimens and achieve deep responses, but rather be held in reserve without early exposure to the clinical and genomic toxicity inherent to this approach.
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Affiliation(s)
- Dickran Kazandjian
- Multiple Myeloma Program, Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Clifton C. Mo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Jerome Lipper Multiple Myeloma Center, Boston, MA
| | - Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Paul G. Richardson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Jerome Lipper Multiple Myeloma Center, Boston, MA, USA
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Hanafi HHW, Husin A, Yaacob NM, Abdullah AD. Relapsed/Progressive Disease and Its Prognostic Factors among Multiple Myeloma Patients Receiving Novel Agent Treatment in North East Peninsular Malaysia: A Single Centre Experience. Malays J Med Sci 2020; 27:62-77. [PMID: 33154703 PMCID: PMC7605841 DOI: 10.21315/mjms2020.27.5.7] [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: 03/11/2020] [Accepted: 08/10/2020] [Indexed: 11/25/2022] Open
Abstract
Background Some multiple myeloma (MM) patients still relapse/progress despite novel agent therapy and relapse/progression in MM is therefore a vital area of ongoing research in the novel treatment era. This retrospective cohort study aimed to evaluate the time to relapse/progression (TTP) among MM patients who received novel agents and to determine the associated prognostic factors. Methods This study included 89 MM patients treated at Hospital Universiti Sains Malaysia. We analysed the TTP and the type of relapse/progression (biochemical versus clinical), and a Cox proportional hazard model was used to identify the significant prognostic factors. Results Sixty-four percent of patients had biochemical relapse/progression. The overall median TTP among MM patients who received the novel agent(s) was 29.33 months (95% CI: 21.36–37.29). The type of paraprotein at diagnosis (P = 0.026, P = 0.228), International Staging System (ISS) score (P = 0.036, P = 0.067) and autologous stem cell transplant (ASCT) (P = 0.002) were prognostic factors for relapse/progression by simple Cox regression, but ASCT was the only significant predictor detected by multiple Cox regression (P = 0.003). Conclusion Our study reflects the importance of paraprotein monitoring to detect early features of relapse/progression. ASCT is the most prognostic factor that may lengthen the TTP.
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Affiliation(s)
- Hany Haqimi Wan Hanafi
- Haematopoietic Stem Cell Transplant Unit, Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.,Department of Internal Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Azlan Husin
- Haematopoietic Stem Cell Transplant Unit, Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.,Department of Internal Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Najib Majdi Yaacob
- Unit of Biostatistics and Research Methodology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Abu Dzarr Abdullah
- Haematopoietic Stem Cell Transplant Unit, Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.,Department of Internal Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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67
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Singh G. Serum and Urine Protein Electrophoresis and Serum-Free Light Chain Assays in the Diagnosis and Monitoring of Monoclonal Gammopathies. J Appl Lab Med 2020; 5:1358-1371. [PMID: 33150391 DOI: 10.1093/jalm/jfaa153] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 08/14/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Laboratory methods for diagnosis and monitoring of monoclonal gammopathies have evolved to include serum and urine protein electrophoresis, immunofixation electrophoresis, capillary zone electrophoresis, and immunosubtraction, serum-free light chain assay, mass spectrometry, and newly described QUIET. CONTENT This review presents a critical appraisal of the test methods and reporting practices for the findings generated by the tests for monoclonal gammopathies. Recommendations for desirable practices to optimize test selection and provide value-added reports are presented. The shortcomings of the serum-free light chain assay are highlighted, and new assays for measuring monoclonal serum free light chains are addressed. SUMMARY The various assays for screening, diagnosis, and monitoring of monoclonal gammopathies should be used in an algorithmic approach to avoid unnecessary testing. Reporting of the test results should be tailored to the clinical context of each individual patient to add value. Caution is urged in the interpretation of results of serum-free light chain assay, kappa/lambda ratio, and myeloma defining conditions. The distortions in serum-free light chain assay and development of oligoclonal bands in patients' status post hematopoietic stem cell transplants is emphasized and the need to note the location of original monoclonal Ig is stressed. The need for developing criteria that consider the differences in the biology of kappa and lambda light chain associated lesions is stressed. A new method of measuring monoclonal serum-free light chains is introduced. Reference is also made to a newly defined entity of light chain predominant intact immunoglobulin monoclonal gammopathy. The utility of urine testing in the diagnosis and monitoring of light chain only lesions is emphasized.
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Affiliation(s)
- Gurmukh Singh
- Medical College of Georgia, Augusta University, Augusta, GA
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Dhakal B, D'Souza A, Callander N, Chhabra S, Fraser R, Davila O, Anderson K, Assal A, Badawy SM, Berdeja J, Cerny J, Comenzo R, Chakraborty R, Peter Gale R, Kamble R, Kharfan-Dabaja MA, Krem M, Ganguly S, Janakiram M, Kansagra A, Munker R, Murthy H, Patel S, Kumar S, Shah N, Qazilbash M, Hari P. Novel prognostic scoring system for autologous hematopoietic cell transplantation in multiple myeloma. Br J Haematol 2020; 191:442-452. [PMID: 33094839 DOI: 10.1111/bjh.16987] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/11/2020] [Indexed: 11/28/2022]
Abstract
We studied 2,528 patients with upfront autologous haematopoietic cell transplantation (AHCT) for multiple myeloma (MM) from 2008-2017 to develop a prognostic model to predict outcomes. High-risk cytogenetics included t(4;14), t(14;16), t(14;20), del13q on karyotype, del17p, +1q or 1pdel. A Cox model identified factors prognostic of progression/relapse in a training subset (n = 1,246). A weighted score using these factors was assigned to a validation cohort (n = 774). Presence of high-risk cytogenetics [hazard ratio, (HR) 1·68 (1·3-2·17)] and pre-AHCT bone marrow plasma cells (BMPCs) ≥10% [1·68 (1·33-2·12)] were assigned 4 points each; albumin at diagnosis <3·5 g/dl [1·31 (1·07-1·61)] 2; standard risk cytogenetics 1, and no cytogenetics abnormality, BMPCs <10% at AHCT and albumin ≥3·5 g/dl at diagnosis 0 points each. A three-category system with low risk (0-3), intermediate risk (4-8) and high risk (9-10) showed 3-year progression-free survival in the low vs. intermediate vs. high risk of 58% (95% CI: 52-63) vs. 49% (95% CI: 43-56) vs. 31% (95% CI: 12-51), P < 0.001 respectively, and 3-year OS in low vs. intermediate vs. high risk of 88% (95% CI: 84-91) vs. 81% (95% CI: 76-86) vs. 64% (95% CI: 39-80); P < 0·001. Our prognostic scoring system can identify MM patients at risk for early relapse after AHCT.
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Affiliation(s)
- Binod Dhakal
- BMT and Cellular Therapy, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Anita D'Souza
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Saurabh Chhabra
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Raphael Fraser
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Omar Davila
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Amer Assal
- Department of Medicine, Bone Marrow Transplant and Cell Therapy Program, Columbia University Irving Medical Center, New York, NY, USA
| | - Sherif M Badawy
- Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Jan Cerny
- Division of Hematology/Oncology, Department of Medicine, University of Massachusetts Medical Center, Worcester, MA, USA
| | | | | | - Robert Peter Gale
- Haematology Research Centre, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Rammurti Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Maxwell Krem
- University of Louisville Hospital/James Brown Cancer Center, Louisville, KY, USA
| | - Siddhartha Ganguly
- Division of Hematological Malignancy and Cellular Therapeutics, University of Kansas Health System, Kansas City, KS, USA
| | | | - Ankit Kansagra
- UT Southwestern Medical Center - BMT Program, Dallas, TX, USA
| | - Reinhold Munker
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
| | - Hemant Murthy
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Sagar Patel
- Blood and Marrow Transplant Program, University of Utah, Salt Lake City, UT, USA
| | - Shaji Kumar
- Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nina Shah
- Division of Hematology-Oncology, University of California San Francisco, San Francisco, CA, USA
| | | | - Parameswaran Hari
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Propylene Glycol-Free Melphalan versus PG-Melphalan as Conditioning for Autologous Hematopoietic Cell Transplantation for Myeloma. Biol Blood Marrow Transplant 2020; 26:2229-2236. [PMID: 32920204 DOI: 10.1016/j.bbmt.2020.08.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/31/2020] [Accepted: 08/31/2020] [Indexed: 12/12/2022]
Abstract
High-dose melphalan (Mel) conditioning before autologous hematopoietic cell transplantation (autoHCT) is standard of care for patients with transplantation-eligible multiple myeloma. The traditional lyophilized Mel formulation has inadequate solubility and stability after reconstitution, leading to the use of propylene glycol (PG) as a solubilizing agent. A newer PG-free Mel preparation (Evomela) uses beta cyclodextrin captisol as a solubilizing agent and was approved by the United States Food and Drug Administration as a conditioning agent based on a single-phase IIb study showing bioequivalence. We compared the outcomes of consecutive patients with myeloma undergoing autoHCT using the 2 formulations of Mel for conditioning as our center switched from using the older formulation (PG-Mel) to the newer one (PGF-Mel). Of 294 autoHCT recipients, 162 received PG-Mel conditioning and 132 received PGF-Mel conditioning. The PGF-Mel group was older and had a lower average Karnofsky Performance Status score. PGF-Mel was associated with faster neutrophil recovery (median, 12 days versus 13 days; P < .001), fewer grade 3-4 infections within 30 days of autoHCT (1.5% versus 8.0%; P = .048), and a lower 30-day rehospitalization rate (6.8% versus 17.9%; P = .04), as confirmed by propensity-weighted analysis. No significant between-group differences were detected in mucositis, organ toxicity, myeloma response, or 100-day mortality.
