51
|
Tariq SM, Abdallah AO, Goodman A, Sborov D, Mohyuddin GR, Britt A. The Landscape of Currently Enrolling Maintenance Trials in Multiple Myeloma. Clin Hematol Int 2023:10.1007/s44228-023-00044-8. [PMID: 37133718 DOI: 10.1007/s44228-023-00044-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/27/2023] [Indexed: 05/04/2023] Open
Abstract
Maintenance therapies in multiple myeloma improve survival after induction treatment. This study characterizes the strategies for maintenance therapy being employed in currently enrolling clinical trials for patients with multiple myeloma and highlights how high-risk myeloma patients may be assigned to maintenance strategies incongruent with current US guidelines.
Collapse
Affiliation(s)
| | - Al-Ola Abdallah
- Division of Hematological Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Aaron Goodman
- Division of Hematology and Oncology, University of California San Diego, La Jolla, CA, USA
| | - Douglas Sborov
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, UT, USA
| | - Ghulam Rehman Mohyuddin
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, UT, USA.
| | - Alec Britt
- Division of Hematological Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, USA
| |
Collapse
|
52
|
Suzuki K, Yano S. Treatment Strategy for Ultra-High-Risk Multiple Myelomas with Chromosomal Aberrations Considering Minimal Residual Disease Status and Bone Marrow Microenvironment. Cancers (Basel) 2023; 15:cancers15092418. [PMID: 37173885 PMCID: PMC10177433 DOI: 10.3390/cancers15092418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/12/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023] Open
Abstract
Despite the development of anti-myeloma therapeutics, such as proteasome inhibitors, immunomodulatory drugs, anti-CD38 monoclonal antibodies, and autologous stem cell transplantation (ASCT), multiple myeloma remains incurable. A trial treatment combining four drugs-daratumumab, carfilzomib, lenalidomide, and dexamethasone-followed by ASCT frequently results in minimal residual disease (MRD) negativity and prevents progressive disease in patients with standard- and high-risk cytogenetics; however, it is insufficient to overcome the poor outcomes in patients with ultra-high-risk chromosomal aberration (UHRCA). In fact, MRD status in autografts can predict clinical outcomes after ASCT. Therefore, the current treatment strategy might be insufficient to overcome the negative impact of UHRCA in patients with MRD positivity after the four-drug induction therapy. High-risk myeloma cells lead to poor clinical outcomes not only by aggressive myeloma behavior but also via the generation of a poor bone marrow microenvironment. Meanwhile, the immune microenvironment effectively suppresses myeloma cells with a low frequency of high-risk cytogenetic abnormalities in early-stage myeloma compared to late-stage myeloma. Therefore, early intervention might be key to improving clinical outcomes in myeloma patients. The purpose of this review is to improve clinical outcomes in patients with UHRCA by considering MRD assessment results and improvement of the microenvironment.
Collapse
Affiliation(s)
- Kazuhito Suzuki
- Division of Clinical Oncology and Hematology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishi-Shimbashi, Minato-ku, Tokyo 105-0003, Japan
| | - Shingo Yano
- Division of Clinical Oncology and Hematology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishi-Shimbashi, Minato-ku, Tokyo 105-0003, Japan
| |
Collapse
|
53
|
Gagelmann N, Eikema DJ, Koster L, Netelenbos T, McDonald A, Stoppa AM, Fenk R, Anagnostopoulos A, van Gorkom G, Deconinck E, Bulabois CE, Delforge M, Bunjes D, Arcese W, Reményi P, Itälä-Remes M, Thurner L, Bolaman AZ, Nabil Y, Lund J, Labussière-Wallet H, Hayden PJ, Beksac M, Schönland S, Yakoub-Agha I. Impact of newly diagnosed extramedullary myeloma on outcome after first autograft followed by maintenance: A CMWP-EBMT study. Eur J Haematol 2023. [PMID: 37082839 DOI: 10.1111/ejh.13981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND No adequate data exist on the impact of multiple myeloma (MM) with extramedullary disease (EMD) after autograft and maintenance therapy. METHODS We identified 808 patients with newly diagnosed MM who received first autograft, of whom 107 had EMD (83 paraskeletal and 24 organ involvement), and who had been reported to the EBMT registry December 2018. Distribution according to type of involvement was similar between the treatment groups (p = .69). For EMD, 46 (40%) received thalidomide, 59 (51%) lenalidomide, and 11 (10%) bortezomib. RESULTS The median follow-up from maintenance start was 44 months. Three-year progression-free survival (PFS) was 52% (48%-57%) for no EMD, 56% (44%-69%) for paraskeletal involvement, and 45% (22%-68%) for organ involvement (p = .146). Early PFS (within first year) appeared to be significantly worse for organ involvement (hazard ratio, 3.40), while no significant influence was found after first year from maintenance start. Three-year overall survival (OS) was 81% (77%-84%), 88% (80%-96%), and 68% (47%-89%; p = .064), respectively. With thalidomide as reference, lenalidomide was significantly associated with better PFS and OS, whereas bortezomib appeared to improve outcome specifically in EMD. CONCLUSION Lenalidomide maintenance is standard of care for MM without EMD, whereas extramedullary organ involvement remains a significant risk factor for worse outcome, especially for early events after maintenance start.
Collapse
Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dirk-Jan Eikema
- Department of Statistics, Leiden University Medical Centre, Leiden, The Netherlands
| | | | | | - Andrew McDonald
- Alberts Cellular Therapy, Pretoria East Hospital, Pretoria, South Africa
| | | | - Roland Fenk
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | | | - Gwendolyn van Gorkom
- Department of Internal Medicine, Division of Hematology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Eric Deconinck
- Clinical Hematology, Besançon University Hospital, Besançon, France
| | - Claude-Eric Bulabois
- Service d'Hematologie, CHU Grenoble Alpes-Universite Grenoble Alpes, Grenoble, France
| | | | - Donald Bunjes
- Department of Internal Medicine III, Bone Marrow Transplantation Unit, University Hospital of Ulm, Ulm, Germany
| | - William Arcese
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Péter Reményi
- St. István and St. László Hospital of Budapest, Budapest, Hungary
| | - Maija Itälä-Remes
- Turku University Hospital, Stem Cell Transplantation Unit, Turku, Finland
| | - Lorenz Thurner
- Department of Oncology, Hematology, Rheumatology and Clinical Immunology, Saarland University Medical Center, Homburg, Germany
| | - Ali Zahit Bolaman
- Internal Medicine, Division of Hematology, Adnan Menderes University, Aydin, Turkey
| | - Yafour Nabil
- Établissement hospitalier et universitaire, Service d'hématologie et de thérapie cellulaire, Université d'Oran 1, Ahmed Ben Bella, faculté de médecine, Oran, Algeria
| | - Johan Lund
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska Institute & University Hospital, Stockholm, Sweden
| | | | - Patrick J Hayden
- Department of Haematology, St. James's Hospital, Dublin, Ireland
| | | | - Stefan Schönland
- Medical Department V, Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Ibrahim Yakoub-Agha
- INSERM U1286, Centre Hospitalier Universitaire de Lille LIRIC, Lille, France
| |
Collapse
|
54
|
Morè S, Corvatta L, Manieri VM, Olivieri A, Offidani M. Current Main Topics in Multiple Myeloma. Cancers (Basel) 2023; 15:2203. [PMID: 37190132 PMCID: PMC10136770 DOI: 10.3390/cancers15082203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 05/17/2023] Open
Abstract
Multiple Myeloma (MM) remains a difficult to treat disease mainly due to its biological heterogeneity, of which we are more and more knowledgeable thanks to the development of increasingly sensitive molecular methods that allow us to build better prognostication models. The biological diversity translates into a wide range of clinical outcomes from long-lasting remission in some patients to very early relapse in others. In NDMM transplant eligible (TE) patients, the incorporation of mAb as daratumumab in the induction regimens, followed by autologous stem cell transplantation (ASCT) and consolidation/maintenance therapy, has led to a significant improvement of PFS and OS.; however, this outcome remains poor in ultra-high risk MM or in those who did not achieve a minimal residual disease (MRD) negativity. Several trials are exploring cytogenetic risk-adapted and MRD-driven therapies in these patients. Similarly, quadruplets-containing daratumumab, particularly when administered as continuous therapies, have improved outcome of patients not eligible for autologous transplant (NTE). Patients who become refractory to conventional therapies have noticeably poor outcomes, making their treatment a difficult challenge in need of novel strategies. In this review, we will focus on the main points regarding risk stratification, treatment and monitoring of MM, highlighting the most recent evidence that could modify the management of this still incurable disease.
Collapse
Affiliation(s)
- Sonia Morè
- Clinica di Ematologia Azienda Ospedaliero, Universitaria delle Marche, 60126 Ancona, Italy
| | - Laura Corvatta
- Unità Operativa Complessa di Medicina, Ospedale Profili, 60044 Fabriano, Italy
| | | | - Attilio Olivieri
- Clinica di Ematologia Azienda Ospedaliero, Universitaria delle Marche, 60126 Ancona, Italy
| | - Massimo Offidani
- Clinica di Ematologia Azienda Ospedaliero, Universitaria delle Marche, 60126 Ancona, Italy
| |
Collapse
|
55
|
Panopoulou A, Cairns DA, Holroyd A, Nichols I, Cray N, Pawlyn C, Cook G, Drayson M, Boyd K, Davies FE, Jenner M, Morgan GJ, Owen R, Houlston R, Jackson G, Kaiser MF. Optimizing the value of lenalidomide maintenance by extended genetic profiling: an analysis of 556 patients in the Myeloma XI trial. Blood 2023; 141:1666-1674. [PMID: 36564045 PMCID: PMC10113174 DOI: 10.1182/blood.2022018339] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/29/2022] [Accepted: 12/04/2022] [Indexed: 12/25/2022] Open
Abstract
Prediction of individual patient benefit from lenalidomide (Len) maintenance after autologous stem cell transplant (ASCT) remains challenging. Here, we investigated extended molecular profiling for outcome prediction in patients in the National Cancer Research Institute Myeloma XI (MyXI) trial. Patients in the MyXI trial randomized to Len maintenance or observation after ASCT were genetically profiled for t(4;14), t(14;16), t(14;20), del(1p), gain(1q), and del(17p) and co-occurrence of risk markers was computed. Progression-free survival (PFS), subsequent progression (PFS2), and overall survival (OS) were calculated from maintenance randomization, and groups were compared using Cox proportional hazards regression. Of 556 patients, 17% with double-hit multiple myeloma (MM) (≥2 risk markers), 32% with single-hit (1 risk marker), and 51% without risk markers were analyzed. Single-hit MM derived the highest PFS benefit from Len maintenance, specifically, isolated del(1p), del(17p), and t(4;14), with ∼40-fold, 10-fold, and sevenfold reduced risk of progression or death (PFS), respectively, compared with observation. This benefit translated into improved PFS2 and OS for this group of patients compared with observation; median PFS was 10.9 vs 57.3 months for observation vs Len maintenance. Patients with isolated gain(1q) derived no benefit, and double-hit MM limited benefit (regardless or risk lesions involved) from Len maintenance. Extended genetic profiling identifies patients deriving exceptional benefit from Len maintenance and should be considered for newly diagnosed patients to support management discussions along their treatment pathway. This trial was registered at www.isrctn.com/ISRCTN49407852 as # ISRCTN49407852.
Collapse
Affiliation(s)
- Aikaterini Panopoulou
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, United Kingdom
- Department of Haematology, Royal Marsden Hospital, London, United Kingdom
| | - David A. Cairns
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, Leeds, United Kingdom
| | - Amy Holroyd
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, United Kingdom
| | - Isabel Nichols
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, United Kingdom
| | - Nikita Cray
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, United Kingdom
| | - Charlotte Pawlyn
- Department of Haematology, Royal Marsden Hospital, London, United Kingdom
- Division of Cancer Therapeutics, Institute of Cancer Research, London, United Kingdom
| | - Gordon Cook
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, Leeds, United Kingdom
| | - Mark Drayson
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Kevin Boyd
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, United Kingdom
- Department of Haematology, Royal Marsden Hospital, London, United Kingdom
| | | | - Matthew Jenner
- Department of Haematology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | | | - Roger Owen
- Haematological Malignancy Diagnostic Service, St James’s University Hospital, Leeds, United Kingdom
| | - Richard Houlston
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, United Kingdom
| | - Graham Jackson
- Department of Haematology, University of Newcastle, Newcastle Upon Tyne, United Kingdom
| | - Martin F. Kaiser
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, United Kingdom
- Department of Haematology, Royal Marsden Hospital, London, United Kingdom
| |
Collapse
|
56
|
Mateos MV, González-Calle V. Lenalidomide maintenance based on a genetic profile. Blood 2023; 141:1649-1650. [PMID: 37022733 DOI: 10.1182/blood.2022019352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Affiliation(s)
- María-Victoria Mateos
- University Hospital of Salamanca
- Institute for Biomedical Research of Salamanca
- Institute of Cancer Molecular and Cellular Biology
| | - Verónica González-Calle
- University Hospital of Salamanca
- Institute for Biomedical Research of Salamanca
- Institute of Cancer Molecular and Cellular Biology
| |
Collapse
|
57
|
Jenner MW, Pawlyn C, Davies FE, Menzies T, Hockaday A, Olivier C, Jones JR, Karunanithi K, Lindsay J, Kishore B, Cook G, Drayson MT, Kaiser MF, Owen RG, Gregory W, Cairns DA, Morgan G, Jackson GH. The addition of vorinostat to lenalidomide maintenance for patients with newly diagnosed multiple myeloma of all ages: results from 'Myeloma XI', a multicentre, open-label, randomised, phase III trial. Br J Haematol 2023; 201:267-279. [PMID: 36541152 PMCID: PMC10952726 DOI: 10.1111/bjh.18600] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/16/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
Lenalidomide is an effective maintenance agent for patients with myeloma, prolonging first remission and, in transplant eligible patients, improving overall survival (OS) compared to observation. The 'Myeloma XI' trial, for newly diagnosed patients, aimed to evaluate whether the addition of the histone deacetylase inhibitor vorinostat to the lenalidomide maintenance backbone could improve outcomes further. Patients included in this analysis were randomised to maintenance therapy with lenalidomide alone (10 mg/day on days 1-21 of each 28-day cycle), or in combination with vorinostat (300 mg/day on day 1-7 and 15-21 of each 28-day cycle) with treatment continuing until unacceptable toxicity or progressive disease. There was no significant difference in median progression-free survival between those receiving lenalidomide-vorinostat or lenalidomide alone, 34 and 40 months respectively (hazard ratio [HR] 1.18, 95% confidence interval [CI] 0.96-1.44, p = 0.109). There was also no significant difference in median OS, not estimable and 75 months respectively (HR 0.99, 95% CI 0.76-1.29, p = 0.929). Subgroup analysis demonstrated no statistically significant heterogeneity in outcomes. Combination lenalidomide-vorinostat appeared to be poorly tolerated with more dose modifications, fewer cycles of maintenance therapy delivered and higher rates of discontinuation due to toxicity than lenalidomide alone. The trial did not meet its primary end-point, there was no benefit from the addition of vorinostat to lenalidomide maintenance.