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70
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Wang N, Ji J, Yu S, Chang J, Chen Y, Yu B. In reply to the letter to the editor regarding "The Relationship Between Serum Vitamin D and Fracture Risk in the Elderly: A Meta-Analysis". J Orthop Surg Res 2020; 15:324. [PMID: 32795312 PMCID: PMC7427934 DOI: 10.1186/s13018-020-01820-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/27/2020] [Indexed: 12/14/2022] Open
Affiliation(s)
- Ning Wang
- Shandong University of Traditional Chinese Medicine, Jinan, 250014, China
| | - Jindou Ji
- Shandong University of Traditional Chinese Medicine, Jinan, 250014, China
| | - Shengwen Yu
- Shandong University of Traditional Chinese Medicine, Jinan, 250014, China
| | - Jinlei Chang
- Shandong University of Traditional Chinese Medicine, Jinan, 250014, China
| | - Yungang Chen
- Department of Orthopaedics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, 250014, China
| | - Bo Yu
- Department of Orthopaedics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, 250014, China.
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Xu L, Wang X, Pan X, Wang X, Wang Q, Wu B, Cai J, Zhao Y, Chen L, Li W, Li J. Education level as a predictor of survival in patients with multiple myeloma. BMC Cancer 2020; 20:737. [PMID: 32770980 PMCID: PMC7414648 DOI: 10.1186/s12885-020-07178-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 07/13/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Disparities in multiple myeloma (MM) prognosis based on sociodemographic factors may exist. We investigated whether education level at diagnosis influenced Chinese MM patient outcomes. METHODS We performed a multicenter retrospective analysis of data from 773 MM patients across 9 centers in China from 2006 to 2019. Sociodemographic and clinical factors at diagnosis and treatment regimens were recorded, and univariate and multivariate analyses were performed. RESULTS Overall, 69.2% of patients had low education levels. Patients with low education levels differed from those with high education levels in that they were more likely to be older, and a higher proportion lived in rural areas, were unemployed, had lower annual incomes and lacked insurance. Additionally, compared to patients with high education levels, patients with low education levels had a higher proportion of international staging system (ISS) stage III classification and elevated lactate dehydrogenase (LDH) levels and underwent transplantation less often. Patients with high education levels had a median progression-free survival (PFS) of 67.50 (95% confidence interval (CI): 51.66-83.39) months, which was better than that of patients with low education levels (30.60 months, 95% CI: 27.38-33.82, p < 0.001). Similarly, patients with high education levels had a median overall survival (OS) of 122.27 (95% CI: 117.05-127.49) months, which was also better than that of patients with low education levels (58.83 months, 95% CI: 48.87-62.79, p < 0.001). In the multivariable analysis, patients with high education levels had lower relapse rates and higher survival rates than did those with low education level in terms of PFS and OS (hazard ratio (HR) = 0.50 [95% CI: 0.34-0.72], p < 0.001; HR = 0.32 [0.19-0.56], p < 0.001, respectively). CONCLUSIONS Low education levels may independently predict poor survival in MM patients in China.
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Affiliation(s)
- Limei Xu
- Department of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiuju Wang
- Department of Hematology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Xueyi Pan
- Department of Hematology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong, China
| | - Xiaotao Wang
- Department of Hematology, The Second Affiliated Hospital of Guilin Medical University, Guilin, Guangxi, China
| | - Qing Wang
- Department of Hematology, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Bingyi Wu
- Department of Hematology, Shunde Hospital of Southern Medical University, Shunde, Guangdong, China
| | - Jiahui Cai
- Department of Hematology, Shunde Hospital of Southern Medical University, Shunde, Guangdong, China
| | - Ying Zhao
- Department of Hematology, First People's Hospital of Foshan, Foshan, Guangdong, China
| | - Lijuan Chen
- Department of Hematology, The First Affiliated Hospital With Nanjing Medical University, Nanjing, Jiangsu, China
| | - Wuping Li
- Department of Internal Medicine, Jiangxi Tumor Hospital, Nanchang, Jiangxi, China
| | - Juan Li
- Department of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
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Dhakal B, D'Souza A, Kleman A, Chhabra S, Mohan M, Hari P. Salvage second transplantation in relapsed multiple myeloma. Leukemia 2020; 35:1214-1217. [PMID: 32747684 DOI: 10.1038/s41375-020-1005-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 07/22/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Binod Dhakal
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Anita D'Souza
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ariel Kleman
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Saurabh Chhabra
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Meera Mohan
- Division of Hematology/Oncology, University of Arkansas, Little Rock, AR, USA
| | - Parameswaran Hari
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
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Jung SH, Jo JC, Song GY, Ahn SY, Yang DH, Ahn JS, Kim HJ, Lee JJ. Frontline therapy for newly diagnosed patients with multiple myeloma. Blood Res 2020; 55:S37-S42. [PMID: 32719175 PMCID: PMC7386893 DOI: 10.5045/br.2020.s007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/22/2020] [Accepted: 01/30/2020] [Indexed: 12/18/2022] Open
Abstract
Since the introduction of an alkylator to the treatment of multiple myeloma (MM), new effective agents have been developed, such as immunomodulatory drugs including thalidomide, lenalidomide, and pomalidomide; proteasome inhibitors including bortezomib, carfilzomib, and ixazomib; monoclonal antibodies including daratumumab and elotuzumab; and deacetylase inhibitors including panobinostat. Numerous regimens with these new agents have been developed and they have contributed in improving survival outcomes in MM patients. In addition, the recommended therapies for newly diagnosed MM change every year based on the results of clinical trials. This review will discusses the appropriate induction therapies based on recent clinical trials for patients with newly diagnosed MM.
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Affiliation(s)
- Sung-Hoon Jung
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Jae-Cheol Jo
- Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Ga-Young Song
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Seo-Yeon Ahn
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Deok-Hwan Yang
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Jae-Sook Ahn
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Hyeoung-Joon Kim
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Je-Jung Lee
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
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Upfront stem cell transplantation for newly diagnosed multiple myeloma with del(17p) and t(4;14): a study from the CMWP-EBMT. Bone Marrow Transplant 2020; 56:210-217. [PMID: 32710010 DOI: 10.1038/s41409-020-01007-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/13/2020] [Accepted: 07/17/2020] [Indexed: 12/15/2022]
Abstract
We analyzed newly diagnosed multiple myeloma patients with del(17p) and/or t(4;14) undergoing either upfront single autologous (auto), tandem autologous (auto-auto) or tandem autologous/reduced-intensity allogeneic (auto-allo) stem cell transplantation. 623 patients underwent either auto (n = 446), auto-auto (n = 105), or auto-allo (n = 72) between 2000 and 2015. 46% of patients had t(4;14), 45% had del(17p) while 9% were reported having both abnormalities. Five-year overall survival (OS) was 51% (95% confidence interval [CI], 45-58%) for single auto, 60% (95% CI, 49-72%) for auto-auto, and 67% (95% CI, 53-80%) for auto-allo (p = 0.187). Five-year progression-free survival (PFS) was 17% (95% CI, 12-22%), 33% (95% CI, 22-43%), and 34% (95% CI, 21-38%; p = 0.048). Five-year relapse rate was 82, 63, and 56%, while non-relapse mortality was 1, 4, and 10%. In multivariable analysis, in t(4;14) with single auto as reference, auto-auto (hazard ratio [HR], 0.44; p = 0.007) and auto-allo (HR, 0.45; p = 0.018) were associated with better PFS. In terms of t(4;14) and OS, auto-auto appeared to improve outcome compared with single auto (HR, 0.49; p = 0.096). In del(17p), outcome in PFS was similar between single auto and auto-auto, while auto-allo appeared to improve PFS (HR, 0.65; p = 0.097). No significant difference in OS was identified between the groups in patients with del(17p).
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75
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Chhabra S, Thapa B, Szabo A, Konings S, D'Souza A, Dhakal B, Jerkins JH, Pasquini MC, Johnson BD, Hari PN, Hamadani M. Utilization and Cost Implications of Hematopoietic Progenitor Cells Stored for a Future Salvage Autologous Transplantation or Stem Cell Boost in Myeloma Patients. Biol Blood Marrow Transplant 2020; 26:2011-2017. [PMID: 32717431 DOI: 10.1016/j.bbmt.2020.07.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/04/2020] [Accepted: 07/15/2020] [Indexed: 01/24/2023]
Abstract
Autologous hematopoietic cell transplantation (autoHCT) is a standard initial treatment for multiple myeloma (MM). Consensus guidelines recommend collecting sufficient hematopoietic progenitor cells (HPCs) for 2 autoHCTs in all eligible patients. Despite a lack of published data on the utilization of HPCs stored for future use, it is common practice across transplantation programs to collect enough HPCs for 2 autoHCTs in MM patients. In this single-center retrospective study, we analyzed the utilization of HPCs collected and stored at the time of first autoHCT in patients with MM, along with the cost implications of HPC collection targets sufficient for 2 transplantations. In a cohort of 400 patients (median age, 63 years; range, 22 to 79 years), after a median follow-up of 50.4 months, 197 patients had relapsed and 36 had received HPC infusion as salvage autoHCT (n = 29) and/or HPC boost (n = 8). In this cohort, a median CD34+ cell dose of 4.3 × 106/kg (range, 1.1 to 12.94.3 × 106/kg) was used for first autoHCT, and a median of 4.4 × 106/kg (range, 1.0 to 20.2× 106/kg) CD34+ cells were stored for future use. At 6 years after the first autoHCT, the estimated cumulative incidence of salvage autoHCT was 12.0% without HPC boost and 13.9% with HPC boost. HPC utilization was significantly higher in the 60- to 64-year age group, whereas no patients who were age ≥70 years at the time of first autoHCT received salvage autoHCT. Using the CD34+ cell dose infused during the first autoHCT as the cutoff for individual patients, the estimated mean additional cost of HPC collection intended for subsequent use (over and above the HPCs used for first autoHCT) was $10,795 ($4.32 million for the entire cohort), an estimated 14% of which (ie, $583,600) was actually used up in salvage autoHCT by 6 years from first autoHCT. In conclusion, our results suggest the need for reappraisal of HPC collection targets for salvage autoHCT and argue against HPC collection and storage for salvage autoHCT in patients age ≥70 years at the time of first autoHCT.
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Affiliation(s)
- Saurabh Chhabra
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin.
| | - Bicky Thapa
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aniko Szabo
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Steve Konings
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anita D'Souza
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin
| | - Binod Dhakal
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - James H Jerkins
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Marcelo C Pasquini
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin
| | - Bryon D Johnson
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Parameswaran N Hari
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin
| | - Mehdi Hamadani
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin
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76
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Asrar MM, Lad DP, Prinja S, Bansal D. A systematic review of economic evaluations of treatment regimens in multiple myeloma. Expert Rev Pharmacoecon Outcomes Res 2020; 21:799-809. [PMID: 32496881 DOI: 10.1080/14737167.2020.1779064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The expansion of advanced expensive therapeutic innovations for Multiple Myeloma (MM) led to increased disclosure of economic evaluations. The present analysis systematically reviewed and appraised the reporting quality of economic evaluations in MM. METHODOLOGY A comprehensive literature search in Ovid, MEDLINE(R), PubMed, and Cochrane libraries was conducted for studies published in the past decade. Two independent authors performed study selection and data extraction in a standardized form. Study methodological quality assessment was performed using 10-item Drummond's tool. RESULTS Of potentially eligible 1150 retrieved studies, 17 met eligibility criteria. Six evaluations (35%) were in newly diagnosed MM and 11 (65%) in relapse refractory (RR) MM. Nine studies (53%) embraced the payer's perspective, five (29%) adopted health care system, one (6%) societal and two did not report. Six (35%) employed partitioned survival model, 4(24%) discrete event simulation, 4(24%) Markov model and 2(12%) used decision tree model. The methodological quality has improved significantly; 16 (94%) studies comprehended a well-defined question by affirming the analysis perspective and examined both costs and outcomes while 13 (71%) provided a comprehensive description of competing alternatives. CONCLUSION The addition of novel drugs to the treatment armamentarium of MM is considerably cost-effective. The evaluations became more frequent, methodological quality has improved in the last decade.
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Affiliation(s)
- Mir Mahmood Asrar
- Clinical Research Unit, Department of Pharmacy Practice, National Institute of Pharmaceutical Education & Research, Mohali, Punjab, India
| | - Deepesh P Lad
- Clinical Haematology, Blood & Marrow Transplantation, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Shankar Prinja
- School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Dipika Bansal
- Clinical Research Unit, Department of Pharmacy Practice, National Institute of Pharmaceutical Education & Research, Mohali, Punjab, India
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77
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Garderet L, Morris C, Beksac M, Gahrton G, Schönland S, Yakoub-Agha I, Hayden PJ. Are Autologous Stem Cell Transplants Still Required to Treat Myeloma in the Era of Novel Therapies? A Review from the Chronic Malignancies Working Party of the EBMT. Biol Blood Marrow Transplant 2020; 26:1559-1566. [PMID: 32417491 DOI: 10.1016/j.bbmt.2020.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 12/27/2022]
Abstract
Melphalan at a myeloablative dose followed by autologous stem cell transplantation (ASCT) remains the standard of care for transplant-eligible patients with myeloma. However, therapies such as new immunomodulatory drugs and proteasome inhibitors and, more recently, monoclonal antibodies and chimeric antigen receptor T cells are challenging the traditional role of ASCT. Which patients benefit from ASCT? Can its use be delayed until first relapse? The field is moving rapidly as novel agents lead to new patient care strategies. The place of ASCT in this changing landscape will be reviewed and reassessed.
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Affiliation(s)
- Laurent Garderet
- Sorbonne Université, INSERM, UMR_S 938, Centre de Recherche Saint-Antoine-Team Proliferation and Differentiation of Stem Cells, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié Salpêtrière, Service d'Hématologie, Paris, France.
| | - Curly Morris
- Haematology, Queen's University Belfast Faculty of Medicine Health and Life Sciences, Belfast, United Kingdom
| | | | - Gösta Gahrton
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Stefan Schönland
- Amyloidosis Center, Division of Stem Cell Transplantation, Department Internal Medicine V, Hematology, Oncology, Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Patrick J Hayden
- Department of Haematology, Trinity College Dublin, St. James's Hospital, Dublin, Ireland
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Monoclonal Gammopathies After Renal Transplantation: A Single-center Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e468-e473. [PMID: 32340914 DOI: 10.1016/j.clml.2020.02.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/20/2020] [Accepted: 02/27/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Plasma cell disorders (PCDs) are clonal plasma cell disorders that include conditions such as monoclonal gammopathy of undetermined significance (MGUS), monoclonal gammopathy of renal significance (MGRS), multiple myeloma (MM), smoldering MM (SMM), solitary plasmacytoma, and light-chain (AL) amyloidosis. The risk factors associated with and the clinical course of PCDs after renal transplantation is not well established although immunosuppressive protocols may impact the incidence and natural history of PCDs posttransplant. PATIENTS AND METHODS This single-center retrospective study evaluated patients with a history of renal transplant who developed a PCD between January 1, 2014-December 31, 2018. RESULT A total of 41 patients met the inclusion criteria including 29 with MGUS and 12 with symptomatic PCD (4 with MM, 2 with SMM, 4 with MGRS, 1 with AL amyloidosis, and 1 with solitary plasmacytoma). The median follow-up of survivors was 41.6 months. Three patients (1 with MGUS and 2 with MGRS) progressed to MM during the follow-up period. There was a male preponderance in both groups. There was no correlation between the donor and immunosuppressive regimen and the development of a PCD. Patients with symptomatic PCD had higher serum creatinine and M-protein levels at diagnosis and higher free light chain ratio and plasma cell burden. There was also a higher percentage of allograft failure noted in the symptomatic PCD subset 50% (n = 6), whereas only 23% (n = 7) of patients had allograft failure in the MGUS group. CONCLUSION This study shows the importance of considering monoclonal gammopathy in the differential of renal dysfunction after kidney transplant and the need to follow these patients closely to monitor for progression to symptomatic PCD.
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Patel PR, Senyuk V, Sweiss K, Calip GS, Pan D, Rodriguez N, Oh A, Mahmud N, Rondelli D. PARP Inhibition Synergizes with Melphalan but Does not Reverse Resistance Completely. Biol Blood Marrow Transplant 2020; 26:1273-1279. [PMID: 32194286 DOI: 10.1016/j.bbmt.2020.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 02/21/2020] [Accepted: 03/06/2020] [Indexed: 12/20/2022]
Abstract
High-dose melphalan (MEL) and autologous stem cell transplantation (ASCT) is the standard of care in the treatment of multiple myeloma (MM). Resistance to MEL has been linked to increased DNA repair. Here we sought to identify whether inhibition of poly(ADP-ribose) polymerase (PARP) synergizes with MEL and can overcome resistance. We tested the synergistic cytotoxicity of 3 inhibitors of PARP (PARPi)-veliparib (VEL), olaparib (OLA), and niraparib (NIRA)-combined with MEL in RPMI8226 and U266 MM cell lines, as well as in their MEL resistance counterparts, RPMI8226-LR5 (LR5) and U266-LR6 (LR6). The addition of VEL, OLA, and NIRA to MEL reduced the half maximal inhibitory concentration (IC50) in RPMI8226 cells from 27.8 µM to 23.1 µM, 22.5 µM, and 18.0 µM, respectively. Similarly, the IC50 of MEL in U266 cells was decreased from 6.2 µM to 3.2 µM, 3.3 µM, and 3.0 µM, respectively. In LR5 and LR6 cells, PARPi did not reverse MEL resistance. We confirmed this in a NOD/SCID/gamma null xenograft mouse model with either MEL-sensitive (RPMI8226) or MEL-resistant (LR5) MM. Treatment with a MEL-VEL combination prolonged survival compared with MEL alone in RPMI8226 mice (107 days versus 67.5 days; P = .0009), but not in LR5 mice (41 versus 39 days; P = .09). We next tested whether 2 double-stranded DNA repair mechanisms, homologous recombination (HR) and nonhomologous end-joining (NHEJ), cause MEL resistance in LR5 and LR6 cells. In an HR assay, LR6 cells had a 4.5-fold greater HR capability than parent U226 cells (P = .05); however, LR5 cells had an equivalent HR ability as parent RPMI8226 cells. We hypothesized that NHEJ may be a mediator of MEL resistance in LR5 cells. Given that DNA-PK is integral to NHEJ and may be a therapeutic target, we treated LR5 cells with the DNA-PK inhibitor NU7026 in combination with MEL. Although NU7026 alone at 2.5 µM had no cytotoxicity, in combination it completely reversed resistance to MEL (MEL IC50, 46.4 µM versus 14.4 µM). We examined the clinical implications of our findings in a dataset of 414 patients treated with tandem ASCT. High PARP1 expressers had lower survival compared with patients with low expression (median 42.7 months versus median not reached; P = .003). We hypothesized that combined expression of the HR gene BRCA1, the NHEJ gene PRKDC (DNA-PK), and PARP1 may predict survival and found that overexpression of 0 (n = 101), 1 or 2 (n = 287), or all 3 (n = 26) genes had a negative impact on median survival (undefined versus 57.8 months versus 14.8 months; P < .0001). Here we demonstrate that PARPi synergized with MEL, but that resistance (which may be due to HR and NHEJ pathways) is not completely reversed by PARPi. In addition, we observed that a 3-gene analysis may be tested to identify patients resistant or sensitive to high-dose MEL.