Collapse
Affiliation(s)
| | - Charlotte Pawlyn
- The Institute of Cancer ResearchLondonUK
- The Royal Marsden NHS Foundation TrustLondonUK
| | | | - Tom Menzies
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | - Anna Hockaday
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | - Catherine Olivier
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | - John R. Jones
- Eastbourne District General HospitalEastbourneUK
- Brighton and Sussex Medical SchoolUniversity of SussexSussexUK
- Kings College Hospital NHS Foundation TrustLondonUK
| | | | | | - Bhuvan Kishore
- University Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Gordon Cook
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
- Leeds Cancer CentreLeeds Teaching Hospitals TrustLeedsUK
| | - Mark T. Drayson
- Institute of Immunology and ImmunotherapyUniversity of BirminghamBirminghamUK
| | - Martin F. Kaiser
- The Institute of Cancer ResearchLondonUK
- The Royal Marsden NHS Foundation TrustLondonUK
| | - Roger G. Owen
- Haematological Malignancy Diagnostic Service (HMDS), Leeds Cancer CentreLeeds Teaching Hospitals TrustLeedsUK
| | - Walter Gregory
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | - David A. Cairns
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | | | | | | |
Collapse
|
58
|
Raje N, Mateos MV, Iida S, Reece D. Clinical evidence for immune-based strategies in early-line multiple myeloma: current challenges in decision-making for subsequent therapy. Blood Cancer J 2023; 13:41. [PMID: 36944635 PMCID: PMC10030780 DOI: 10.1038/s41408-023-00804-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 02/07/2023] [Accepted: 02/23/2023] [Indexed: 03/23/2023] Open
Abstract
Almost all patients with multiple myeloma (MM) will eventually develop disease that has relapsed with or become refractory to available treatments and will require additional therapy. However, data are still lacking on how best to sequence regimens in the relapsed/refractory (RR) setting after the failure of early-line lenalidomide, bortezomib, and/or daratumumab, the most commonly used agents in clinical practice today. With the treatment landscape rapidly changing in response to emerging clinical trial data and approvals of several new drugs and additional combinations, it is critically important to focus on patients with RRMM. Variability in patient baseline characteristics, such as the number of prior lines of treatment, refractoriness to prior treatments, prior stem cell transplant, and timing and dosing of prior lenalidomide, makes it difficult to select the best options for patients with RRMM for whom first-line treatments have failed. The aim of this review is to provide both an overview of current therapies and future directions within the RRMM treatment landscape, and a framework for clinicians to choose the most promising next treatment option.
Collapse
Affiliation(s)
- Noopur Raje
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA.
| | - María-Victoria Mateos
- University Hospital of Salamanca/IBSAL/Cancer Research Center-IBMCC (USAL-CSIC), Salamanca, Spain
| | - Shinsuke Iida
- Department of Hematology and Oncology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Donna Reece
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| |
Collapse
|
59
|
Xu T, Yang Y, Li J, Xu J, Wang W, Wang Y, Maihemaiti A, Ren L, Lan T, Zhou C, Li P, Wang P, Liu P. Real world outcomes of lenalidomide or bortezomib maintenance in patients with multiple myeloma not undergoing stem cell transplantation. Ann Hematol 2023; 102:1171-1184. [PMID: 36882560 DOI: 10.1007/s00277-023-05148-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 12/19/2022] [Indexed: 03/09/2023]
Abstract
Maintenance is one form of long-term therapies in multiple myeloma (MM). Lenalidomide and bortezomib are two commonly used options. The role of maintenance in patients not undergoing transplant remains unclear. A total of 248 newly diagnosed MM patients who received over 180 days of any standard-of-care induction therapy and did not receive autologous stem cell transplantation were included. Patients either receive lenalidomide, bortezomib or no maintenance. Patterns of usage, survival benefit, discontinuation status were analyzed. 93, 99 and 56 patients received no, lenalidomide (Len) and bortezomib (Bor) maintenance respectively. Patients receiving Bor had a higher incidence of traditional high-risk cytogenetics (14.0% (No) vs 14.1% (Len) vs 41.1% (Bor), P < 0.001). Len maintenance conferred a superior progression-free survival (PFS) and overall survival (OS) compared to no maintenance (median PFS, 60.1 vs 26.9 months, P = 0.003; median OS, NR vs 56.7 months, P = 0.046), with a near independent impact on PFS (adjusted HR 0.580, P = 0.058). The PFS and OS benefit of Len maintenance was seen in subgroups of ISS stage I/II, traditional standard-risk cytogenetics, and pre-maintenance < CR. Bor maintenance did not confer PFS or OS benefit for the entire cohort, but improved OS in patients with pre-maintenance < CR. Discontinuation due to toxicity was recorded in 11.1% and 8.9% of patients receiving Len or Bor maintenance respectively. Our study supports lenalidomide maintenance as the standard-of-care in MM patients not undergoing transplant. Further studies are warranted for bortezomib maintenance in the non-transplant setting, and better maintenance strategy is needed for patients with adverse prognostic factors.
Collapse
Affiliation(s)
- Tianhong Xu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Shanghai Geriatric Medical Center, Shanghai, China
| | - Yang Yang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing Li
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiadai Xu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenjing Wang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yawen Wang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Aziguli Maihemaiti
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Liang Ren
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tianwei Lan
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chi Zhou
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Panpan Li
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Pu Wang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Peng Liu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China. .,Department of Hematology, Shanghai Geriatric Medical Center, Shanghai, China.
| |
Collapse
|
60
|
Lenalidomide Maintenance and Measurable Residual Disease in a Real-World Multiple Myeloma Transplanted Population Receiving Different Treatment Strategies Guided by Access to Novel Drugs in Brazil. Cancers (Basel) 2023; 15:cancers15051605. [PMID: 36900396 PMCID: PMC10000507 DOI: 10.3390/cancers15051605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
Despite recent advances in multiple myeloma (MM), the incorporation of novel agents and measurable residual disease (MRD) monitoring in low-income countries remains a challenge. Although lenalidomide maintenance (M-Len) after autologous stem cell transplantation (ASCT) has been associated with improved outcomes and MRD has refined the prognosis of complete response (CR) cases, until now, there have been no data on the benefits of these approaches in Latin America. Here, we evaluate the benefits of M-Len and MRD using next-generation flow cytometry (NGF-MRD) at Day + 100 post-ASCT (n = 53). After ASCT, responses were evaluated based on the International Myeloma Working Group criteria and NGF-MRD. MRD was positive in 60% of patients with a median progression-free survival (PFS) of 31 months vs. not reached (NR) for MRD-negative cases (p = 0.05). The patients who received M-Len continuously had a significantly better PFS and overall survival (OS) than those without M-Len (median PFS: NR vs. 29 months, p = 0.007), with progression in 11% vs. 54% of cases after a median follow-up of 34 months, respectively. In a multivariate analysis, MRD status and M-Len therapy emerged as independent predictors of PFS (median PFS of M-Len/MRD- vs. no M-Len/MRD+ of NR vs. 35 months, respectively; p = 0.01). In summary, M-Len was associated with improved survival outcomes in our real-world MM cohort in Brazil, with MRD emerging as a useful reproducible tool to identify patients at an earlier risk of relapse. The inequity in drug access remains a hurdle in countries with financial constraints, with a negative impact on MM survival.
Collapse
|
61
|
Etekal T, Koehn K, Sborov DW, McClune B, Prasad V, Haslam A, Berger K, Booth C, Al Hadidi S, Abdallah AO, Goodman A, Mohyuddin GR. Time-to-event surrogate end-points in multiple myeloma randomised trials from 2005 to 2019: A surrogacy analysis. Br J Haematol 2023; 200:587-594. [PMID: 36495317 DOI: 10.1111/bjh.18568] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/25/2022] [Accepted: 11/04/2022] [Indexed: 12/14/2022]
Abstract
Use of surrogate end-points such as progression-free survival (PFS) and other time-to-event (TTE) end-points is common in multiple myeloma (MM) clinical trials. This systematic review characterises all published randomised controlled trials (RCTs) in MM using PFS or other TTE end-points between 2005 and 2019 and assesses strength of surrogacy of PFS for overall survival (OS). The association between OS hazard ratios (HRs) and PFS HRs was evaluated with linear regression, and the coefficient of determination with Pearson's correlation. We identified 88 RCTs of which 67 (76%) used PFS as the primary/co-primary end-point. One trial indicated whether progression was biochemical or clinical. Of the variance in OS, 39% was due to variance in PFS. Correlation between PFS and OS was weak (0.62, 95% confidence interval [CI] 0.38-0.78). In newly diagnosed MM, 43% of the variance in OS was due to changes in PFS. The correlation between PFS and OS was weak (0.65, 95% CI 0.30-0.84). In relapsed/refractory MM, 58% of the variance in OS was due to changes in PFS. Correlation between PFS and OS was medium (0.76, 95% CI 0.42-0.91). We demonstrate that PFS and progression characteristics are characterised poorly in MM trials and that PFS is a poor surrogate for OS in MM.
Collapse
Affiliation(s)
- Tommy Etekal
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Kelly Koehn
- Division of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Lawrence, Kansas, USA
| | - Douglas W Sborov
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, Utah, USA
| | - Brian McClune
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, Utah, USA
| | - Vinay Prasad
- Division of Hematology/Oncology, University of California San Francisco, San Francisco, California, USA
| | - Alyson Haslam
- Department of Epidemiology/Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Katherine Berger
- Patient Advocate, University of Hartford, West Hartford, Connecticut, USA
| | - Christopher Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - Samer Al Hadidi
- Myeloma Institute, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Al-Ola Abdallah
- Division of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Lawrence, Kansas, USA
| | - Aaron Goodman
- Division of Blood and Marrow Transplantation, University of California San Diego, La Jolla, California, USA
| | - Ghulam Rehman Mohyuddin
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
62
|
Bringhen S, Pour L, Benjamin R, Grosicki S, Min CK, de Farias DLC, Vorog A, Labotka RJ, Wang B, Cherepanov D, Cain LE, Manne S, Rajkumar SV, Dimopoulos MA. Ixazomib Versus Placebo as Post-Induction Maintenance Therapy in Newly Diagnosed Multiple Myeloma Patients: An Analysis by Age and Frailty Status of the TOURMALINE-MM4 Study. CLINICAL LYMPHOMA MYELOMA AND LEUKEMIA 2023:S2152-2650(23)00093-9. [PMID: 37149398 DOI: 10.1016/j.clml.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 02/28/2023] [Accepted: 03/14/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND The TOURMALINE-MM4 trial demonstrated a significant and clinically meaningful progression-free survival (PFS) benefit with ixazomib versus placebo as postinduction maintenance in nontransplant, newly-diagnosed multiple myeloma patients, with a manageable and well-tolerated toxicity profile. MATERIALS AND METHODS In this subgroup analysis, efficacy and safety were assessed by age (< 65, 65-74, and ≥ 75 years) and frailty status (fit, intermediate-fit, and frail). RESULTS In this analysis, PFS benefit with ixazomib versus placebo was seen across age subgroups, including patients aged < 65 years (hazard ratio [HR], 0.576; 95% confidence interval [CI], 0.299-1.108; P = .095), 65-74 years (HR, 0.615; 95% CI, 0.467-0.810; P < .001), and ≥ 75 years (HR, 0.740; 95% CI, 0.537-1.019; P = .064). PFS benefit was also seen across frailty subgroups, including fit (HR, 0.530; 95% CI, 0.387-0.727; P < .001), intermediate-fit (HR, 0.746; 95% CI, 0.526-1.058; P = .098), and frail (HR, 0.733; 95% CI, 0.481-1.117; P = .147) patients. With ixazomib versus placebo, rates of grade ≥ 3 treatment-emergent adverse events (TEAEs; 28-44% vs. 10-36%), serious TEAEs (15-29% vs. 3-29%), and discontinuation due to TEAEs (7-19% vs. 5-11%) were higher or similar across age and frailty subgroups, and generally somewhat higher in older age groups and intermediate-fit/frail patients in both arms. Treatment with ixazomib versus placebo did not adversely affect patient-reported quality-of-life scores across age and frailty status subgroups. CONCLUSION Ixazomib is a feasible and effective maintenance option for prolonging PFS across this heterogeneous patient population.
Collapse
|
63
|
Jolles S, Giralt S, Kerre T, Lazarus HM, Mustafa SS, Ria R, Vinh DC. Agents contributing to secondary immunodeficiency development in patients with multiple myeloma, chronic lymphocytic leukemia and non-Hodgkin lymphoma: A systematic literature review. Front Oncol 2023; 13:1098326. [PMID: 36824125 PMCID: PMC9941665 DOI: 10.3389/fonc.2023.1098326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/04/2023] [Indexed: 02/09/2023] Open
Abstract
Introduction Patients with hematological malignancies (HMs), like chronic lymphocytic leukemia (CLL), multiple myeloma (MM), and non-Hodgkin lymphoma (NHL), have a high risk of secondary immunodeficiency (SID), SID-related infections, and mortality. Here, we report the results of a systematic literature review on the potential association of various cancer regimens with infection rates, neutropenia, lymphocytopenia, or hypogammaglobulinemia, indicative of SID. Methods A systematic literature search was performed in 03/2022 using PubMed to search for clinical trials that mentioned in the title and/or abstract selected cancer (CLL, MM, or NHL) treatments covering 12 classes of drugs, including B-lineage monoclonal antibodies, CAR T therapies, proteasome inhibitors, kinase inhibitors, immunomodulators, antimetabolites, anti-tumor antibiotics, alkylating agents, Bcl-2 antagonists, histone deacetylase inhibitors, vinca alkaloids, and selective inhibitors of nuclear export. To be included, a publication had to report at least one of the following: percentages of patients with any grade and/or grade ≥3 infections, any grade and/or grade ≥3 neutropenia, or hypogammaglobulinemia. From the relevant publications, the percentages of patients with lymphocytopenia and specific types of infection (fungal, viral, bacterial, respiratory [upper or lower respiratory tract], bronchitis, pneumonia, urinary tract infection, skin, gastrointestinal, and sepsis) were collected. Results Of 89 relevant studies, 17, 38, and 34 included patients with CLL, MM, and NHL, respectively. In CLL, MM, and NHL, any grade infections were seen in 51.3%, 35.9% and 31.1% of patients, and any grade neutropenia in 36.3%, 36.4%, and 35.4% of patients, respectively. The highest proportion of patients with grade ≥3 infections across classes of drugs were: 41.0% in patients with MM treated with a B-lineage monoclonal antibody combination; and 29.9% and 38.0% of patients with CLL and NHL treated with a kinase inhibitor combination, respectively. In the limited studies, the mean percentage of patients with lymphocytopenia was 1.9%, 11.9%, and 38.6% in CLL, MM, and NHL, respectively. Two studies reported the proportion of patients with hypogammaglobulinemia: 0-15.3% in CLL and 5.9% in NHL (no studies reported hypogammaglobulinemia in MM). Conclusion This review highlights cancer treatments contributing to infections and neutropenia, potentially related to SID, and shows underreporting of hypogammaglobulinemia and lymphocytopenia before and during HM therapies.
Collapse
Affiliation(s)
- Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom
| | - Sergio Giralt
- Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Tessa Kerre
- Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Hillard M. Lazarus
- Department of Medicine, Hematology-Oncology, Case Western Reserve University, Cleveland, OH, United States
| | - S. Shahzad Mustafa
- Rochester Regional Health, Rochester, NY, United States
- Department of Medicine, Allergy/Immunology and Rheumatology, University of Rochester, Rochester, NY, United States
| | - Roberto Ria
- Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Bari, Italy
| | - Donald C. Vinh
- Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| |
Collapse
|
64
|
Dytfeld D, Wróbel T, Jamroziak K, Kubicki T, Robak P, Walter-Croneck A, Czyż J, Tyczyńska A, Druzd-Sitek A, Giannopoulos K, Nowicki A, Szczepaniak T, Łojko-Dankowska A, Matuszak M, Gil L, Puła B, Rybka J, Majcherek M, Usnarska-Zubkiewicz L, Szukalski Ł, Końska A, Zaucha JM, Walewski J, Mikulski D, Czabak O, Robak T, Lahoud OB, Zonder JA, Griffith K, Stefka A, Major A, Derman BA, Jakubowiak AJ. Carfilzomib, lenalidomide, and dexamethasone or lenalidomide alone as maintenance therapy after autologous stem-cell transplantation in patients with multiple myeloma (ATLAS): interim analysis of a randomised, open-label, phase 3 trial. Lancet Oncol 2023; 24:139-150. [PMID: 36642080 PMCID: PMC10337122 DOI: 10.1016/s1470-2045(22)00738-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 11/19/2022] [Accepted: 11/23/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Lenalidomide is a cornerstone of maintenance therapy in patients with newly diagnosed multiple myeloma after autologous stem-cell transplantation. We aimed to compare the efficacy and safety of maintenance therapy with carfilzomib, lenalidomide, and dexamethasone versus lenalidomide alone in this patient population. METHODS This study is an interim analysis of ATLAS, which is an investigator-initiated, multicentre, open-label, randomised, phase 3 trial in 12 academic and clinical centres in the USA and Poland. Participants were aged 18 years or older with newly diagnosed multiple myeloma, completed any type of induction and had stable disease or better, autologous stem-cell transplantation within 100 days, initiated induction 12 months before enrolment, and an Eastern Cooperative Oncology Group performance status of 0 or 1. Patients were randomly assigned (1:1) using permuted blocks of sizes 4 and 6 and a web-based system to receive up to 36 cycles of carfilzomib, lenalidomide, and dexamethasone (28-day cycles of carfilzomib 20 mg/m2 administered intravenously in cycle one on days 1 and 2 then 36 mg/m2 on days 1, 2, 8, 9, 15, and 16 in cycles one to four and 36 mg/m2 on days 1, 2, 15, and 16 from cycle five up to 36 [per protocol]; lenalidomide 25 mg administered orally on days 1-21; and dexamethasone 20 mg administered orally on days 1, 8, 15, and 22) or lenalidomide alone (10 mg administered orally for the first three cycles and then at the best tolerated dose [≤15 mg for 28 days in 28-day cycles]) until disease progression or unacceptable toxicity as maintenance therapy. After 36 cycles, patients in both treatment groups received lenalidomide maintenance. Randomisation was stratified by response to previous treatment, cytogenetic risk factors, and country. Investigators and patients were not masked to treatment allocation. Patients in the carfilzomib, lenalidomide, and dexamethasone group with no detectable minimal residual disease after cycle six (as per International Myeloma Working Group criteria) and standard-risk cytogenetics were switched to lenalidomide maintenance as of cycle nine. The primary endpoint was progression-free survival in the intention-to-treat population (defined as all randomly assigned patients). Safety was analysed in all randomly assigned patients who received at least one dose of study treatment. This unplanned interim analysis was triggered by the occurrence of 59 (61%) of the expected 96 events for the primary analysis and the results are considered preliminary. This trial is registered with ClinicalTrials.gov, NCT02659293 (active, not recruiting) and EudraCT, 2015-002380-42. FINDINGS Between June 10, 2016, and Oct 21, 2020, 180 patients were randomly assigned to receive either carfilzomib, lenalidomide, and dexamethasone (n=93) or lenalidomide alone (n=87; intention-to-treat population). The median age of patients was 59·0 years (IQR 49·0-63·0); 84 (47%) patients were female and 96 (53%) were male. With a median follow-up of 33·8 months (IQR 20·9-42·9), median progression-free survival was 59·1 months (95% CI 54·8-not estimable) in the carfilzomib, lenalidomide, and dexamethasone group versus 41·4 months (33·2-65·4) in the lenalidomide group (hazard ratio 0·51 [95% CI 0·31-0·86]; p=0·012). The most common grade 3 and 4 adverse events were neutropenia (44 [48%] in the carfilzomib, lenalidomide, and dexamethasone group vs 52 [60%] in the lenalidomide group), thrombocytopenia (12 [13%] vs six [7%]), and lower respiratory tract infections (seven [8%] vs one [1%]). Serious adverse events were reported in 28 (30%) patients in the carfilzomib, lenalidomide, and dexamethasone group and 19 (22%) in the lenalidomide group. One treatment-related adverse event led to death (respiratory failure due to severe pneumonia) in the carfilzomib, lenalidomide, and dexamethasone group. INTERPRETATION This interim analysis provides support for considering carfilzomib, lenalidomide, and dexamethasone therapy in patients with newly diagnosed multiple myeloma who completed any induction regimen followed by autologous stem-cell transplantation, which requires confirmation after longer follow-up of this ongoing phase 3 trial. FUNDING Amgen and Celgene (Bristol Myers Squibb).
Collapse
Affiliation(s)
| | | | | | | | | | | | - Jarosław Czyż
- Department of Hematology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Torun, Poland
| | - Agata Tyczyńska
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | | | | | - Adam Nowicki
- Poznan University of Medical Sciences, Poznan, Poland
| | | | | | | | - Lidia Gil
- Poznan University of Medical Sciences, Poznan, Poland
| | - Bartosz Puła
- Poznan University of Medical Sciences, Poznan, Poland
| | | | | | | | - Łukasz Szukalski
- Department of Hematology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Torun, Poland
| | | | - Jan Maciej Zaucha
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | - Jan Walewski
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | | | - Olga Czabak
- Medical University of Lublin, Lublin, Poland
| | | | - Oscar B Lahoud
- Memorial Sloan-Kettering Cancer Institute, New York, NY, USA
| | | | | | - Andrew Stefka
- University of Chicago Medical Center, Chicago, IL, USA
| | - Ajay Major
- University of Chicago Medical Center, Chicago, IL, USA; University of Colorado School of Medicine, Aurora, CO, USA
| | | | | |
Collapse
|
65
|
Ailawadhi S, Ogbonnaya A, Murty S, Cherepanov D, Schroader BK, Romanus D, Farrelly E, Chari A. Duration of frontline therapy and impact on clinical outcomes in newly diagnosed multiple myeloma patients not receiving frontline stem cell transplant. Cancer Med 2023; 12:3145-3159. [PMID: 36151787 PMCID: PMC9939178 DOI: 10.1002/cam4.5239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/06/2022] [Accepted: 09/02/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Extended first-line therapy (1LT) has improved clinical outcomes in newly diagnosed multiple myeloma (NDMM). This retrospective study of NDMM patients evaluated the relationship between dose-attenuation of 1LT and duration of therapy (DOT) and DOT on outcomes. METHODS Adults with NDMM not undergoing stem cell transplant (SCT) from January 1, 2012 toMarch 31, 2018 from the Integrated Oncology Network were included; 300 were randomly selected for chart review. 1LT DOT, time to next treatment (TTNT), progression-free survival (PFS), and overall survival (OS) were estimated using Kaplan-Meier analysis. Marginal structural models evaluated relationships between DOT and TTNT, PFS, and OS at 2 years accounting for confounders and survival bias from the time-dependent nature of DOT. RESULTS Of 300 chart-reviewed patients, 93 were excluded for incomplete data or meeting exclusion criteria. Among 207 NDMM patients, median age was 74 years; 146 (70.5%) did not receive dose-attenuation during 1LT. Patients with short DOT were older, frailer, with a higher comorbidity burden, and a significantly lower proportion had an Eastern Cooperative Oncology Group PS = 0. As DOT increased, more patients underwent dose-attenuation (p < 0.0001). The median 1LT DOT was 20.9 (95% confidence interval [CI]: 13.9, 26.4) versus 4.2 months (95% CI: 3.2, 4.9) for patients receiving versus not receiving dose-attenuation, respectively (p < 0.0001). After accounting for survival bias, confounder-adjusted TTNT was prolonged with each additional month of 1LT (odds ratio [OR]: 0.76 [95% CI: 0.75, 0.78]); likelihoods of risks of disease progression (OR: 0.87 [95% CI: 0.86, 0.88]) and death at 2 years (OR: 0.72 [95% CI: 0.70, 0.74]) were reduced with each month of 1LT (p < 0.0001 for all outcomes). CONCLUSIONS Dose-attenuated 1LT was associated with longer DOT among patients with non-SCT NDMM. Each additional month of 1LT was associated with a reduced adjusted likelihood of disease progression and death at 2 years. Dose-attenuation of 1LT can extend DOT; longer DOT may improve clinical outcomes.
Collapse
Affiliation(s)
- Sikander Ailawadhi
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, Florida, United States
| | | | | | - Dasha Cherepanov
- Takeda Development Center Americas, Inc (TDCA), Lexington, Massachusetts, United States
| | | | - Dorothy Romanus
- Takeda Development Center Americas, Inc (TDCA), Lexington, Massachusetts, United States
| | | | - Ajai Chari
- Hematology and Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| |
Collapse
|
66
|
Jonasson E, Antulov R, Trøllund Pedersen P, Sejbæk T. Progressive multifocal leukoencephalopathy in a patient with multiple myeloma: a case report and analysis of the FDA adverse event reporting system. Front Neurol 2023; 14:1098930. [PMID: 37213905 PMCID: PMC10192558 DOI: 10.3389/fneur.2023.1098930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/27/2023] [Indexed: 05/23/2023] Open
Abstract
This paper demonstrates a case of progressive multifocal leukoencephalopathy (PML) in a patient with multiple myeloma (MM) treated with nine different MM therapies. This case report contributes to the already published 16 cases of PML in patients with MM. Additionally, this paper presents an analysis of cases from the United States Food and Drug Administration Adverse Event Report System database (n = 117) with a description of demographics and MM-specific therapies. Patients with MM, that developed PML, were treated with immunomodulatory drugs (97%), alkylating agents (52%), and/or proteasome inhibitors (49%). Prior to PML diagnosis, 72% of patients received two or more MM therapies. These results indicate that PML in MM is underreported and could be related to treatment with multiple immunosuppressive therapies rather than MM as a disease itself. Physicians should be aware of potential PML in the late stage of heavily treated MM patients.