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Affiliation(s)
- Pritesh R Patel
- Division of Hematology/ Oncology, University of Illinois at Chicago, Chicago, Illinois.
| | - Vitalyi Senyuk
- Division of Hematology/ Oncology, University of Illinois at Chicago, Chicago, Illinois
| | - Karen Sweiss
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois
| | - Greg S Calip
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, Illinois
| | - Dipanjan Pan
- Department of Bioengineering, University of Illinois at Urbana-Champaign, Urbana, Illinois; Biomedical Research Center, Carle Foundation Hospital, Urbana, Illinois
| | - Natalie Rodriguez
- University of Illinois at Chicago, College of Medicine, Chicago, Illinois
| | - Annie Oh
- Division of Hematology/ Oncology, University of Illinois at Chicago, Chicago, Illinois
| | - Nadim Mahmud
- Division of Hematology/ Oncology, University of Illinois at Chicago, Chicago, Illinois
| | - Damiano Rondelli
- Division of Hematology/ Oncology, University of Illinois at Chicago, Chicago, Illinois
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Optimizing Immunomodulatory Drug With Proteasome Inhibitor Combinations in Newly Diagnosed Multiple Myeloma. ACTA ACUST UNITED AC 2020; 25:2-10. [PMID: 30694854 DOI: 10.1097/ppo.0000000000000348] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In the modern era of multiple myeloma therapeutics, proteasome inhibitor (PI) and immunomodulatory drugs (IMiDs) have replaced chemotherapy regimens for newly diagnosed multiple myeloma patients. Treatment combinations that comprise both first- and next-generation PIs, including bortezomib, carfilzomib, and ixazomib and IMiDs, including thalidomide and lenalidomide, have been evaluated in phases II and III clinical trials and have shown significant efficacy with manageable toxicity profiles. Bortezomib or carfilzomib with lenalidomide and dexamethasone (VRD and KRD) are the most promising regimens resulting in significant survival improvement. Disease and patient characteristics should lead the individualization of treatment, with the eligibility for autologous transplant being of principal importance. The addition of a monoclonal antibody to PI with IMiD combinations is currently under clinical investigation and may lead to further treatment optimization.
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Mair M, Straka C, Buratti T, Tauber M, Mitterer M, Fong D. Clinical outcomes and prognostic factors in patients with multiple myeloma in South Tyrol: a retrospective single-center analysis. Ann Hematol 2020; 99:1031-1040. [PMID: 32140891 DOI: 10.1007/s00277-020-03969-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 02/18/2020] [Indexed: 12/13/2022]
Abstract
High-dose chemotherapy followed by autologous stem cell transplantation (HD-ASCT) as well as the introduction of novel agents (NA) significantly improved survival for patients with multiple myeloma (MM). A total of 150 unselected newly diagnosed MM patients treated at our institution from 1998 to 2017 were retrospectively analyzed. Median age at diagnosis was 69 years (range 33-93 years) with a median follow-up of 48.6 months. The median overall survival (OS) for the entire cohort was 60.7 months (range 0.3-280.1). Patients who received frontline HD-ASCT (p < 0.01) or NA-based first-line treatment (p = 0.043) had a significantly better OS. According to the revised Myeloma Comorbidity Index (R-MCI), patients were defined as fit (36.5%), intermediate-fit (44.5%), or frail (19%) with a significant difference in OS between these categories (p < 0.01). Multivariate analysis revealed R-MCI as an independent prognostic factor for OS (p < 0.01). Presence of subclinical amyloid deposits (A+) was detected in 18 out of 66 patients (27.3%) and significantly correlated with a serum free light chain (sFLC) ratio ≥ 100 (p = 0.01) and bone marrow plasma cell infiltration > 60% (p = 0.04). Furthermore, patients with A+ had significantly worse OS compared with their counterparts (p = 0.048). Our results corroborate the efficacy of both early HD-ASCT and the use of new agents as initial therapy of MM patients in "real-world" daily clinical practice. The R-MCI is an easily applicable tool to stratify MM patients and may support treatment decisions. The prognostic value of subclinical amyloid deposition should be validated within prospective studies.
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Affiliation(s)
- Maximilian Mair
- Department of Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Christian Straka
- Hematology, Oncology and Infectiology, Munich Schwabing Hospital, Munich, Germany
| | - Thomas Buratti
- Department of Oncology and Hematology, Franz Tappeiner Hospital, Merano, Italy
| | - Martina Tauber
- Department of Pathology, Bolzano Regional Hospital, Bolzano, Italy
| | - Manfred Mitterer
- Department of Oncology and Hematology, Franz Tappeiner Hospital, Merano, Italy
| | - Dominic Fong
- Department of Oncology and Hematology, Franz Tappeiner Hospital, Merano, Italy.
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Suzuki K. Latest treatment strategies aiming for a cure in transplant-eligible multiple myeloma patients: how I cure younger MM patients with lower cost. Int J Hematol 2020; 111:512-518. [PMID: 32125606 DOI: 10.1007/s12185-020-02841-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/06/2020] [Indexed: 12/24/2022]
Abstract
This article presents a practical overview of the treatment of younger, newly diagnosed multiple myeloma patients, focusing on novel treatment strategies. With the introduction of effective new agents, multiple myeloma is one of the most active and changing fields in clinical oncology. In addition, monitoring technology has become reliable and practical. Achieving and sustaining minimal residual disease negativity (MRD- ), such as multiparameter flow cytometry (MFC) < 10-5, is one of the goals of therapy. MRD- is significantly associated with prolonged progression-free survival, whereas MRD persistence (MRD +) is an independent factor for poor progression-free survival. Evidence from several recent studies evaluating modern therapy has further supported the positive correlation between depth of response and outcomes. Multiple myeloma can become a chronic illness with sustained MRD- in a significant number of patients. Our ultimate hope is to leverage tumoricidal-immunomodulatory sequential therapies and to cure a subset of our patients.
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Affiliation(s)
- Kenshi Suzuki
- Director of Myeloma and Amyloidosis Center, Japanese Red Cross Medical Center, Shibuya-ku, Hiroo 4-1-22, Tokyo, Japan.
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83
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Lymphoid Neoplasms With Plasmablastic Differentiation: A Comprehensive Review and Diagnostic Approaches. Adv Anat Pathol 2020; 27:61-74. [PMID: 31725418 DOI: 10.1097/pap.0000000000000253] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Plasmablastic neoplasms encompass several entities including plasmablastic lymphoma, plasmablastic plasmacytoma/multiple myeloma, primary effusion lymphoma and its extracavitary variant, anaplastic lymphoma kinase-positive large B-cell lymphoma, and Kaposi sarcoma-associated herpesvirus/human herpesvirus 8 (HHV8)-positive diffuse large B-cell lymphoma, not otherwise specified. Morphologically, the tumor cells are large with eccentrically located nuclei, prominent nucleoli, and basophilic/amphophilic cytoplasm. Immunophenotypically, the tumor cells express plasma cell-related antigens including CD38, CD138, interferon regulatory factor-4 (IRF4)/MUM1, PR domain zinc finger protein-1 (PRDM1), and/or X-box binding protein-1 (XBP1), with frequent loss of CD20. These tumors are diagnostically challenging for general pathologists due to their overlapping morphology and immunophenotype, and due to their rarity, and particularly so when clinical and radiologic information is insufficient. We also discuss HHV8-negative effusion-based lymphoma due to its overlapping features with primary effusion lymphoma. In this review, we focus on the useful diagnostic markers and pertinent molecular findings in these distinct entities and propose a practical diagnostic algorithm using anaplastic lymphoma kinase, HHV8, in situ hybridization for Epstein-Barr virus-encoded small RNA, immunoglobulin M, light chain stains, and clinicoradiologic criteria to avoid misdiagnosis. At the molecular level, MYC protein overexpression with or without MYC rearrangement and PRDM1-inactivating mutations or deletions are noted in a subset of such tumors, especially in plasmablastic lymphoma. Prognosis in these entities is dismal with conventional CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy. Therefore, novel target therapies, such as anti-CD30 agents, and/or immune blockade therapy, are potential treatment options in the future.
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84
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Kumar L, Ramavath D, Kataria B, Tiwari A, Raj A, Chellapuram SK, Mookerjee A, Sahoo RK, Malik PS, Sharma A, Gupta R, Sharma OD, Biswas A, Kumar R, Thulkar S. High-dose chemotherapy followed by autologous stem cell transplant for multiple myeloma: Predictors of long-term outcome. Indian J Med Res 2020; 149:730-739. [PMID: 31496525 PMCID: PMC6755776 DOI: 10.4103/ijmr.ijmr_1593_18] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background & objectives Survival of patients with multiple myeloma (MM) has improved in the past two decades following use of novel agents and autologous stem cell transplantation. To determine predictors of long-term outcome, data of MM patients who underwent autologous stem cell transplantation (ASCT) at a tertiary care centre in north India were retrospectively analyzed. Methods Between 1995 and 2016, 349 MM patients underwent ASCT. Patients' median age was 52 yr, ranging from 29 to 68 yr, 68.2 per cent were males. Thirty three per cent patients had international staging system (ISS) Stage III and 68.5 per cent had received novel agents-based induction. High-dose melphalan (200 mg/m2) was used for conditioning; patients with renal insufficiency (estimated glomerular filtration rate <40 ml/min) received melphalan 140-150 mg/m2. Results Post-transplant, 317 of 349 (90.8%) patients responded; complete [complete response (CR)] -213 (61%)], very good partial response (VGPR) -62 (17.8%) and PR in 42 (12%)]. Induction with novel agents, pre-transplant chemosensitive disease, transplant in first remission and serum albumin (≥3.5 g/dl) were predictors of significant response. At a median follow up of 73 months, median overall survival (OS) was 90 months [95% confidence interval (CI) 70.8-109.2], and progression-free survival (PFS) was 41 months (95% CI 33.0-49.0). On multivariate analysis, achievement of CR post-transplant, transplant in first remission, ISS Stages I and II (vs. III), absence of extramedullary disease and serum albumin ≥3.5 g/dl were predictors of prolonged OS. For PFS, achievement of post-transplant CR and transplant in first remission were predictors of superior outcome. Interpretation & conclusions Treatment with novel agents, achievement of complete remission post-transplant, ISS Stages I and II, absence of extramedullary disease and transplant in first remission were predictors of long-term survival for patients with MM.
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Affiliation(s)
- Lalit Kumar
- Department of Medical Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Dev Ramavath
- Department of Medical Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Babita Kataria
- Department of Medical Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Akash Tiwari
- Department of Medical Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Abhishek Raj
- Department of Medical Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Santosh Kumar Chellapuram
- Department of Medical Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Anjali Mookerjee
- Department of Medical Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Ranjit Kumar Sahoo
- Department of Medical Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Prabhat S Malik
- Department of Medical Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Atul Sharma
- Department of Medical Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Ritu Gupta
- Department of Laboratory Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Om Dutt Sharma
- Department of Laboratory Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Ahitagni Biswas
- Department of Radiation Oncology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Kumar
- Department of Nuclear Medicine, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Thulkar
- Department of Radio-diagnosis, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
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85
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Bair SM, Brandstadter JD, Ayers EC, Stadtmauer EA. Hematopoietic stem cell transplantation for blood cancers in the era of precision medicine and immunotherapy. Cancer 2020; 126:1837-1855. [PMID: 32073653 DOI: 10.1002/cncr.32659] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/08/2019] [Accepted: 09/19/2019] [Indexed: 01/12/2023]
Abstract
Hematopoietic stem cell transplantation (HCT) has been an integral component in the treatment of many hematologic malignancies. Since the development of HCT nearly 50 years ago, the role of this modality has evolved as newer treatment approaches have been developed and integrated into the standard of care. In the last decade, novel and highly active targeted therapies and immunotherapies have been approved for many hematologic malignancies, raising the question of whether HCT continues to retain its prominent role in the treatment paradigms of various hematologic malignancies. In this review, the authors have described the current role of autologous and allogeneic HCT in the treatment of patients with acute leukemias, aggressive B-cell lymphomas, and multiple myeloma and discussed how novel targeted therapies and immunotherapies have changed the potential need, timing, and goal of HCT in patients with these diseases.
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Affiliation(s)
- Steven M Bair
- Division of Hematology-Oncology, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua D Brandstadter
- Division of Hematology-Oncology, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily C Ayers
- Division of Hematology-Oncology, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward A Stadtmauer
- Division of Hematology-Oncology, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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86
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Hamilton EM, Nath KD, Vangaveti VN, McCutchan AD, Marsh JL, Birchley AJ, Casey JM, McNamara C, Lai HC, Morris ES, Hodges G, Irving IM. A 14-year retrospective analysis of indications and outcomes of autologous haemopoietic stem cell transplantation in regional Queensland: a single-centre experience. Intern Med J 2020; 50:214-221. [PMID: 32037713 DOI: 10.1111/imj.14395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 04/26/2019] [Accepted: 06/03/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Townsville Hospital is a tertiary hospital in North Queensland with one of the largest regional transplant centres in Australia, performing primarily autologous haemopoietic stem cell transplants (HSCT) for various haematological malignancies. AIMS This single-centre, retrospective, observational study aims to describe the activity and outcomes of autologous HSCT at The Townsville Hospital between 2003 and 2017 to verify safety standards. METHODS Patient-level data were collected, including demographics, frequency and indication for transplant, conditioning, current clinical status and cause of death. Key outcomes included overall survival, non-relapse mortality, incidence of therapy-related neoplasm and causes of death. Progression-free survival in the multiple myeloma (MM) subgroup was also assessed. RESULTS There were 319 autologous HSCT in 286 patients, with a median age of 58 years (range 14-71 years); 62% of patients were male. Indications for transplantation were: MM 53.7%, non-Hodgkin lymphoma 29.4%, Hodgkin lymphoma 5.0% and other 11.9%. Causes of death were: disease progression/relapse (65.2%), second malignancy (17.0%), infection (9.8%) and other (8.0%). Non-relapse mortality was 1.2% (95% confidence interval 0.4-3.0) and 3.2% (1.7-5.7) at 100 days and 1 year, respectively, post-HSCT. Overall survival at 2 years was 81.0% (73.8-86.4) for MM and 69.6% (58.8-78.1) for non-Hodgkin lymphoma. The median progression-free survival in the MM cohort was 3.3 years. CONCLUSION The Townsville Hospital transplant centre provides an important transplant service in regional Queensland, with outcomes comparable to national data. We reported a relatively high rate of second malignancy as a cause of death.
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Affiliation(s)
- Elizabeth M Hamilton
- Department of Haematology and Bone Marrow Transplantation, The Townsville Hospital, Townsville, Australia.,School of Medicine, Griffith University, Gold Coast, Australia
| | - Karthik D Nath
- Department of Haematology and Bone Marrow Transplantation, The Townsville Hospital, Townsville, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Venkat N Vangaveti
- College of Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Andrew D McCutchan
- Department of Haematology and Bone Marrow Transplantation, The Townsville Hospital, Townsville, Australia
| | - Jodie L Marsh
- Department of Haematology and Bone Marrow Transplantation, The Townsville Hospital, Townsville, Australia
| | - Andrew J Birchley
- Department of Haematology and Bone Marrow Transplantation, The Townsville Hospital, Townsville, Australia
| | - John M Casey
- Department of Haematology and Bone Marrow Transplantation, The Townsville Hospital, Townsville, Australia
| | | | - Hock C Lai
- Department of Haematology and Bone Marrow Transplantation, The Townsville Hospital, Townsville, Australia
| | - Edward S Morris
- Department of Haematology and Bone Marrow Transplantation, The Townsville Hospital, Townsville, Australia
| | - Georgina Hodges
- Department of Haematology and Bone Marrow Transplantation, The Townsville Hospital, Townsville, Australia
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87
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Hock BD, Mulholland KS, Ganly P, McKenzie JL, Pearson JF, MacPherson SA. Impact of increased access to novel agents on the survival of multiple myeloma patients treated at a single New Zealand centre. Intern Med J 2020; 49:598-606. [PMID: 30411451 DOI: 10.1111/imj.14155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 10/11/2018] [Accepted: 10/29/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The impact of changes in novel agent (NA) usage on the survival of multiple myeloma (MM) patients in real-world hospital settings is unclear. In New Zealand (NZ) in 2011, frontline bortezomib became available and thalidomide availability was expanded. AIM This retrospective study analyses the impact these change had on the survival of MM patients treated at a NZ hospital. METHODS Clinical and overall survival (OS) data were collected on MM patients who were treated at Christchurch Hospital during 2000-2009 (pre-cohort, n = 337) and 2011-2017 (post-cohort, n = 343). Outcomes were compared using pre-cohort data truncated at 2011. RESULTS Patients in the post-cohort had significant increases (P < 0.001) in not only NA usage (85 vs 55%) and OS (median = 56 vs 44 months) but also the proportion (74 vs 49%) of young patients (age < 70) who received an autologous stem cell transplant (ASCT). Separate analysis of older patients demonstrated that those in the post-cohort had significantly longer OS (median OS 28 vs 17, P < 0.001) although 5-year relative survival remained less than 50%. Separate analysis of young patients demonstrated that those in the post-cohort had significantly increased initial OS with the survival curves converging at 5 years. Although ASCT-treated patients had similar OS in each cohort, their progression-free survival (PFS) was significantly increased in the post-cohort (median 40 vs 20 months, P < 0.0001). CONCLUSION In the setting of a NZ hospital the increased availability of NA was associated with a significant improvement in both the OS of older patients and the PFS of ASCT patients.