Collapse
Affiliation(s)
- Elise Jonasson
- Department of Hematology, Hospital South West Jutland, University Hospital of Southern Denmark, Esbjerg, Denmark
- *Correspondence: Elise Jonasson
| | - Ronald Antulov
- Department of Radiology and Nuclear Medicine, Hospital South West Jutland, University Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
| | - Per Trøllund Pedersen
- Department of Hematology, Hospital South West Jutland, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Tobias Sejbæk
- Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
- Department of Neurology, Hospital South West Jutland, University Hospital of Southern Denmark, Esbjerg, Denmark
| |
Collapse
|
67
|
Carfilzomib induction, consolidation, and maintenance with or without autologous stem-cell transplantation in patients with newly diagnosed multiple myeloma: pre-planned cytogenetic subgroup analysis of the randomised, phase 2 FORTE trial. Lancet Oncol 2023; 24:64-76. [PMID: 36528035 DOI: 10.1016/s1470-2045(22)00693-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/21/2022] [Accepted: 11/03/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients with newly diagnosed multiple myeloma and high-risk cytogenetic abnormalities (HRCA) represent an unmet medical need. In the FORTE trial, lenalidomide and dexamethasone plus carfilzomib (KRd) induction resulted in a higher proportion of patients with at least a very good partial response as compared with carfilzomib, cyclophosphamide, and dexamethasone (KCd), and carfilzomib plus lenalidomide maintenance prolonged progression-free survival compared with lenalidomide maintenance. In this prespecified analysis of the FORTE trial, we described the outcomes of enrolled patients according to their cytogenetic risk. METHODS The UNITO-MM-01/FORTE was a randomised, open-label, phase 2 trial done at 42 Italian academic and community practice centres, which enrolled transplant-eligible patients with newly diagnosed multiple myeloma aged 18-65 years. Eligible patients had newly diagnosed multiple myeloma based on standard International Myeloma Working Group criteria, a Karnofsky performance status of at least 60%, and had not received any previous treatment with anti-myeloma therapy. At enrolment, patients were stratified according to International Staging System stage (I vs II/III) and age (<60 years vs 60-65 years) and randomly assigned (1:1:1) to KRd plus autologous stem-cell transplantation (ASCT; four 28-day induction cycles with KRd, melphalan at 200 mg/m2 and ASCT [MEL200-ASCT], followed by four 28-day KRd consolidation cycles), 12 28-day KRd cycles, or KCd plus ASCT (four 28-day induction cycles with KCd, MEL200-ASCT, and four 28-day KCd consolidation cycles), using a web-based system (block randomisation, block size of 12). Carfilzomib was administered at 20 mg/m2 on days 1 and 2 of cycle 1, followed by 36 mg/m2 intravenously administered on days 8, 9, 15, and 16 of cycle 1, and then 36 mg/m2 intravenously administered for all subsequent doses on days 1, 2, 8, 9, 15, 16; lenalidomide 25 mg was administered orally on days 1-21; cyclophosphamide 300 mg/m2 was administered orally on days 1, 8, and 15; and dexamethasone 20 mg was administered orally or intravenously on days 1, 2, 8, 9, 15, 16, 22, and 23. After the consolidation phase, patients were stratified according to induction-consolidation treatment and randomly assigned (1:1; block size of 8) to maintenance treatment with carfilzomib plus lenalidomide or lenalidomide alone. Carfilzomib 36 mg/m2 was administered intravenously on days 1-2 and days 15-16, every 28 days for up to 2 years, and lenalidomide 10 mg was administered orally on days 1-21 every 28 days until progression or intolerance in both groups. The primary endpoints were the proportion of patients with at least a very good partial response after induction with KRd versus KCd and progression-free survival with carfilzomib plus lenalidomide versus lenalidomide alone as maintenance treatment. In this preplanned analysis, we included patients enrolled in the FORTE trial with complete cytogenetic data on del(17p), t(4;14), t(14;16), del(1p), gain(1q) (3 copies), and amp(1q) (≥4 copies) assessed by fluorescence in-situ hybridisation analysis on CD138-positive sorted cells. We assessed progression-free survival, overall survival, minimal residual disease negativity, and 1-year sustained minimal residual disease negativity according to the presence of zero, one, and two or more HRCA across treatment groups. The FORTE trial is ongoing, and registered with ClinicalTrials.gov, NCT02203643. FINDINGS Between Feb 23, 2015, and April 5, 2017, 477 patients were enrolled, of whom 396 (83%) had complete cytogenetic data and were analysed (176 [44%] of whom were women and 220 [56%] were men). The median follow-up from first randomisation was 51 months (IQR 46-56). 4-year progression-free survival was 71% (95% CI 64-78) in patients with zero HRCA, 60% (95% CI 52-69) in patients with one HRCA, and 39% (95% CI 30-50) in patients with two or more HRCA. Compared with patients with zero HRCA, the risk of progression or death was similar in patients with one HRCA (hazard ratio [HR] 1·33 [95% CI 0·90-1·97]; p=0·15) and higher in patients with two or more HRCA (HR 2·56 [95% CI 1·74-3·75]); p<0·0001) across the induction-intensification-consolidation groups. Moreover, the risk of progression or death was also higher in patients with two or more HRCA versus those with one HRCA (HR 1·92 [95% CI 1·34-2·76]; p=0·0004). 4-year overall survival from the first randomisation was 94% (95% CI 91-98) in patients with zero HRCA, 83% (95% CI 76-90) in patients with one HRCA, and 63% (95% CI 54-74) in patients with two or more HRCA. Compared with patients with zero HRCA, the risk of death was significantly higher in patients with one HRCA (HR 2·55 [95% CI 1·22-5·36]; p=0·013) and two or more HRCA (HR 6·53 [95% CI 3·24-13·18]; p<0·0001). Patients with two or more HRCA also had a significantly higher risk of death than those with one HRCA (HR 2·56 [95% CI 1·53-4·28]; p=0·0004). The rates of 1-year sustained minimal residual disease negativity were similar in patients with zero HRCA (53 [35%] of 153] and with one HRCA (57 [41%] of 138) and were lower in patients with two or more HRCA (25 [24%] of 105). The median duration of follow-up from second randomisation was 37 months (IQR 33-42). 3-year progression-free survival from the second randomisation was 80% (95% CI 74-88) in patients with zero HRCA, 68% (95% CI 59-78) in patients with one HRCA, and 53% (95% CI 42-67) in patients with two or more HRCA. The risk of progression or death was higher in patients with one HRCA (HR 1·68 [95% CI 1·01-2·80]; p=0·048) and two or more HRCA (2·74 [95% CI 1·60-4·69], p=0·0003) than in patients with zero HRCA. INTERPRETATION This preplanned analysis of the FORTE trial showed that carfilzomib-based induction-intensification-consolidation regimens are effective strategies in patients with standard risk (zero HRCA) and high-risk (one HRCA) myeloma, resulting in similar rates of progression-free survival and 1-year sustained minimal residual disease negativity. Despite promising progression-free survival, patients with ultra-high-risk disease (those with 2 or more HRCA) still have an increased risk of progression and death and therefore represent an unmet medical need. FUNDING Amgen and Celgene/Bristol Myers Squibb.
Collapse
|
68
|
Zhuang Z, Tian Y, Shi L, Zou D, Feng R, Tian WW, Yu H, Dong F, Liao A, Ma Y, Liu Q, Liu S, Jing H, Fu R, Ma LM, Liu H, Sun W, Bao L, Wu Y, Chen W, Zhuang J. Lenalidomide or bortezomib as maintenance treatment remedy the inferior impact of high-risk cytogenetic abnormalities in non-transplant patients with newly diagnosed multiple myeloma: a real-world multi-centered study in China. Front Oncol 2023; 13:1028571. [PMID: 37152063 PMCID: PMC10157094 DOI: 10.3389/fonc.2023.1028571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 03/29/2023] [Indexed: 05/09/2023] Open
Abstract
Maintenance treatment is a pivotal part in the whole process management of multiple myeloma (MM), which further deepens response and improves survival. However, evidence of maintenance in non-transplant MM patients is inadequate in real-world practice. Here, we retrospectively analyzed the efficacy and survival of 375 non-transplant MM patients from 11 centers between 2010 and 2021 in north China. After a median of seven cycles of front-line regimens, there were 141, 79, and 155 patients receiving lenalidomide maintenance (L-MT), bortezomib maintenance (B-MT), or thalidomide maintenance (T-MT), respectively. Patients on L-MT and B-MT had significantly greater proportions of high-risk cytogenetic abnormalities (HRCAs) detected by fluorescence in situ hybridization (FISH), which was defined as 1q21 gain, 17p deletion, adverse immunoglobulin heavy chain (IgH) translocations. Although the progression-free survival (PFS) and overall survival (OS) were comparable among the three groups, L-MT and B-MT remedied the negative impact of HRCAs on survival (PFS of patients with HRCAs vs. patients without HRCAs: L-MT, 26.9 vs. 39.2 months, p=0.19; B-MT, 20.0 vs. 29.7 months, p=0.36; OS not reached in all groups). Patients with HRCAs in the T-MT group presented inferior clinical outcomes compared to standard-risk patients (PFS, 12.1 vs. 22.8 months, p=0.02, HR=1.8, 95% CI 1.0-3.4; OS, 54.9 months vs. NR, p<0.001, HR=3.2, 95% CI 1.5-7.0). Achieving complete response (CR) after induction therapy led to superior PFS compared to other degrees of response, regardless of maintenance medication. Furthermore, maintenance duration over 24 months correlated with favorable survival. Due to the large gap of transplant eligibility in China, optimizing maintenance therapy is important for non-transplant MM patients. In this real-world multi-centered study, our findings suggest that clinicians prefer to prescribe lenalidomide or bortezomib as maintenance therapy in high-risk settings, which are superior to thalidomide in non-transplant MM patients. Achievement of CR and maintenance duration over 2 years are positive factors that influence survival.
Collapse
Affiliation(s)
- Zhe Zhuang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ying Tian
- Department of Hematology, Beijing Chao-Yang Hospital Capital Medical University, Beijing, China
| | - Lei Shi
- Department of Hematology, Beijing University, Beijing Jishuitan Hospital, Beijing, China
| | - Dongmei Zou
- Department of Hematology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Ru Feng
- Department of Hematology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Science, Beijing, China
| | - Wei-wei Tian
- Department of Hematology, Shanxi Bethune Hospital of Shanxi Medical University, Taiyuan, China
| | - Hong Yu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Fei Dong
- Department of Hematology, Peking University Third Hospital, Beijing, China
| | - Aijun Liao
- Department of Hematology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yanping Ma
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Qinhua Liu
- Department of Hematology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Shuangjiao Liu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hongmei Jing
- Department of Hematology, Peking University Third Hospital, Beijing, China
| | - Rong Fu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Liang-ming Ma
- Department of Hematology, Shanxi Bethune Hospital of Shanxi Medical University, Taiyuan, China
| | - Hui Liu
- Department of Hematology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Science, Beijing, China
| | - Wanling Sun
- Department of Hematology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Li Bao
- Department of Hematology, Beijing University, Beijing Jishuitan Hospital, Beijing, China
- *Correspondence: Li Bao, ; Yin Wu, ; Wenming Chen, ; Junling Zhuang,
| | - Yin Wu
- Department of Hematology, Beijing Chao-Yang Hospital Capital Medical University, Beijing, China
- *Correspondence: Li Bao, ; Yin Wu, ; Wenming Chen, ; Junling Zhuang,
| | - Wenming Chen
- Department of Hematology, Beijing Chao-Yang Hospital Capital Medical University, Beijing, China
- *Correspondence: Li Bao, ; Yin Wu, ; Wenming Chen, ; Junling Zhuang,
| | - Junling Zhuang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Li Bao, ; Yin Wu, ; Wenming Chen, ; Junling Zhuang,
| |
Collapse
|
69
|
Offidani M, Morè S, Corvatta L. Maintenance therapy in multiple myeloma: Two is not always better than one. Br J Haematol 2022; 201:181-182. [PMID: 36541138 DOI: 10.1111/bjh.18614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
In multiple myeloma (MM) long-term therapy aims to control disease and delay progression for as long as possible. In this issue Jenner et al. failed to demonstrate a benefit of maintenance with lenalidomide plus vorinostat compared with lenalidomide in both transplant eligible (TE) and ineligible (NTE) patients enrolled in the Myeloma XI trial. Commentary on: Jenner et al. The addition of vorinostat to lenalidomide maintenance for patients with newly diagnosed multiple myeloma of all ages: results from 'Myeloma XI', a multicentre, open-label, randomised, phase III trial. Br J Haematol. 2023;201:276-288.
Collapse
Affiliation(s)
- Massimo Offidani
- Clinica di Ematologia Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona Ancona Italy
| | - Sonia Morè
- Clinica di Ematologia Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona Ancona Italy
| | | |
Collapse
|
70
|
Costello CL. Newly diagnosed multiple myeloma: making sense of the menu. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:539-550. [PMID: 36485145 PMCID: PMC9820388 DOI: 10.1182/hematology.2022000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The development of new drugs and subsequent novel combinations for the treatment of newly diagnosed multiple myeloma (NDMM) has resulted in a plethora of treatment options that can make the choice of initial induction therapy a challenge. A greater understanding of both patient- and disease-specific factors can provide a personalized approach to help design a treatment course. Historically, the choice of an induction regimen has been tethered to an initial impression of transplant eligibility at the time of diagnosis. As more effective and better-tolerated induction regimens have emerged, there has been increasing overlap in the induction strategies used for all patients with NDMM, which increasingly provide the ultimate goal of deep and durable remissions. The current treatment options and strategies for the management of NDMM are evaluated using the best available data to provide a rationale for these decisions.
Collapse
Affiliation(s)
- Caitlin L. Costello
- Correspondence Caitlin L. Costello, UCSD, 3855 Health Sciences Drive, MC 0960, La Jolla, CA 92093, USA; e-mail:
| |
Collapse
|
71
|
Pawlyn C, Khan AM, Freeman CL. Fitness and frailty in myeloma. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:337-348. [PMID: 36485137 PMCID: PMC9820647 DOI: 10.1182/hematology.2022000346] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
As the aging population grows, so too does the number of well-tolerated antimyeloma therapies. Physicians will see an increasing volume of patients for subsequent lines of therapy, which could now extend this relationship for over a decade. For younger patients, treatment choices are infrequently impacted by concerns of fitness, but instead about effecting the deepest, most durable response. Older adults, in contrast, are more likely to experience under- than overtreatment, and therefore more objective (and ideally straightforward) ways to evaluate their fitness and ability to tolerate therapy will increasingly assist in decision-making. Post hoc analyses categorizing the fitness of trial patients in the modern treatment era globally demonstrate that even in highly selected populations, those that are recategorized as less fit or frail are consistently at higher risk of inferior outcomes and increased toxicities. Real-world data are comparatively lacking but do demonstrate that most patients with myeloma are not representative of those enrolled on clinical trials, generally more heavily burdened by comorbidities and more likely to be categorized as "less than fit." Simultaneously, the number of therapeutic options open to patients in the relapsed setting continues to grow, now including T-cell engagers and cellular therapies, with their unique toxicity profiles. The aim of this review is to summarize the available data, highlight some of the approaches possible to easily assess fitness and how results might inform treatment selection, and illustrate ways that patients' condition can be optimized rather than lead to exclusion from the more complex therapies newly available.