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Affiliation(s)
- Barry D Hock
- Haematology Research Group, Christchurch Hospital and Department of Pathology and Biomedical Science, Christchurch, New Zealand
| | | | - Peter Ganly
- Haematology Department, Christchurch Hospital, Christchurch, New Zealand
| | - Judith L McKenzie
- Haematology Research Group, Christchurch Hospital and Department of Pathology and Biomedical Science, Christchurch, New Zealand
| | - John F Pearson
- Biostatistics and Computational Biology Unit, Christchurch, New Zealand
| | - Sean A MacPherson
- Haematology Research Group, Christchurch Hospital and Department of Pathology and Biomedical Science, Christchurch, New Zealand.,Haematology Department, Christchurch Hospital, Christchurch, New Zealand
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88
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Goto D, Khairnar R, Yared JA, Yong C, Romanus D, Onukwugha E, Slejko JF. Utilization of novel systemic therapies for multiple myeloma: A retrospective study of front-line regimens using the SEER-Medicare data. Cancer Med 2020; 9:626-639. [PMID: 31801177 PMCID: PMC6970041 DOI: 10.1002/cam4.2698] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 09/20/2019] [Accepted: 10/13/2019] [Indexed: 11/17/2022] Open
Abstract
The landscape of treatment for multiple myeloma (MM) has significantly changed over the last decade due to novel agents that have shown superiority in efficacy such as proteasome inhibitors (PIs) and immunomodulatory drugs (IMiDs) over traditional therapies. However, the real-world utilization of these new agents has not been studied well. This study evaluated year-to-year changes in treatment choices in a cohort of patients aged 66 or older in the Surveillance, Epidemiology, and End Results (SEER) registry linked with Medicare claims (SEER-Medicare) data who were diagnosed with MM between 2007 and 2011. We identified 2477 symptomatic newly diagnosed patients who were followed for 6 months or more postdiagnosis and treated with systemic therapies but not with stem cell transplantation. Symptomatic patients were identified by evidence of hypercalcemia, renal failure, anemia, or bone lesions (CRAB criteria). The minimum follow-up was imposed to ensure sufficient data to characterize treatment. Our analysis found that the proportion of treated patients increased from 75% in the 2007 cohort to 79% in the 2011 cohort. The share of PI-based regimens including PI plus alkylating agents, PI plus IMiD, and PI-only increased from 9% to 21%, 3% to 11%, and 16% to 22%, respectively, between 2007 and 2011. These findings translate to the share of PI-based regimens having increased from 28% to 55% and that of IMiDs-based regimens (excluding PI plus IMiD) having decreased from 43% to 27%. In conclusion, while the usage of PIs among elderly MM patients increased significantly replacing IMiD-based regimens (with or without alkylating agents but not with PI) between 2007 and 2011, this significant shift did not increase the proportion of treated patients.
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Affiliation(s)
| | - Rahul Khairnar
- Department of Pharmaceutical Health Services ResearchUniversity of Maryland School of PharmacyBaltimoreMDUSA
| | - Jean A. Yared
- Department of MedicineUniversity of Maryland School of MedicineBaltimoreMDUSA
| | | | - Dorothy Romanus
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company LimitedCambridgeMAUSA
| | - Eberechukwu Onukwugha
- Department of Pharmaceutical Health Services ResearchUniversity of Maryland School of PharmacyBaltimoreMDUSA
| | - Julia F. Slejko
- Department of Pharmaceutical Health Services ResearchUniversity of Maryland School of PharmacyBaltimoreMDUSA
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89
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Badar T, Hari P, Dávila O, Fraser R, Wirk B, Dhakal B, Freytes CO, Valdes CR, Lee C, Vesole DH, Malek E, Hildebrandt GC, Landau H, Murthy HS, Lazarus HM, Berdeja JG, Meehan KR, Solh M, Diaz MA, Kharfan-Dabaja MA, Callander NS, Farhadfar N, Bashir Q, Kamble RT, Vij R, Munker R, Kyle RA, Chhabra S, Hashmi S, Siddhartha Ganguly, Jagannath S, Nishihori T, Nieto Y, Kumar S, Shah N, D’Souza A. African Americans with translocation t(11;14) have superior survival after autologous hematopoietic cell transplantation for multiple myeloma in comparison with Whites in the United States. Cancer 2020; 127:82-92. [PMID: 32966625 PMCID: PMC7736245 DOI: 10.1002/cncr.33208] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/07/2020] [Accepted: 06/13/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Multiple myeloma (MM) with the translocation t(11;14) may have inferior outcomes in comparison with other standard-risk MM, and it has been suggested to portend a worse prognosis in African Americans in comparison with Whites. This study used the Center for International Blood and Marrow Transplant Research (CIBMTR) database to examine the impact of t(11;14) on the clinical outcomes of patients with MM of African American and White descent. METHODS This study evaluated 3538 patients who underwent autologous hematopoietic cell transplantation (autoHCT) for MM from 2008 to 2016 and were reported to the CIBMTR. Patients were analyzed in 4 groups: African Americans with t(11;14) (n = 117), African Americans without t(11;14) (n = 968), Whites with t(11;14) (n = 266), and Whites without t(11;14) (n = 2187). RESULTS African Americans with t(11;14) were younger, had lower Karnofsky scores, and had more advanced stage MM with a higher Hematopoietic Cell Transplantation-Comorbidity Index (HCT-CI). Fewer African Americans with t(11;14) (21%) had a coexistent high-risk marker in comparison with Whites with t(11;14) (27%). In a multivariate analysis, race and t(11;14) had no association with progression-free survival. However, overall survival was superior among African Americans with t(11;14) in comparison with Whites with t(11;14) (hazard ratio, 0.53; 95% confidence interval, 0.30-0.93; P = .03). Survival was also associated with female sex, stage, time from diagnosis to transplant, a low HCT-CI, and receipt of maintenance. CONCLUSIONS Race may have a differential impact on the survival of patients with t(11;14) MM who undergo autoHCT and needs to be further studied.
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Affiliation(s)
- Talha Badar
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Parameswaran Hari
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Omar Dávila
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Raphael Fraser
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI,Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Baldeep Wirk
- Penn State Cancer Institute, Bone Marrow Transplant Program, Hershey, PA
| | - Binod Dhakal
- BMT and Cellular Therapy, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI
| | | | | | - Cindy Lee
- Royal Adelaide Hospital, Adelaide, Australia
| | - David H. Vesole
- John Theurer Cancer Center at Hackensack UMC, Hackensack, NJ
| | - Ehsan Malek
- Seidman Cancer Center-University Hospitals Cleveland Medical Center, Cleveland, OH
| | | | - Heather Landau
- Bone Marrow Transplant Service, Division of Hematology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hemant S. Murthy
- Division of Hematology Oncology, Blood and Marrow Transplantation Program, Mayo Clinic Florida, Jacksonville, FL
| | - Hillard M. Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | | | | | - Melhem Solh
- The Blood and Marrow Transplant Group of Georgia, Northside Hospital, Atlanta, GA
| | - Miguel Angel Diaz
- Department of Hematology/Oncology, Hospital Infantil Universitario Nino Jesus, Madrid, Spain
| | - Mohamed A. Kharfan-Dabaja
- Division of Hematology Oncology, Blood and Marrow Transplantation Program, Mayo Clinic Florida, Jacksonville, FL
| | | | - Nosha Farhadfar
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, FL
| | - Qaiser Bashir
- Department of Stem Cell Transplantation & Cellular Therapy, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rammurti T. Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX
| | - Ravi Vij
- Division of Hematology and Oncology, Washington University School of Medicine, St. Louis, MO
| | | | | | - Saurabh Chhabra
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI,CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Shahrukh Hashmi
- Department of Internal Medicine, Mayo Clinic, MS,Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Siddhartha Ganguly
- Division of Hematological Malignancy and Cellular Therapeutics, University of Kansas Health System, Kansas City, KS
| | | | - Taiga Nishihori
- Department of Blood & Marrow Transplant and Cellular Immunotherapy (BMT CI), Moffitt Cancer Center, Tampa, FL
| | - Yago Nieto
- Department of Stem Cell Transplantation & Cellular Therapy, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Nina Shah
- Department of Stem Cell Transplantation & Cellular Therapy, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anita D’Souza
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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90
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Chew C, Ng HY. Efficacy and Safety of Nivestim Versus Neupogen for Mobilization of Peripheral Blood Stem Cells for Autologous Stem Cell Transplantation. Sci Rep 2019; 9:19938. [PMID: 31882793 PMCID: PMC6934574 DOI: 10.1038/s41598-019-56477-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 11/04/2019] [Indexed: 11/22/2022] Open
Abstract
A retrospective cohort study was conducted in Singapore General Hospital to study the safety and efficacy of biosimilar granulocyte-colony stimulating factor (G-CSF) Nivestim for chemo-mobilization of stem cells for autologous stem cell transplant (autoSCT). All patients who underwent an autoSCT between January 2011 and December 2016 were screened for eligibility. A total of 194 patients were screened, and 131 were included. Nivestim was used in 65 patients and the originator G-CSF (Neupogen) in 66. Patient characteristics were similar between both arms except for chemo-mobilization regimen used (p < 0.0001). Mobilization success rates were found to be comparable, at 96.9% (Nivestim) and 97% (Neupogen). Adverse events rates were also similar. Median duration of G-CSF use and hospitalization were both found to be shorter in the Nivestim arm. Median drug acquisition cost per mobilization cycle was significantly lower in the Nivestim arm at $533.40 (range $213.40–$1280.20) as compared to $1261.90 (range $574–$2755.20) in the Neupogen arm (p < 0.0001). No difference was observed for neutrophil and platelet engraftment after autoSCT. Nivestim was found to be safe and non-inferior to Neupogen for chemo-mobilization of stem cells for autoSCT, and associated with lower cost and shorter length of hospitalization.
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Affiliation(s)
- Cindy Chew
- Department of Pharmacy, National Cancer Centre, Singapore, 11 Hospital Crescent, 169610, Singapore.
| | - Hong Yen Ng
- Department of Pharmacy, Singapore General Hospital, Block 7 Level 2, Outram Road, 169608, Singapore
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91
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Ntanasis-Stathopoulos I, Gavriatopoulou M, Kastritis E, Terpos E, Dimopoulos MA. Multiple myeloma: Role of autologous transplantation. Cancer Treat Rev 2019; 82:101929. [PMID: 31770695 DOI: 10.1016/j.ctrv.2019.101929] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/31/2019] [Accepted: 11/05/2019] [Indexed: 01/07/2023]
Abstract
Autologous stem cell transplantation (ASCT) has been the mainstay of multiple myeloma (MM) treatment for approximately 30 years. Although the continuous introduction of novel agents in the armamentarium against MM has questioned its value, ASCT remains a backbone treatment for fit MM patients. However, there is no unanimous approach for several aspects including the positioning of ASCT in the therapeutic algorithm either upfront or following the first relapse, the need for single or tandem ASCT, as well as the role of ASCT as salvage therapy. Furthermore, the anti-CD38 monoclonal antibodies along with the next generation proteasome inhibitors and immunomodulatory drugs provide a platform for optimizing the induction and consolidation/maintenance regimens. In this review, we present current data pertaining to all aspects of ASCT in MM, whereas we highlight the open issues that should be addressed in the design of future clinical trials in the field.