Collapse
Affiliation(s)
- Charlotte Pawlyn
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Abdullah M Khan
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Ciara L Freeman
- H. Lee Moffitt Cancer Centre & Research Institute, Morsani College of Medicine, University of South Florida, Tampa, FL
| |
Collapse
|
72
|
Second primary malignancies in patients with haematological cancers treated with lenalidomide: a systematic review and meta-analysis. THE LANCET HAEMATOLOGY 2022; 9:e906-e918. [DOI: 10.1016/s2352-3026(22)00289-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/11/2022] [Accepted: 08/22/2022] [Indexed: 11/30/2022]
|
73
|
Slade M, Martin TG, Nathwani N, Fiala MA, Rettig MP, Gao F, Deol A, Buadi FK, Kaufman JL, Hofmeister CC, Gregory TK, Berdeja J, Chari A, Rosko A, Vij R. Ixazomib, lenalidomide and dexamethasone consolidation with randomized ixazomib or lenalidomide maintenance after autologous transplant in newly diagnosed multiple myeloma. Leukemia 2022; 36:2917-2921. [PMID: 36114265 PMCID: PMC10445424 DOI: 10.1038/s41375-022-01691-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Michael Slade
- Washington University School of Medicine, St. Louis, MO, USA
| | - Thomas G Martin
- University of California- San Francisco, San Francisco, CA, USA
| | - Nitya Nathwani
- Judy and Bernard Briskin Center for Multiple Myeloma Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Mark A Fiala
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - Feng Gao
- Washington University School of Medicine, St. Louis, MO, USA
| | - Abhinav Deol
- Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | | | | | | | | | | | - Ajai Chari
- Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | | | - Ravi Vij
- Washington University School of Medicine, St. Louis, MO, USA.
| |
Collapse
|
74
|
Hu SL, Liu M, Zhang JY. Comparing the efficacy of different dexamethasone regimens for maintenance treatment of multiple myeloma in standard-risk patients non-eligible for transplantation. World J Clin Cases 2022; 10:11712-11725. [PMID: 36405288 PMCID: PMC9669873 DOI: 10.12998/wjcc.v10.i32.11712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/13/2022] [Accepted: 10/18/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Multiple myeloma (MM) is a plasma cell malignancy, while MM outcomes have significantly improved due to novel agents and combinations, MM remains an incurable disease. The key goal of treatment in MM is to achieve a maximal response and the subsequent consolidation of response after initial therapy. Many studies analyzed an improved progression-free survival (PFS) following lenalidomide alone maintenance versus placebo or observation after autologous stem cell transplant (ASCT) in patients with NDMM. In the SWOG S0777 clinical trial, patients newly diagnosed with MM (NDMM) without ASCT received lenalidomide plus low-dose dexamethasone (DXM) maintenance until progressive disease, where PFS and overall survival (OS) were significantly improved. In the present study, we assessed the efficacy and toxicity of the different doses of DXM combined with lenalidomide for maintenance treatment of NDMM for transplant noneligible patients in the standard-risk group.
AIM To investigate the efficacy and adverse effects of different administration modes of DXM combined with lenalidomide for maintenance treatment of MM in standard-risk patients ineligible for transplantation.
METHODS A total of 96 MM patients were enrolled in this study, among whom 48 patients received maintenance treatment that consisted of oral administration of 25 milligrams (mg) of lenalidomide from days 1-21 and 40 mg of DXM on days 1, 8, 15, and 22 (DXM 40 mg group), repeated every 4 wk. Another group was treated with oral administration of 25 mg of lenalidomide from days 1-21 and 20 mg of DXM on days 1-2, 8-9, 15-16, and 22-23 (DXM 20 mg group), which was also repeated every 4 wk.
RESULTS The median PFS was 37.25 mo in the DXM 40.00 mg group and 38.17 mo in the DXM 20 mg group (P = 0.171). The median OS was 50.78 mo in the DXM 40 mg group and 51.69 mo in the DXM 20 mg group (P = 0.171). Fourteen patients in the DXM 40 mg group and 6 patients in the DXM 20 mg group suffered from adverse gastrointestinal reactions after the oral administration of the DXM tablet (P = 0.044). Ten patients suffered from abnormal glucose tolerance (GTA), impaired fasting glucose (IFG), or diabetes mellitus in the DXM 40 mg group during our observation time compared to 19 patients with GTA, IFG, or DM in the DXM 20 mg group (P = 0.033). Abnormal β-crosslaps or higher were found in 5 patients in the DXM 40 mg group and 12 patients in the DXM 20 mg group (P = 0.049). Insomnia or an increase in insomnia compared to the previous condition was evident in 2 patients in the DXM 40 mg group after maintenance treatment for more than 6 mo compared to 11 patients in the DXM 20 mg group (P = 0.017).
CONCLUSION The DXM 40 mg group exhibited efficacy similar to that of the DXM 20 mg group. However, the DXM 40 mg group had significantly decreased toxicity compared with the DXM 20 mg group in the long term.
Collapse
Affiliation(s)
- Sai-Ling Hu
- Department of Cardiology, Lishui Central Hospital, Lishui 323000, Zhejiang Province, China
| | - Min Liu
- Department of Hematology, Lishui Municipal Central Hospital, Lishui 323000, Zhejiang Province, China
| | - Jun-Yu Zhang
- Department of Hematology, Lishui Municipal Central Hospital, Lishui 323000, Zhejiang Province, China
| |
Collapse
|
75
|
Major A, Jakubowiak A, Derman B. Longitudinal Real-World Neuropathy and Patient-Reported Outcomes With Bortezomib and Lenalidomide in Newly Diagnosed Multiple Myeloma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e1000-e1008. [PMID: 35922273 DOI: 10.1016/j.clml.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/01/2022] [Accepted: 07/06/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Peripheral neuropathy is a common treatment-emergent side effect during the treatment of newly diagnosed multiple myeloma. Although bortezomib is most commonly implicated, real-world data suggest that lenalidomide and dexamethasone (VRd) and autologous stem cell transplantation (ASCT) may also contribute to neuropathy and health-related quality of life (HRQoL). METHODS The Multiple Myeloma Research Foundation (MMRF) CoMMpass Registry was queried for all patients who received frontline VRd or bortezomib, cyclophosphamide and dexamethasone (VCd). Incidence of neuropathy and patient-reported HRQoL outcomes over the first 12 months after diagnosis were compared between patients receiving VRd or VCd with or without early ASCT before 6 months. RESULTS There were 368 and 191 patients treated with VRd and VCd, respectively. VRd with early ASCT was associated with worse grade 1 neuropathy compared to VRd without early ASCT, as well as compared to VCd with early ASCT. There were no differences in neuropathy between VRd and VCd without early ASCT, and no differences in grade ≥2 neuropathy. There were significant improvements in HRQoL between baseline and 12 months in both VRd and VCd cohorts, regardless of early ASCT. Development of neuropathy was not associated with decrements in progression-free survival or overall survival. CONCLUSIONS In this longitudinal database analysis, there were no differences in grade ≥2 neuropathy between VRd and VCd frontline induction, and overall HRQoL significantly improved across all cohorts. However, differences in grade 1 neuropathy between VRd and VCd induction suggest that lenalidomide and high-dose melphalan may augment the risk of neuropathy in newly diagnosed multiple myeloma.
Collapse
Affiliation(s)
- Ajay Major
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL.
| | - Andrzej Jakubowiak
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL
| | - Benjamin Derman
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL
| |
Collapse
|
76
|
Liu J, Mi R, Chen L, Guo X, Liang T, Yin Q. Efficacy and safety of lenalidomide in diffuse large B-cell lymphoma: a meta-analysis of randomized controlled trials. Clin Exp Med 2022:10.1007/s10238-022-00920-2. [PMID: 36315313 PMCID: PMC10390621 DOI: 10.1007/s10238-022-00920-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/11/2022] [Indexed: 06/16/2023]
Abstract
As an immunomodulatory agent with antitumor activity, lenalidomide has been evaluated for its value in diffuse large B-cell lymphoma (DLBCL). We performed a meta-analysis to gain a better understanding of the efficacy and safety of lenalidomide in DLBCL. PubMed, Cochrane Library, and Embase were searched up to March 2022 for potential studies. The pooled hazard ratio (HR) and relative risk (RR) with 95% confidence interval (CI) were estimated by the fixed/random effects model. Overall, 6 randomized controlled trials including 1938 patients were included. The complete response rate (CRR) of the group containing lenalidomide was 47.7% (95%CI 28.5-67.2%), which was higher than the 37.8% (95%CI 16.7-61.5%) of the control group without lenalidomide (RR = 1.11, 95%CI 1.03-1.20, P = 0.008). The overall estimation of survival showed a benefit for progression-free survival (PFS) (HR = 0.77, 95%CI 0.66-0.90, P = 0.001) but not overall survival (OS) or event-free survival (EFS). The lenalidomide group had a significant incidence of grade ≥ 3 hematological adverse events (AEs) involving neutropenia (RR = 1.56, 95%CI 1.15-2.11, P = 0.004) and febrile neutropenia (RR = 1.81, 95%CI 1.31-2.49, P < 0.001), with the incidence of neutropenia (48.3%, 95%CI 37.5-59.1%) being highest. In conclusion, addition of lenalidomide results in a higher CRR and better PFS but a higher incidence of grade ≥ 3 hematological AEs involving neutropenia and febrile neutropenia.
Collapse
Affiliation(s)
- Jia Liu
- The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Ruihua Mi
- The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Lin Chen
- The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Xiaoli Guo
- The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Taotao Liang
- The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Qingsong Yin
- The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China.
| |
Collapse
|
77
|
Hao Z, Liang P, He C, Sha S, Yang Z, Liu Y, Shi J, Zhu Z, Chang Q. Prognostic risk assessment model and drug sensitivity analysis of colon adenocarcinoma (COAD) based on immune-related lncRNA pairs. BMC Bioinformatics 2022; 23:435. [PMID: 36258178 PMCID: PMC9579580 DOI: 10.1186/s12859-022-04969-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 09/30/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE The aim of this study was to identify and screen long non-coding RNA (lncRNA) associated with immune genes in colon cancer, construct immune-related lncRNA pairs, establish a prognostic risk assessment model for colon adenocarcinoma (COAD), and explore prognostic factors and drug sensitivity. METHOD Our method was based on data from The Cancer Genome Atlas (TCGA). To begin, we obtained all pertinent demographic and clinical information on 385 patients with COAD. All lncRNAs significantly related to immune genes and with differential expression were identified to construct immune lncRNA pairs. Subsequently, least absolute shrinkage and selection operator and Cox models were used to screen out prognostic-related immune lncRNAs for the establishment of a prognostic risk scoring formula. Finally, We analysed the functional differences between subgroups and screened the drugs, and establish an individual prediction nomogram model. RESULTS Our final analysis confirmed eight lncRNA pairs to construct prognostic risk assessment model. Results showed that the high-risk and low-risk groups had significant differences (training (n = 249): p < 0.001, validation (n = 114): p = 0.022). The prognostic model was certified as an independent prognosis model. Compared with the common clinicopathological indicators, the prognostic model had better predictive efficiency (area under the curve (AUC) = 0.805). Finally, We have analysed highly differentiated cellular pathways such as mucosal immune response, identified 9 differential immune cells, 10 sensitive drugs, and establish an individual prediction nomogram model (C-index = 0.820). CONCLUSION Our study verified that the eight lncRNA pairs mentioned can be used as biomarkers to predict the prognosis of COAD patients. Identified cells, drugs may have an positive effect on colon cancer prognosis.
Collapse
Affiliation(s)
- Zezhou Hao
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, 200093, China
- Clinical Research Center, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai, 201800, China
| | - Pengchen Liang
- School of Microelectronics, Shanghai University, Shanghai, 201800, China
| | - Changyu He
- Shanghai Key Laboratory of Gastric Neoplasms, Department of Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200020, China
| | - Shuang Sha
- Clinical Research Center, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai, 201800, China
| | - Ziyuan Yang
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, 200093, China
| | - Yixin Liu
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, 200093, China
| | - Junfeng Shi
- Department of Prosthodontics, Shanghai Engineering Research Center of Advanced Dental Technology and Materials, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Shanghai, 200011, China
| | - Zhenggang Zhu
- Shanghai Key Laboratory of Gastric Neoplasms, Department of Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200020, China.
| | - Qing Chang
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, 200093, China.
- Shanghai Key Laboratory of Gastric Neoplasms, Department of Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200020, China.
| |
Collapse
|
78
|
CRL4 CRBN E3 Ligase Complex as a Therapeutic Target in Multiple Myeloma. Cancers (Basel) 2022; 14:cancers14184492. [PMID: 36139651 PMCID: PMC9496858 DOI: 10.3390/cancers14184492] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/14/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Immunomodulatory drugs (IMiDs) are effective in the treatment of multiple myeloma (MM) and other hematological malignancies. Cereblon (CRBN), a target of IMiDs, forms the CRL4 E3 ubiquitin ligase complex (CRL4CRBN) with DDB1, CUL4A and RBX1. The insight into the molecular mechanism of IMiDs action has advanced dramatically since the identification of cereblon (CRBN) as their direct target. Targeting CRBN by IMiDs modifies CRL4CRBN substrate specificity towards non-physiological protein targets which are subsequently ubiquitinated and degraded by the proteasome. To date, IMiDs are the only known group of protein degraders used in clinical practice. This review provides the current state of knowledge about thalidomide and its derivatives’ mechanisms of action, and highlights the future perspectives for targeted protein degraders. Abstract Multiple myeloma (MM) is the second most common hematological malignancy with a recurrent clinical course. The introduction of immunomodulatory drugs (IMiDs) was one of the milestones in MM therapy leading to a significant improvement in patients’ prognosis. Currently, IMiDs are the backbone of MM therapy in newly diagnosed and relapsed/refractory settings. It is now known that IMiDs exert their anti-myeloma activity mainly by binding cereblon (CRBN), the substrate receptor protein of the CRL4 E3 ubiquitin ligase (CRL4CRBN) complex. By binding CRBN, IMiDs alter its substrate specificity, leading to ubiquitination and proteasomal degradation of proteins essential for MM cell survival. Following the success of IMiDs, it is not surprising that the possibility of using the CRL4CRBN complex’s activity to treat MM is being further explored. In this review, we summarize the current state of knowledge about novel players in the MM therapeutic landscape, namely the CRBN E3 ligase modulators (CELMoDs), the next generation of IMiDs with broader biological activity. In addition, we discuss a new strategy of tailored proteolysis called proteolysis targeting chimeras (PROTACs) using the CRL4CRBN to degrade typically undruggable proteins, which may have relevance for the treatment of MM and other malignancies in the future.