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Affiliation(s)
- Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
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92
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Combined immune score of lymphocyte to monocyte ratio and immunoglobulin levels predicts treatment-free survival of multiple myeloma patients after autologous stem cell transplant. Bone Marrow Transplant 2019; 55:199-206. [PMID: 31527821 DOI: 10.1038/s41409-019-0681-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 07/04/2019] [Accepted: 07/13/2019] [Indexed: 12/22/2022]
Abstract
Outcomes after ASCT are highly variable making it difficult to predict risk of disease progression. We analyzed the impact of clinically available immune-related biomarkers on treatment-free survival (TFS) in 130 patients receiving Mel200 and ASCT. Absolute lymphocyte count (ALC), monocyte count (AMC), neutrophil count (ANC), and immunoglobulin (Ig) levels were collected on day -2 and 90 of ASCT. The lymphocyte-monocyte (LMR) and neutrophil-lymphocyte ratios (NLR) were then derived. At Day +90, we found that low ALC (18 versus 23 months, p = 0.04) or AMC (13 versus 25 months, p = 0.02) predicted for worse TFS. A low LMR predicted for worse TFS (16 versus 52 months, p = 0.004). Patients with two or three suppressed Ig levels had worse TFS (17 versus 51 months, p = 0.04). Median TFS for poor (low LMR and 2-3 suppressed Ig), intermediate, and good (high LMR and 0-1 suppressed Ig) risk groups was 7.5 versus 27 versus 79 months, respectively (p = 0.0004). In a multivariate analysis, a low LMR and suppressed Ig levels were strong independent predictors of poor TFS. We propose an immune score combining these available tests to stratify patients at risk for early progression and identify those who may benefit from intensified post-ASCT consolidation or immunotherapy based approaches.
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93
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Nampoothiri RV, Kasudhan KS, Patil AN, Malhotra P, Khadwal A, Prakash G, Jain A, Malhotra S, Verma Attri S, Varma N, Varma S, Lad DP. Impact of frailty, melphalan pharmacokinetics, and pharmacogenetics on outcomes post autologous hematopoietic cell transplantation for multiple myeloma. Bone Marrow Transplant 2019; 54:2088-2095. [DOI: 10.1038/s41409-019-0631-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/22/2019] [Accepted: 07/13/2019] [Indexed: 12/27/2022]
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94
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Uttervall K, Borg Bruchfeld J, Gran C, Wålinder G, Månsson R, Lund J, Gahrton G, Alici E, Nahi H. Upfront bortezomib, lenalidomide, and dexamethasone compared to bortezomib, cyclophosphamide, and dexamethasone in multiple myeloma. Eur J Haematol 2019; 103:247-254. [PMID: 31231833 DOI: 10.1111/ejh.13280] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES At our center, patients with multiple myeloma (MM) were treated upfront with bortezomib, cyclophosphamide, and dexamethasone (VCD) until cyclophosphamide was replaced with lenalidomide in the combination (VRD). These treatments have never been compared head-to-head in large real-life patient material. METHOD A retrospective analysis of patients treated with VRD and VCD in the first line, both with and without subsequent high-dose treatment (HDT) and autologous stem cell transplantation. A total of 681 patients were included, 117 receiving VRD (71 with, 46 without HDT) and 564 receiving VCD (351 with, 213 without HDT). RESULTS Overall response rate (≥partial response) was higher with VRD compared to VCD in the entire VRD group (98% vs 88%, P < 0.001) and in the non-HDT group (98% vs 79%, P < 0.001). Progression-free survival (PFS) at 18 months was longer with VRD compared to VCD in the entire VRD group, the non-HDT group and the HDT group (88% vs 63%, 82% vs 32% and 91% vs 73%, respectively). Overall survival at 18 months was better for VRD-treated patients in the entire VRD group (95% vs 89%, P = 0.048). CONCLUSION Upfront VRD gives better responses and longer PFS compared to VCD in MM patients with or without subsequent HDT.
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Affiliation(s)
- Katarina Uttervall
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Hematology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Johanna Borg Bruchfeld
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Hematology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Charlotte Gran
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - Göran Wålinder
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Hematology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Robert Månsson
- Hematology Center, Karolinska University Hospital, Stockholm, Sweden.,Department of Laboratory Medicine, Center for Hematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Johan Lund
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Hematology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Gösta Gahrton
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Hematology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Evren Alici
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hareth Nahi
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Hematology Center, Karolinska University Hospital, Stockholm, Sweden
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95
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Gagelmann N, Eikema DJ, Koster L, Caillot D, Pioltelli P, Lleonart JB, Reményi P, Blaise D, Schaap N, Trneny M, Passweg J, Porras RP, Cahn JY, Musso M, Poiré X, Fenk R, Itälä-Remes M, Pavone V, Fouillard L, Maertens J, Bron D, Pouli A, Schroyens W, Schönland S, Garderet L, Yakoub-Agha I, Kröger N. Tandem Autologous Stem Cell Transplantation Improves Outcomes in Newly Diagnosed Multiple Myeloma with Extramedullary Disease and High-Risk Cytogenetics: A Study from the Chronic Malignancies Working Party of the European Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2019; 25:2134-2142. [PMID: 31288095 DOI: 10.1016/j.bbmt.2019.07.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 01/01/2023]
Abstract
Although high-dose therapy and autologous stem cell transplant combined with novel agents continues to be the hallmark of first-line treatment in newly diagnosed transplant-eligible multiple myeloma patients, the impact of tandem autologous or autologous/reduced-intensity allogeneic transplant for patients with extramedullary disease (EMD) and high-risk cytogenetics is not yet defined. Here, we analyzed clinical and cytogenetic data from 488 adult myeloma patients with EMD undergoing single autologous (n = 373), tandem autologous (n = 84), or autologous-allogeneic transplant (n = 31) between 2003 and 2015. At least 1 high-risk abnormality was present in 41% (n = 202), with del(17p) (40%) and t(4;14) (45%) the most frequent. More than 1 high-risk abnormality was found in 54%. High-risk cytogenetics showed worse 4-year overall survival (OS) and progression-free survival (PFS) of 54% and 29%, respectively, versus 78% and 49% for standard-risk cytogenetics (P < .001). Co-segregation of high-risk abnormalities did not seem to affect outcome. Regarding transplant regimen, OS and PFS were 70% and 43% for single autologous versus 83% and 52% for tandem autologous and 88% and 58% for autologous-allogeneic (P = .06 and P = .30). In multivariate analysis high-risk cytogenetics were associated with worse survival (hazard ratio [HR], 2.00; P = .003), whereas tandem autologous significantly improved outcome versus single autologous transplant (HRs, .46 and .64; P = .02 and P = .03). Autologous-allogeneic transplant did not significantly differ in outcome but appeared to improve survival, but results were limited because of small population (HR, .31). In conclusion, high-risk cytogenetics is frequently observed in newly diagnosed myeloma with EMD and significantly worsens outcome after single autologous, whereas a tandem autologous transplant strategy may overcome onset poor prognosis.
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Affiliation(s)
- Nico Gagelmann
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | | | | | - Péter Reményi
- St. István and St. Laszlo Hospital, Budapest, Hungary
| | | | - Nicolaas Schaap
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Marek Trneny
- Charles University Hospital, Prague, Czech Republic
| | | | | | | | | | - Xavier Poiré
- Cliniques Universitaires St. Luc, Brussels, Belgium
| | - Roland Fenk
- Heinrich Heine University, Düsseldorf, Germany
| | | | | | | | | | | | | | | | - Stefan Schönland
- Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | | | - Nicolaus Kröger
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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96
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Nair CK, Selvaraj K, Raghavan V, A M, Shenoy PK, Kurup AR, Duraisamy K, Shringarpure K, Venugopal V. Limiting factors for autologous transplantation among transplant-eligible multiple myeloma patients: Lesson from a Tertiary Cancer Centre in rural India. Leuk Res 2019; 83:106167. [PMID: 31200146 DOI: 10.1016/j.leukres.2019.106167] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 06/05/2019] [Accepted: 06/06/2019] [Indexed: 12/22/2022]
Abstract
There is limited data from low and middle income countries on the exact proportion of Myeloma patients undergoing transplant even if they are eligible for the same. In this retrospective analysis of all newly diagnosed transplant eligible Myeloma treated between January 2011 to June 2017, number of patients undergoing transplant were recorded and among those not opting for transplant, reasons for the same were noted. Among 89 eligible patients, 23 (26%) patients could undergo transplantation. Most common reasons for not undergoing transplant were fear of the complications in 42 (47%) and financial reasons in 41 (46%) of patients. The transplanted group had better progression free survival when compared against the non-transplanted group (3 year PFS of 80% versus 36%, HR = 0.09, 95%CI 0.02-0.4, p = 0.001). Future studies may be conducted to arrive at measures, for correcting the transplant related concerns and fears, through psycho-social interventions.