Collapse
|
79
|
Agbuduwe C, Iqbal G, Cairns D, Menzies T, Dunn J, Gregory W, Kaiser M, Owen R, Pawlyn C, Child JA, Davies F, Morgan GJ, Jackson GH, Drayson MT, Basu S. Clinical characteristics and outcomes of IgD myeloma: experience across UK national trials. Blood Adv 2022; 6:5113-5123. [PMID: 35790108 PMCID: PMC9631630 DOI: 10.1182/bloodadvances.2022007608] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/22/2022] [Indexed: 11/20/2022] Open
Abstract
Immunoglobulin D (IgD) myeloma is a subtype often considered to have adverse features and inferior survival, but there is a paucity of data from large clinical studies. We compare the clinical characteristics and outcomes of patients with IgD myeloma from UK phase 3 myeloma trials analyzed in 2 groups: old (1980-2002) and recent (2002-2016) clinical trials, based on the time of adoption of novel myeloma therapies. Patients with IgD myeloma comprised 44 of 2789 (1.6%) and 70 of 5773 (1.2%) of the old and recent trials, respectively. Overall, IgD myeloma was associated with male predominance, low-level paraproteinemia (<10g/L), and λ light chain preference. The frequency of ultra-high-risk cytogenetics was similar in IgD myeloma compared with other subtypes (4.3% vs 5.3%, P > .99). Despite the old trial series being a younger group (median age: 59 vs 63 years, P = .015), there was a higher frequency of bone lesions, advanced stage at diagnosis, worse performance status, and severe renal impairment compared with the recent trials. Furthermore, the early mortality rate was significantly higher for the old trial series (20% vs 4%, P = .01). The overall response rate following induction therapy was significantly higher in the recent trials (89% vs 43%, P < .0001), and this was consistent with improved median overall survival (48 months; 95% confidence interval [CI] 35-67 months vs 22 months; 95% CI, 16-29 months). Survival outcomes for IgD myeloma have significantly improved and are now comparable to other myeloma types because of earlier diagnosis, novel therapies, and improved supportive care. This trial was registered at clinicaltrials.gov as # NCT01554852.
Collapse
Affiliation(s)
- Charles Agbuduwe
- UCL Cancer Institute, London, United Kingdom
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Gulnaz Iqbal
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - David Cairns
- Leeds Cancer Research UK Clinical Trials Unit, University of Leeds, Leeds, United Kingdom
| | - Tom Menzies
- Leeds Cancer Research UK Clinical Trials Unit, University of Leeds, Leeds, United Kingdom
| | - Janet Dunn
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Walter Gregory
- Leeds Cancer Research UK Clinical Trials Unit, University of Leeds, Leeds, United Kingdom
| | - Martin Kaiser
- The Institute of Cancer Research, London, United Kingdom
- The Haemato-oncology Unit, The Royal Marsden Hospital, London, United Kingdom
| | - Roger Owen
- Department of Clinical Haematology, St James’s University Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | | | - J. Anthony Child
- Leeds Cancer Research UK Clinical Trials Unit, University of Leeds, Leeds, United Kingdom
| | - Faith Davies
- Perlmutter Cancer Center, NYU Langone Health, New York, NY
| | | | - Graham H. Jackson
- Department of Haematology, Freeman Hospital, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Mark T. Drayson
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
- Clinical Immunology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Supratik Basu
- Department of Haematology, New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom; and
- Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, United Kingdom
| |
Collapse
|
80
|
de Tute RM, Pawlyn C, Cairns DA, Davies FE, Menzies T, Rawstron A, Jones JR, Hockaday A, Henderson R, Cook G, Drayson MT, Jenner MW, Kaiser MF, Gregory WM, Morgan GJ, Jackson GH, Owen RG. Minimal Residual Disease After Autologous Stem-Cell Transplant for Patients With Myeloma: Prognostic Significance and the Impact of Lenalidomide Maintenance and Molecular Risk. J Clin Oncol 2022; 40:2889-2900. [PMID: 35377708 DOI: 10.1200/jco.21.02228] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/14/2022] [Accepted: 02/08/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Minimal residual disease (MRD) can predict outcomes in patients with multiple myeloma, but limited data are available on the prognostic impact of MRD when assessed at serial time points in the context of maintenance therapy after autologous stem-cell transplant (ASCT) and the interaction between MRD and molecular risk. METHODS Data from a large phase III trial (Myeloma XI) were examined to determine the relationship between MRD status, progression-free survival (PFS), and overall survival (OS) in post-ASCT patients randomly assigned to lenalidomide maintenance or no maintenance at 3 months after ASCT. MRD status was assessed by flow cytometry (median sensitivity 0.004%) before maintenance random assignment (ASCT + 3) and 6 months later (ASCT + 9). RESULTS At ASCT + 3, 475 of 750 (63.3%) patients were MRD-negative and 275 (36.7%) were MRD-positive. MRD-negative status was associated with improved PFS (hazard ratio [HR] = 0.47; 95% CI, 0.37 to 0.58 P < .001) and OS (HR = 0.59; 95% CI, 0.40 to 0.85; P = .0046). At ASCT + 9, 214 of 326 (65.6%) were MRD-negative and 112 (34.4%) were MRD-positive. MRD-negative status was associated with improved PFS (HR = 0.20; 95% CI, 0.13 to 0.31; P < .0001) and OS (HR = 0.33; 95% CI, 0.15 to 0.75; P = .0077). The findings were very similar when restricted to patients with complete response/near complete response. Sustained MRD negativity from ASCT + 3 to ASCT + 9 or the conversion to MRD negativity by ASCT + 9 was associated with the longest PFS/OS. Patients randomly assigned to lenalidomide maintenance were more likely to convert from being MRD-positive before maintenance random assignment to MRD-negative 6 months later (lenalidomide 30%, observation 17%). High-risk molecular features had an adverse effect on PFS and OS even for those patients achieving MRD-negative status. On multivariable analysis of MRD status, maintenance therapy and molecular risk maintained prognostic impact at both ASCT + 3 and ASCT + 9. CONCLUSION In patients with multiple myeloma, MRD status at both ASCT + 3 and ASCT + 9 is a powerful predictor of PFS and OS.
Collapse
Affiliation(s)
- Ruth M de Tute
- Haematological Malignancy Diagnostic Service, Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Charlotte Pawlyn
- The Institute of Cancer Research, London, United Kingdom
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - David A Cairns
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Faith E Davies
- Perlmutter Cancer Center, NYU Langone Health, New York, NY
| | - Tom Menzies
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Andy Rawstron
- Haematological Malignancy Diagnostic Service, Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - John R Jones
- Eastbourne District General Hospital, Eastbourne, United Kingdom
- Brighton and Sussex Medical School, University of Sussex, Sussex, United Kingdom
- Kings College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Anna Hockaday
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Rowena Henderson
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Gordon Cook
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
- Kings College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Mark T Drayson
- Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Matthew W Jenner
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Martin F Kaiser
- The Institute of Cancer Research, London, United Kingdom
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Walter M Gregory
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | | | - Graham H Jackson
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Roger G Owen
- Haematological Malignancy Diagnostic Service, Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| |
Collapse
|
81
|
Bomsztyk J, Khwaja J, Wechalekar AD. Recent guidelines for high dose chemotherapy and autologous stem cell transplant for systemic AL amyloidosis: a practitioner's perspective. Expert Rev Hematol 2022; 15:781-788. [PMID: 36039749 DOI: 10.1080/17474086.2022.2115353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION High dose melphalan followed by autologous stem cell transplant (ASCT) has been transformative in treating AL amyloidosis since the early nineties. Recently, the European Haematology Association (EHA) and International Society of Amyloidosis (ISA) have developed a combined guideline for the management of patients undergoing an ASCT for AL amyloidosis. AREAS COVERED In this practitioner's perspective, we review the guideline, focussing on 6 major areas and offer practical advice for its application. We provide a perspective on the optimal use of ASCT and its potential application in the future. EXPERT OPINION The EHA-ISA guideline comprehensively outlines the practicalities of performing an ASCT in AL amyloidosis. The critical aspect is careful patient selection. Vigilant fluid balance assessments are crucial as associated complications are common and dangerous.The role of ASCT is changing with improving haematological responses associated with novel agents. Evidence is limited for the use of ASCT in patients who achieve a complete haematological response (CR). Therefore, ASCT should be considered for those who only achieve a very good partial response (VGPR)/partial response (PR) and fulfil the strict selection criteria. Future research identifying the cohort who would benefit most from ASCT in the era of novel therapies is warranted.
Collapse
Affiliation(s)
- Joshua Bomsztyk
- National Amyloidosis Centre, University College London, Rowland Hill Street, London NW3 2PF, UK
| | - Jahanzaib Khwaja
- Department of Haematology, University College London Hospitals, London, NW1 2BU, UK
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, University College London, Rowland Hill Street, London NW3 2PF, UK.,Department of Haematology, University College London Hospitals, London, NW1 2BU, UK
| |
Collapse
|
82
|
Rajkumar SV. Multiple myeloma: 2022 update on diagnosis, risk stratification, and management. Am J Hematol 2022; 97:1086-1107. [PMID: 35560063 PMCID: PMC9387011 DOI: 10.1002/ajh.26590] [Citation(s) in RCA: 270] [Impact Index Per Article: 135.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/05/2022] [Accepted: 05/06/2022] [Indexed: 12/22/2022]
Abstract
DISEASE OVERVIEW Multiple myeloma accounts for approximately 10% of hematologic malignancies. DIAGNOSIS The diagnosis requires ≥10% clonal bone marrow plasma cells or a biopsy-proven plasmacytoma plus evidence of one or more multiple myeloma defining events (MDE): CRAB (hypercalcemia, renal failure, anemia, or lytic bone lesions) attributable to the plasma cell disorder, bone marrow clonal plasmacytosis ≥60%, serum involved/uninvolved free light chain (FLC) ratio ≥ 100 (provided involved FLC is ≥100 mg/L), or >1 focal lesion on magnetic resonance imaging. RISK STRATIFICATION The presence of del(17p), t(4;14), t(14;16), t(14;20), gain 1q, or p53 mutation is considered high-risk multiple myeloma. The presence of any two high risk factors is considered double-hit myeloma, and three or more high risk factors is triple-hit myeloma. RISK-ADAPTED INITIAL THERAPY In patients who are candidates for autologous stem cell transplantation, induction therapy consists of bortezomib, lenalidomide, dexamethasone (VRd) given for approximately 3-4 cycles followed by autologous stem cell transplantation (ASCT). In high-risk patients, daratumumab, bortezomib, lenalidomide, dexamethasone (Dara-VRd) is an alternative to VRd. Selected standard-risk patients can collect stem cells, get additional cycles of induction therapy, and delay transplant until first relapse. Patients who are not candidates for transplant are treated with VRd for approximately 8-12 cycles followed by maintenance or alternatively with daratumumab, lenalidomide, dexamethasone (DRd) until progression. MAINTENANCE THERAPY Standard-risk patients need lenalidomide maintenance, while bortezomib plus lenalidomide maintenance is needed for high-risk myeloma. MANAGEMENT OF RELAPSED DISEASE A triplet regimen is usually needed at relapse, with the choice of regimen varying with each successive relapse.
Collapse
|
83
|
Davies FE, Pawlyn C, Usmani SZ, San-Miguel JF, Einsele H, Boyle EM, Corre J, Auclair D, Cho HJ, Lonial S, Sonneveld P, Stewart AK, Bergsagel PL, Kaiser MF, Weisel K, Keats JJ, Mikhael JR, Morgan KE, Ghobrial IM, Orlowski RZ, Landgren CO, Gay F, Caers J, Chng WJ, Chari A, Walker BA, Kumar SK, Costa LJ, Anderson KC, Morgan GJ. Perspectives on the Risk-Stratified Treatment of Multiple Myeloma. Blood Cancer Discov 2022; 3:273-284. [PMID: 35653112 PMCID: PMC9894570 DOI: 10.1158/2643-3230.bcd-21-0205] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The multiple myeloma treatment landscape has changed dramatically. This change, paralleled by an increase in scientific knowledge, has resulted in significant improvement in survival. However, heterogeneity remains in clinical outcomes, with a proportion of patients not benefiting from current approaches and continuing to have a poor prognosis. A significant proportion of the variability in outcome can be predicted on the basis of clinical and biochemical parameters and tumor-acquired genetic variants, allowing for risk stratification and a more personalized approach to therapy. This article discusses the principles that can enable the rational and effective development of therapeutic approaches for high-risk multiple myeloma.
Collapse
Affiliation(s)
| | - Charlotte Pawlyn
- Division of Cancer Therapeutics, The Institute of Cancer Research, London, United Kingdom
- The Royal Marsden Hospital, Department of Haematology, London, United Kingdom
| | - Saad Z. Usmani
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Hermann Einsele
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | | | - Jill Corre
- Unité de Génomique du Myélome, Institut Universitaire du Cancer, Toulouse France. Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Daniel Auclair
- The Multiple Myeloma Research Foundation, Norwalk, Connecticut
| | - Hearn Jay Cho
- The Multiple Myeloma Research Foundation, Norwalk, Connecticut
- Multiple Myeloma Center of Excellence, Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Sagar Lonial
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Pieter Sonneveld
- Erasmus MC Cancer Institute, Department of Hematology, Rotterdam, the Netherlands
| | - A. Keith Stewart
- University Health Network and the Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | | | - Martin F. Kaiser
- The Royal Marsden Hospital, Department of Haematology, London, United Kingdom
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, United Kingdom
| | - Katja Weisel
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jonathan J. Keats
- Integrated Cancer Genomics, Translational Genomics Research Institute, Phoenix, Arizona
| | - Joseph R. Mikhael
- Translational Genomics Research Institute, City of Hope Cancer Center, Phoenix, Arizona
| | | | - Irene M. Ghobrial
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Robert Z. Orlowski
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - C. Ola Landgren
- Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Francesca Gay
- Division of Hematology, University of Torino, Torino, Italy
| | - Joseph Caers
- Department of Hematology, Centre Hospitalier Universitaire (CHU) de Liège, Liège, Belgium
| | - Wee Joo Chng
- Melvin and Bren Simon Comprehensive Cancer Center, Division of Hematology Oncology, Indiana University, Indianapolis, Indiana
- Department of Hematology, Mayo Clinic, Rochester, Minnesota
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ajai Chari
- Multiple Myeloma Center of Excellence, Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Brian A. Walker
- Melvin and Bren Simon Comprehensive Cancer Center, Division of Hematology Oncology, Indiana University, Indianapolis, Indiana
| | - Shaji K. Kumar
- Department of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Luciano J. Costa
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kenneth C. Anderson
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | | |
Collapse
|
84
|
Maiolino A, Crusoé EDQ, Martinez GA, Braga WMT, de Farias DLC, Bittencourt RI, Neto JVP, Ribeiro GN, Bernardo WM, Tristão L, Magalhaes RJP, Hungria VTDM. Guidelines on the diagnosis and management of multiple myeloma treatment: Associação Brasileira de Hematologia e Hemoterapia e Terapia Celular Project guidelines: Associação Médica Brasileira – 2022. Part I. Hematol Transfus Cell Ther 2022; 44:410-418. [PMID: 35970751 PMCID: PMC9477772 DOI: 10.1016/j.htct.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 06/29/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Angelo Maiolino
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil; Instituto Americas de Ensino e Pesquisa, Rio de Janeiro, RJ, Brazil.
| | - Edvan de Queiroz Crusoé
- Hospital Professor Edgar Santos da Universidade Federal da Bahia (HUPES-UFBA), Salvador, BA, Brazil
| | - Gracia Aparecida Martinez
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | | | | | | | | | | | | | - Luca Tristão
- Associação Médica Brasileira (AMB), São Paulo, SP, Brazil
| | | | | |
Collapse
|
85
|
Slavin A, Kurdi A, Wilson M. What patient assessment skills do pharmacist independent prescribers require to prescribe immunomodulators in myeloma? J Oncol Pharm Pract 2022:10781552221110467. [PMID: 35765206 DOI: 10.1177/10781552221110467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM To gain consensus on the patient assessment skills required by pharmacist independent prescribers prescribing immunomodulators in myeloma across National Health Service Scotland. METHODS This was a two-phase study which used nominal group technique to gain local consensus followed by a two-round eDelphi questionnaire to gain national consensus across all cancer networks. SETTING This project was conducted across the three cancer networks within NHS Scotland: South East Scotland Cancer Network; West of Scotland Cancer Network and North Cancer Alliance. SUBJECTS Participants were invited from each cancer network (South East Scotland Cancer Network, West of Scotland Cancer Network and North Cancer Alliance) and included haematology consultants, haematology specialist registrars, haematology advanced nurse practitioners and haematology pharmacists. RESULTS There were five participants in the nominal group technique. Twenty-two out of 31 patient assessment skills gained local consensus, seven patient assessment skills did not gain consensus and two patient assessment skills were deemed irrelevant. There were 12 and 14 participants in round one and two of the eDelphi questionnaire, respectively. Twenty-nine patient assessment skills were included in the first-round questionnaire and 21 gained consensus. The remaining eight patient assessment skills were included in round two where seven did not achieve consensus and one achieved disagreement consensus. CONCLUSION This research outlines 21 patient assessment skills required for pharmacist independent prescribers to prescribe immunomodulators for myeloma patients according to haematology specialists in Scotland. Discussion on patient assessment skills without consensus showed that the pharmacist independent prescribers would have a shared responsibility with the consultant. This work should inform the development of a competency framework to allow training of pharmacist independent prescribers in Scotland. Some patient assessment skills could be transferrable for pharmacist independent prescribers prescribing systemic anti-cancer therapy for other haematological malignancies.
Collapse
Affiliation(s)
- Anton Slavin
- Edinburgh Cancer Centre, 3129NHS Lothian, Edinburgh, UK
- Pharmacy, Western General Hospital, Edinburgh, UK
| | - Amanj Kurdi
- Pharmacoepidemiology, 14306Strathclyde Institute of Pharmacy and Biomedical Sciences, Glasgow, UK
- Department of Pharmacology, College of Pharmacy, 125618Hawler Medical University, Erbil, Iraq
| | - Mandy Wilson
- Edinburgh Cancer Centre, 3129NHS Lothian, Edinburgh, UK
| |
Collapse
|
86
|
Lüke F, Harrer DC, Pantziarka P, Pukrop T, Ghibelli L, Gerner C, Reichle A, Heudobler D. Drug Repurposing by Tumor Tissue Editing. Front Oncol 2022; 12:900985. [PMID: 35814409 PMCID: PMC9270020 DOI: 10.3389/fonc.2022.900985] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022] Open
Abstract
The combinatory use of drugs for systemic cancer therapy commonly aims at the direct elimination of tumor cells through induction of apoptosis. An alternative approach becomes the focus of attention if biological changes in tumor tissues following combinatory administration of regulatorily active drugs are considered as a therapeutic aim, e.g., differentiation, transdifferentiation induction, reconstitution of immunosurveillance, the use of alternative cell death mechanisms. Editing of the tumor tissue establishes new biological 'hallmarks' as a 'pressure point' to attenuate tumor growth. This may be achieved with repurposed, regulatorily active drug combinations, often simultaneously targeting different cell compartments of the tumor tissue. Moreover, tissue editing is paralleled by decisive functional changes in tumor tissues providing novel patterns of target sites for approved drugs. Thus, agents with poor activity in non-edited tissue may reveal new clinically meaningful outcomes. For tissue editing and targeting edited tissue novel requirements concerning drug selection and administration can be summarized according to available clinical and pre-clinical data. Monoactivity is no pre-requisite, but combinatory bio-regulatory activity. The regulatorily active dose may be far below the maximum tolerable dose, and besides inhibitory active drugs stimulatory drug activities may be integrated. Metronomic scheduling often seems to be of advantage. Novel preclinical approaches like functional assays testing drug combinations in tumor tissue are needed to select potential drugs for repurposing. The two-step drug repurposing procedure, namely establishing novel functional systems states in tumor tissues and consecutively providing novel target sites for approved drugs, facilitates the systematic identification of drug activities outside the scope of any original clinical drug approvals.
Collapse
Affiliation(s)
- Florian Lüke
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
- Division of Personalized Tumor Therapy, Fraunhofer Institute for Toxicology and Experimental Medicine, Regensburg, Germany
| | - Dennis Christoph Harrer
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Pan Pantziarka
- The George Pantziarka TP53 Trust, London, United Kingdom
| | - Tobias Pukrop
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
- Bavarian Cancer Research Center (BZKF), University Hospital Regensburg, Regensburg, Germany
| | - Lina Ghibelli
- Department of Biology, University of Rome Tor Vergata, Rome, Italy
| | - Christopher Gerner
- Department of Analytical Chemistry, Faculty of Chemistry, University of Vienna, Vienna, Austria
| | - Albrecht Reichle
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Daniel Heudobler
- Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
- Bavarian Cancer Research Center (BZKF), University Hospital Regensburg, Regensburg, Germany
| |
Collapse
|
87
|
Rafae A, Ehsan H, Wahab A, Khan SI, Khan I, Ashraf S, Ali S, Khalid F, Neupane K, Valent J, Khouri J, Samaras C, Mazzoni S, Anwer F. Evidence-based recommendations for induction and maintenance treatment of newly diagnosed transplant-ineligible multiple myeloma patients. Crit Rev Oncol Hematol 2022; 176:103744. [PMID: 35717005 DOI: 10.1016/j.critrevonc.2022.103744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 05/23/2022] [Accepted: 06/13/2022] [Indexed: 11/28/2022] Open
Abstract
There is increasing evidence regarding the role of various maintenance therapy (MT) strategies after initial induction to treat newly diagnosed transplant-ineligible patients with MM. We reviewed the literature on available regimens for patients with transplant-ineligible newly diagnosed multiple myeloma (NDMM). Lenalidomide (R)-based regimens are still the front-line therapy, but there is an increasing use of bortezomib-based regimens. The MT regimen is mainly based on the initial induction regimen. MT has shown survival benefits compared with patients without maintenance therapy. The most common adverse effects of MT include anemia, neutropenia, thrombocytopenia, infections, and peripheral neuropathy. In conclusion, induction followed by maintenance based on lenalidomide, bortezomib, ixazomib, or daratumumab-based regimens has shown promising results. Therefore, it is essential to conduct more clinical trials to better understand the role of MT in the treatment of NDMM patients who are not candidates for autologous stem cell transplantation.
Collapse
Affiliation(s)
- Abdul Rafae
- Department of Internal Medicine, McLaren Flint-Michigan State University, Flint, MI, USA.
| | | | - Ahsan Wahab
- Internal Medicine/Hospital Medicine Department, University of Alabama at Birmingham, Montgomery, AL, USA
| | - Sana Irfan Khan
- SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | | | - Sara Ashraf
- Sharif Medical and Dental College, Lahore, Pakistan
| | - Sundas Ali
- Department of Internal Medicine, Ascension St. Agnes Hospital, Baltimore, MD, USA
| | - Farhan Khalid
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ, USA
| | - Karun Neupane
- Department of Internal Medicine, Jacobi Medical Center, Bronx, NY, USA
| | - Jason Valent
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Jack Khouri
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Christy Samaras
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Sandra Mazzoni
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Faiz Anwer
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
88
|
Efficacy and safety of modified BLd therapy for Japanese patients with transplant-ineligible multiple myeloma. Int J Hematol 2022; 116:563-569. [PMID: 35699890 DOI: 10.1007/s12185-022-03379-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 04/25/2022] [Accepted: 04/25/2022] [Indexed: 10/18/2022]
Abstract
The BLd regimen, which is a triplet regimen of bortezomib (Bor), lenalidomide (Len), and dexamethasone (Dex), is effective against newly diagnosed multiple myeloma (NDMM). However, non-hematological toxicities, such as peripheral neuropathy (PN), often hamper long-term continuation of the regimen, particularly in older adult patients. In this study, we examined the efficacy and safety of the modified BLd regimen with reduced-intensity Bor and standard-dose Len. The chemotherapy regimen consisted of 1.3 mg/m2 Bor administered subcutaneously on days 1 and 8, 25 mg Len administered on days 1-14, and 20 mg Dex on days 1-2 and 8-9 of a 3 week cycle for 8 cycles, followed by a 4 week cycle of Dex (40 mg weekly). Among the 30 patients enrolled, 60.0% (95% CI 40.6-77.3) had a very good partial response or better, and the best overall response rate was 96.7% (95% CI 82.8-99.9). Eight patients (26.7%) achieved a complete response. Grade 3 or higher PN was not observed and hematological toxicity was the most common adverse event. The modified BLd regimen showed favorable efficacy with a manageable safety profile, which suggests it could be a treatment option for transplant-ineligible NDMM.
Collapse
|
89
|
Dhakal B, Shah N, Kansagra A, Kumar A, Lonial S, Garfall A, Cowan A, Poudyal BS, Costello C, Gay F, Cook G, Quach H, Einsele H, Schriber J, Hou J, Costa L, Aljurf M, Chaudhry M, Beksac M, Prince M, Mohty M, Janakiram M, Callander N, Biran N, Malhotra P, Otero PR, Moreau P, Abonour R, Iftikhar R, Silberman R, Mailankody S, Gregory T, Lin Y, Carpenter P, Hamadani M, Usmani S, Kumar S. ASTCT Clinical Practice Recommendations for Transplantation and Cellular Therapies in Multiple Myeloma. Transplant Cell Ther 2022; 28:284-293. [PMID: 35306217 DOI: 10.1016/j.jtct.2022.03.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
Abstract
Over the past decade, therapeutic options in multiple myeloma (MM) have changed dramatically. Given the unprecedented efficacy of novel agents, the role of hematopoietic cell transplantation (HCT) in MM remains under scrutiny. Rapid advances in myeloma immunotherapy including the recent approval of chimeric antigen receptor (CAR) T-cell therapy will impact the MM therapeutic landscape. The American Society for Transplantation and Cellular Therapy convened an expert panel to formulate clinical practice recommendations for role, timing, and sequencing of autologous (auto-HCT), allogeneic (allo-HCT) and CAR T-cell therapy for patients with newly diagnosed (NDMM) and relapsed/refractory MM (RRMM). The RAND-modified Delphi method was used to generate consensus statements. Twenty consensus statements were generated. The panel endorsed continued use of auto-HCT consolidation for patients with NDMM as a standard-of-care option, whereas in the front line allo-HCT and CAR-T were not recommended outside the setting of clinical trial. For patients not undergoing auto-HCT upfront, the panel recommended its use in first relapse. Lenalidomide as a single agent was recommended for maintenance especially for standard risk patients. In the RRMM setting, the panel recommended the use of CAR-T in patients with 4 or more prior lines of therapy. The panel encouraged allo-HCT in RRMM setting only in the context of clinical trial. The panel found RAND-modified Delphi methodology effective in providing a formal framework for developing consensus recommendations for the timing and sequence of cellular therapies for MM.