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Affiliation(s)
- Chandran K Nair
- Department of Clinical Hematology and Medical Oncology, Malabar Cancer Centre, Thalassery, Kerala, India.
| | - Kalaiselvi Selvaraj
- Department of Community Medicine, All India Institute of Medical Sciences, Nagpur, India
| | - Vineetha Raghavan
- Department of Clinical Hematology and Medical Oncology, Malabar Cancer Centre, Thalassery, Kerala, India
| | - Manuprasad A
- Department of Clinical Hematology and Medical Oncology, Malabar Cancer Centre, Thalassery, Kerala, India
| | - Praveen Kumar Shenoy
- Department of Clinical Hematology and Medical Oncology, Malabar Cancer Centre, Thalassery, Kerala, India
| | - Anju R Kurup
- Department of Clinical Hematology and Medical Oncology, Malabar Cancer Centre, Thalassery, Kerala, India
| | | | - Kalpita Shringarpure
- Department of Preventive and Social Medicine, Medical College Baroda, Vadodara, Gujarat, India
| | - Vinayagamoorthy Venugopal
- Department of Community Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
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97
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Gomez-Arteaga A, Mark TM, Guarneri D, Christos PJ, Gergis U, Greenberg JD, Hsu J, Mayer SA, Niesvizky R, Pearse RN, Phillips AA, Rossi A, Coleman M, van Besien K, Shore TB. High-dose bendamustine and melphalan conditioning for autologous stem cell transplantation for patients with multiple myeloma. Bone Marrow Transplant 2019; 54:2027-2038. [PMID: 31190006 DOI: 10.1038/s41409-019-0587-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/13/2019] [Accepted: 05/20/2019] [Indexed: 11/09/2022]
Abstract
High-dose melphalan (MEL200) followed by autologous stem cell transplantation (ASCT) remains a standard of care for multiple myeloma (MM). Bendamustine induces responses in MM resistant to other alkylators. Our prior Phase I trial adding bendamustine to MEL200 transplant conditioning resulted in no additional toxicity. We now report a single-arm, phase II study that evaluated the efficacy of bendamustine 225 mg/m2 with MEL200 conditioning for ASCT in 18 patients with newly diagnosed MM (NDMM) and 17 with relapsed or refractory MM (RRMM). The primary end point was the complete response (CR/sCR) rate at day+ 100. Sample size was determined according to Simon's two-stage design. At stage 1, sixteen patients entered the study. As there were eight patients with CR/sCR, enrollment increased to 28 patients. Sixteen out of the first 28 evaluable patients achieved CR/sCR, meeting the design criteria. Enrollment was then expanded to a total of 35 patients. 51% achieved a CR/sCR. After a median follow-up of 65 months, 21 patients progressed, including 7 deaths. The median PFS for NDMM and RRMM was 48 and 45 months, respectively. Bendamustine/MEL200 conditioning resulted in excellent overall and depth of response as well as PFS, particularly in the RRMM patients, and is worthy of further investigation (NCT00916058).
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Affiliation(s)
- Alexandra Gomez-Arteaga
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA.
| | - Tomer M Mark
- Department of Medicine, Division of Hematology, University of Colorado - Anschutz Medical Campus, New York, NY, USA
| | - Danielle Guarneri
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Paul J Christos
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Usama Gergis
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - June D Greenberg
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Jingmei Hsu
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Sebastian A Mayer
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Ruben Niesvizky
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Roger N Pearse
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Adrienne A Phillips
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Adriana Rossi
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Morton Coleman
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Koen van Besien
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Tsiporah B Shore
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
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98
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Mian H, Mian OS, Rochwerg B, Foley R, Wildes TM. Autologous stem cell transplant in older patients (age ≥ 65) with newly diagnosed multiple myeloma: A systematic review and meta-analysis. J Geriatr Oncol 2019; 11:93-99. [PMID: 31153809 DOI: 10.1016/j.jgo.2019.05.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/08/2019] [Accepted: 05/15/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE While autologous stem cell transplant (ASCT) is a standard of care for newly-diagnosed younger patients with multiple myeloma, its role in older patients remains controversial. We conducted a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs) assessing the efficacy and toxicity of ASCT in older patients (age ≥ 65 years) with newly-diagnosed myeloma. METHODS We searched Medline, Embase, and the Cochrane database through February 2, 2018. The primary outcome was overall survival; secondary outcomes included progression-free survival, response rates and toxicity. The Grading of Recommendations Assessment, Development and Evaluation criteria (GRADE) method was used to assess certainty in evidence. RESULTS Of 8614 abstracts screened, six observational studies and two RCTs were included in the systematic review. For overall survival, pooled observational data favored ASCT (Hazard Ratio [HR] 0.44, 95% Confidence Interval [CI] 0.34-0.58, p < .0001), while the impact of the RCT data was uncertain (HR 0.94, 95% CI 0.25-3.54, p = .93). Observational data showed higher complete response rates with ASCT (odds ratio 5.06, 95% CI 2.60-9.88, p < .0001). Progression free survival benefit from the RCTs was uncertain (HR 1.05, 95% CI 0.36-3.12, p = .93). Data were insufficient to pool for toxicity. CONCLUSION For older patients with newly diagnosed multiple myeloma, ASCT may improve the overall survival and complete response rates based upon observational data although the quality of this evidence is very low. The role of ASCT in improving overall survival based upon RCT data remains uncertain with low quality of evidence. Our study highlights the urgent need for well-conducted studies to understand the role of ASCT in older patients.
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Affiliation(s)
- Hira Mian
- Juravinski Cancer Center, Department of Oncology, McMaster University, Hamilton, Canada.
| | - Owais S Mian
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Ronan Foley
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Tanya M Wildes
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States of America
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99
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Paul B, Lipe B, Ocio EM, Usmani SZ. Induction Therapy for Newly Diagnosed Multiple Myeloma. Am Soc Clin Oncol Educ Book 2019; 39:e176-e186. [PMID: 31099624 DOI: 10.1200/edbk_238527] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The frontline therapy for newly diagnosed multiple myeloma (MM) has continued to evolve over the last 10 years. There has been a growing emphasis on achieving the best depth of response in the context of minimal residual disease negativity, given its prognostic correlation with superior overall survival. Another important area of emphasis has been to improve prognostication and staging by including information on disease biology. There also a growing appreciation of global differences in drug access and patterns of care. The current review explores each of these areas and how best to incorporate the emerging induction regimens in to schema of MM therapy.
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Affiliation(s)
| | - Brea Lipe
- 2 Wilmont Cancer Institute, University of Rochester Medical Center, Rochester, NY
| | - Enrique M Ocio
- 3 University Hospital Marqués de Valdecilla (IDIVAL), University of Cantabria, Santander, Spain
| | - Saad Z Usmani
- 4 Plasma Cell Disorders Division, Department of Hematologic Oncology & Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC
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100
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Duarte RF, Labopin M, Bader P, Basak GW, Bonini C, Chabannon C, Corbacioglu S, Dreger P, Dufour C, Gennery AR, Kuball J, Lankester AC, Lanza F, Montoto S, Nagler A, Peffault de Latour R, Snowden JA, Styczynski J, Yakoub-Agha I, Kröger N, Mohty M. Indications for haematopoietic stem cell transplantation for haematological diseases, solid tumours and immune disorders: current practice in Europe, 2019. Bone Marrow Transplant 2019; 54:1525-1552. [PMID: 30953028 DOI: 10.1038/s41409-019-0516-2] [Citation(s) in RCA: 176] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/05/2019] [Accepted: 03/07/2019] [Indexed: 12/20/2022]
Abstract
This is the seventh special EBMT report on the indications for haematopoietic stem cell transplantation for haematological diseases, solid tumours and immune disorders. Our aim is to provide general guidance on transplant indications according to prevailing clinical practice in EBMT countries and centres. In order to inform patient decisions, these recommendations must be considered together with the risk of the disease, the risk of the transplant procedure and the results of non-transplant strategies. In over two decades since the first report, the EBMT indications manuscripts have incorporated changes in transplant practice coming from scientific and technical developments in the field. In this same period, the establishment of JACIE accreditation has promoted high quality and led to improved outcomes of patient and donor care and laboratory performance in transplantation and cellular therapy. An updated report with operating definitions, revised indications and an additional set of data with overall survival at 1 year and non-relapse mortality at day 100 after transplant in the commonest standard-of-care indications is presented. Additional efforts are currently underway to enable EBMT member centres to benchmark their risk-adapted outcomes as part of the Registry upgrade Project 2020 against national and/or international outcome data.
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Affiliation(s)
- Rafael F Duarte
- Hospital Universitario Puerta de Hierro Majadahonda - Universidad Autónoma de Madrid, Madrid, Spain.
| | - Myriam Labopin
- EBMT Paris Study Office, Hopital Saint Antoine, Paris, France
| | - Peter Bader
- Goethe University Hospital, Frankfurt/Main, Germany
| | | | - Chiara Bonini
- Vita-Salute San Raffaele University & Ospedale San Raffaele Scientific Institute, Milan, Italy
| | - Christian Chabannon
- Institut Paoli Calmettes & Centre d'Investigations Cliniques en Biothérapies, Marseille, France
| | | | - Peter Dreger
- Medizinische Klinik V, Universität Heidelberg, Heidelberg, Germany
| | - Carlo Dufour
- Giannina Gaslini Children's Hospital, Genoa, Italy
| | | | - Jürgen Kuball
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arjan C Lankester
- Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Arnon Nagler
- Chaim Sheva Medical Center, Tel-Hashomer, Israel
| | | | - John A Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Jan Styczynski
- Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | | | - Mohamad Mohty
- Hopital Saint Antoine, Sorbonne Université, Paris, France
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