Collapse
Affiliation(s)
- Binod Dhakal
- Blood and Marrow Transplant and Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nina Shah
- Division of Hematology-Oncology, University of California, San Francisco, California
| | - Ankit Kansagra
- Department of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ambuj Kumar
- Program for Comparative Effectiveness Research, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Sagar Lonial
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Alfred Garfall
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew Cowan
- University of Washington, Seattle WA, and Fred Hutch, Seattle, Washington
| | - Bishesh Sharma Poudyal
- Department of Clinical Hematology and Bone Marrow Transplant, Civil Service Hospital, Kathmandu, Nepal
| | - Caitlin Costello
- UCSD/Sharp Healthcare Transplant Program, Blood & Marrow Transplant Services, Moore's Cancer Center, San-Diego, California
| | - Francesca Gay
- Division of Hematology 1 Clinical Trial Unit, AOU CIttà della salute e della Scienza, University of Torino, Turin, Italy
| | - Gordon Cook
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trial Research, University of Leeds, Leeds, United Kingdom
| | - Hang Quach
- University of Melbourne, St. Vincent's Hospital, Melbourne, Australia
| | - Herman Einsele
- Universitätsklinikum Würzburg, Department of Internal Medicine II, Würzburg, Germany
| | - Jeff Schriber
- Cancer Treatment Centers of America, Phoenix, Arizona
| | - Jian Hou
- Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Luciano Costa
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mahmoud Aljurf
- Oncology Center, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Maria Chaudhry
- Department of hematology/Oncology, George Washington University and Cancer Center, Washington, District of Columbia
| | - Meral Beksac
- Department of Hematology, Ankara University, Ankara, Turkey
| | - Miles Prince
- Epworth Healthcare and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, Paris, France
| | - Murali Janakiram
- Division of Myeloma, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, California
| | | | - Noa Biran
- Hackensack Meridian Health, John Theurer Cancer Center, Multiple Myeloma Division, Hackensack, New Jersey
| | - Pankaj Malhotra
- Department of Clinical Hematology & Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Philippe Moreau
- Department of Hematology, University Hospital Hôtel-Dieu, Nantes, France
| | - Rafat Abonour
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Raheel Iftikhar
- Armed Forces Bone Marrow Transplant Centre, Rawalpindi, Pakistan
| | - Rebecca Silberman
- Department of Medicine, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
| | - Sham Mailankody
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New, York, New York
| | - Tara Gregory
- Colorado Blood Cancer Institute, Sarah Cannon Cancer Network, Denver, Colorado
| | - Yi Lin
- Mayo Clinic, Rochester, Minnesota
| | - Paul Carpenter
- Division of Clinical Research, Fred Hutchinson Cancer Research Center and Department of Pediatrics, University of Washington, Seattle, Washington
| | - Mehdi Hamadani
- Blood and Marrow Transplant and Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Saad Usmani
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New, York, New York
| | | |
Collapse
|
90
|
D'Agostino M, Cairns DA, Lahuerta JJ, Wester R, Bertsch U, Waage A, Zamagni E, Mateos MV, Dall'Olio D, van de Donk NWCJ, Jackson G, Rocchi S, Salwender H, Bladé Creixenti J, van der Holt B, Castellani G, Bonello F, Capra A, Mai EK, Dürig J, Gay F, Zweegman S, Cavo M, Kaiser MF, Goldschmidt H, Hernández Rivas JM, Larocca A, Cook G, San-Miguel JF, Boccadoro M, Sonneveld P. Second Revision of the International Staging System (R2-ISS) for Overall Survival in Multiple Myeloma: A European Myeloma Network (EMN) Report Within the HARMONY Project. J Clin Oncol 2022; 40:3406-3418. [PMID: 35605179 DOI: 10.1200/jco.21.02614] [Citation(s) in RCA: 131] [Impact Index Per Article: 65.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Patients with newly diagnosed multiple myeloma (NDMM) show heterogeneous outcomes, and approximately 60% of them are at intermediate-risk according to the Revised International Staging system (R-ISS), the standard-of-care risk stratification model. Moreover, chromosome 1q gain/amplification (1q+) recently proved to be a poor prognostic factor. In this study, we revised the R-ISS by analyzing the additive value of each single risk feature, including 1q+. PATIENTS AND METHODS The European Myeloma Network, within the HARMONY project, collected individual data from 10,843 patients with NDMM enrolled in 16 clinical trials. An additive scoring system on the basis of top features predicting progression-free survival (PFS) and overall survival (OS) was developed and validated. RESULTS In the training set (N = 7,072), at a median follow-up of 75 months, ISS, del(17p), lactate dehydrogenase, t(4;14), and 1q+ had the highest impact on PFS and OS. These variables were all simultaneously present in 2,226 patients. A value was assigned to each risk feature according to their OS impact (ISS-III 1.5, ISS-II 1, del(17p) 1, high lactate dehydrogenase 1, and 1q+ 0.5 points). Patients were stratified into four risk groups according to the total additive score: low (Second Revision of the International Staging System [R2-ISS]-I, 19.2%, 0 points), low-intermediate (II, 30.8%, 0.5-1 points), intermediate-high (III, 41.2%, 1.5-2.5 points), high (IV, 8.8%, 3-5 points). Median OS was not reached versus 109.2 versus 68.5 versus 37.9 months, and median PFS was 68 versus 45.5 versus 30.2 versus 19.9 months, respectively. The score was validated in an independent validation set (N = 3,771, of whom 1,214 were with complete data to calculate R2-ISS) maintaining its prognostic value. CONCLUSION The R2-ISS is a simple prognostic staging system allowing a better stratification of patients with intermediate-risk NDMM. The additive nature of this score fosters its future implementation with new prognostic variables.
Collapse
Affiliation(s)
- Mattia D'Agostino
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - David A Cairns
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Juan José Lahuerta
- Instituto de Investigación del Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ruth Wester
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Uta Bertsch
- University Hospital Heidelberg, Internal Medicine V and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Anders Waage
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Elena Zamagni
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli," Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - María-Victoria Mateos
- Complejo Asistencial Universitario de Salamanca/IBSAL/CIC/Ciberonc, Salamanca, Spain
| | - Daniele Dall'Olio
- Dipartimento di Fisica e Astronomia, Università di Bologna, Bologna, Italy
| | - Niels W C J van de Donk
- Department of Hematology, Amsterdam UMC, Cancer Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Graham Jackson
- University of Newcastle upon Tyne, Newcastle upon Tyne, United Kingdom
| | - Serena Rocchi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli," Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Hans Salwender
- Asklepios Tumorzentrum Hamburg, AK Altona and AK St Georg, Hamburg, Germany
| | | | - Bronno van der Holt
- HOVON Data Center, Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Gastone Castellani
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Francesca Bonello
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Andrea Capra
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Elias K Mai
- University Hospital Heidelberg, Internal Medicine V and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Jan Dürig
- Department of Hematology, University Clinic Essen, Essen, Germany
| | - Francesca Gay
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Sonja Zweegman
- Department of Hematology, Amsterdam UMC, Cancer Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Michele Cavo
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli," Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Martin F Kaiser
- The Institute of Cancer Research, London, United Kingdom and The Royal Marsden Hospital, London, United Kingdom
| | - Hartmut Goldschmidt
- University Hospital Heidelberg, Internal Medicine V and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Jesús María Hernández Rivas
- Department of Medicine, University of Salamanca, Institute of Biomedical Research of Salamanca (IBSAL), University of Salamanca-Cancer Research Center of Salamanca (IBMCC, USAL-CSIG). Hematology Department, Hospital Universitario de Salamanca (CAUSA/IBSAL), Salamanca, Spain
| | - Alessandra Larocca
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Gordon Cook
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Jesús F San-Miguel
- Clínica Universidad de Navarra, CIMA, IDISNA, CIBER-ONC (CB16/12/00369), Pamplona, Spain
| | - Mario Boccadoro
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Pieter Sonneveld
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| |
Collapse
|
91
|
Abstract
Multiple myeloma (MM) is a type of haematological bone marrow malignancy. Cancer Research UK reports that MM is the 18th most common cancer in the UK, accounting for 2% of all new cancer cases, yet, non-haematologists often lack familiarity with the pathology and initial investigations. This paper aims to demonstrate the diagnostic features, relevant investigations and basic management plan for the non-specialist.
Collapse
Affiliation(s)
- Taran K Nandra
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | | | - John R Jones
- Brighton and Sussex Medical School, Falmer, UK, King's College Hospital, London, UK and Eastbourne District General Hospital, Eastbourne, UK
| |
Collapse
|
92
|
Bertamini L, Bertuglia G, Oliva S. Beyond Clinical Trials in Patients With Multiple Myeloma: A Critical Review of Real-World Results. Front Oncol 2022; 12:844779. [PMID: 35646628 PMCID: PMC9132127 DOI: 10.3389/fonc.2022.844779] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/22/2022] [Indexed: 12/22/2022] Open
Abstract
The current strategies for the treatment of multiple myeloma (MM) have improved, thanks to effective drug classes and combination therapies, for both the upfront and relapsed settings. Clinical trials for newly diagnosed transplant-ineligible patients led to the approval of immunomodulatory drugs (IMiDs) and proteasome inhibitors (PIs) in combination with anti-CD38 monoclonal antibodies (mAbs), to be administered during the induction phase before transplantation and during maintenance treatment, with lenalidomide recommended until relapse. In relapsed/refractory patients, the complex treatment scenario currently includes several options, such as triplets with anti-CD38 mAbs plus IMiDs or PIs, and novel targeted molecules. Comparisons among clinical trials and real-world data showed a good degree of reproducibility of some important results, particularly in terms of overall response rate, progression-free survival, and overall survival. This may help clinicians towards a proper selection of the best treatment options, particularly in real-world settings. However, as compared with the management of real-world settings, clinical trials have some pitfalls in terms of outcome and especially in terms of safety and quality of life. In fact, trials include younger and presumably healthier patients, excluding those with worst clinical conditions due to MM features (e.g., renal insufficiency or bone disease, which can impair the performance status) and comorbidities (e.g., cardiac and pulmonary disease), thus resulting in a possible lack of representativeness of data about the patients enrolled. In this review, we analyze comparable and discrepant results from clinical trials vs. real-world settings published in the last 10 years, focusing on different drugs and combinations for the treatment of MM and providing an overview of treatment choices.
Collapse
Affiliation(s)
| | | | - Stefania Oliva
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| |
Collapse
|
93
|
Gupta RK, Gupta A, Hillengass J, Holstein SA, Suman VJ, Taneja A, McCarthy PL. A review of the current status of lenalidomide maintenance therapy in multiple myeloma in 2022. Expert Rev Anticancer Ther 2022; 22:457-469. [PMID: 35503516 DOI: 10.1080/14737140.2022.2069564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Recent advances in the diagnosis and management of multiple myeloma (MM) have improved patient outcomes. This progress in our understanding of MM has resulted in continuous suppressive therapy concepts, including induction, high dose chemotherapy with autologous stem cell transplantation (ASCT), consolidation, and maintenance therapy. The foundation of maintenance therapy has been with lenalidomide. Other novel immunomodulatory drugs (IMiDs), proteasome inhibitors (PIs), and targeted monoclonal antibodies have also contributed to this evolution. AREAS COVERED This review summarizes the outcomes from phase II/III trials with long-term lenalidomide maintenance therapy alone or in combination with other agents in post-ASCT and non-transplant settings for newly diagnosed patients with MM. We review recent data considering a combination with newer medications and ongoing trials. We also review the optimal duration, MRD negativity rate, and safety and tolerability aspects of lenalidomide maintenance therapy. This review aims to present the current and emerging clinical evidence that supports using lenalidomide as a backbone for maintenance therapy in patients with MM. EXPERT OPINION There is increasing evidence to support lenalidomide as the backbone of combination therapy in the maintenance setting.
Collapse
Affiliation(s)
- Ravi Kumar Gupta
- Department of Internal Medicine, Larkin Community Hospital, South Miami, Florida, USA
| | - Ashish Gupta
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Jens Hillengass
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Sarah A Holstein
- Department of Internal Medicine, Division of Oncology and Hematology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Vera J Suman
- Department of Health Sciences, Division of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Alankrita Taneja
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Philip L McCarthy
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| |
Collapse
|
94
|
Goel U, Usmani S, Kumar S. Current approaches to management of newly diagnosed multiple myeloma. Am J Hematol 2022; 97 Suppl 1:S3-S25. [PMID: 35234302 DOI: 10.1002/ajh.26512] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 12/16/2022]
Abstract
Major developments in the treatment of multiple myeloma (MM) over the past decade have led to a continued improvement in survival. Significant progress has been made with deeper and longer remissions seen with newer treatment approaches-both for induction as well as maintenance therapy. The treatment approach to MM is guided by several factors including patient age, frailty, comorbidities, eligibility for autologous stem cell transplantation (ASCT), and risk stratification into standard-risk or high-risk MM. High-risk MM is defined by the presence of t(4;14), t(14;16), t(14;20), del (17p), TP53 mutation, or gain (1q). Transplant eligible patients should receive 4-6 cycles of induction followed by stem cell collection. Patients can then undergo ASCT, or continue induction therapy and shift to maintenance, delaying ASCT till first relapse. Transplant ineligible patients should receive induction therapy followed by maintenance. For induction therapy prior to ASCT, a proteasome inhibitor-IMiD combination remains standard with monoclonal antibody-based quadruplets preferred in high-risk patients. Among transplant ineligible patients, those with standard-risk MM should receive DRd continued until disease progression, while bortezomib containing regimens (VRd or VRd lite) can be considered for high-risk patients. Finally, standard-risk patients should receive lenalidomide maintenance after induction/ASCT, while proteasome inhibitor-IMiD combinations should be used for high-risk patients.
Collapse
Affiliation(s)
- Utkarsh Goel
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota USA
| | - Saad Usmani
- Multiple Myeloma Service, Department of medicine Memorial Sloan Kettering Cancer Center New York New York USA
| | - Shaji Kumar
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota USA
| |
Collapse
|
95
|
Shi X, Yan L, Shang J, Kang L, Yan Z, Jin S, Zhu M, Chang H, Gong F, Zhou J, Chen G, Pan J, Liu D, Zhu X, Tang F, Liu M, Liu W, Yao F, Yu L, Wu D, Fu C. Anti-CD19 and anti-BCMA CAR T cell therapy followed by lenalidomide maintenance after autologous stem-cell transplantation for high-risk newly diagnosed multiple myeloma. Am J Hematol 2022; 97:537-547. [PMID: 35114022 DOI: 10.1002/ajh.26486] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/31/2021] [Accepted: 01/31/2022] [Indexed: 12/30/2022]
Abstract
Few prospective studies have examined posttransplant chimeric antigen receptor (CAR) T cell infusion as candidates for front-line consolidation therapy for high-risk multiple myeloma (MM) patients. This single-arm exploratory clinical trial is the first to evaluate the safety and efficacy of sequential anti-CD19 and anti-BCMA CAR-T cell infusion, followed by lenalidomide maintenance after autologous stem cell transplantation (ASCT), in 10 high-risk newly diagnosed multiple myeloma (NDMM) patients. The treatment was generally well tolerated, with hematologic toxicities being the most common grade 3 or higher adverse events. All patients had cytokine release syndrome (CRS), which was grade 1 in 5 patients (50%) and grade 2 in 5 patients (50%). No neurotoxicity was observed after CAR-T cell infusion. The overall response rate was 100%, with the best response being 90% for a stringent complete response (sCR), and 10% for a complete response (CR). At a median follow-up of 42 (36-49) months, seven (70%) of 10 patients showed sustained minimal residual disease (MRD) negativity for more than 2 years. The median progression-free survival (PFS) and overall survival (OS) were not reached. Although the sample size was small and there was a lack of control in this single-arm study, the clinical benefits observed warrant ongoing randomized controlled trials.
Collapse
Affiliation(s)
- Xiaolan Shi
- National Clinical Research Center for Hematologic Diseases Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University Suzhou China
| | - Lingzhi Yan
- National Clinical Research Center for Hematologic Diseases Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University Suzhou China
| | - Jingjing Shang
- National Clinical Research Center for Hematologic Diseases Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University Suzhou China
| | - Liqing Kang
- Shanghai Unicar‐Therapy Bio‐medicine Technology Co. Ltd. Shanghai China
| | - Zhi Yan
- National Clinical Research Center for Hematologic Diseases Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University Suzhou China
| | - Song Jin
- National Clinical Research Center for Hematologic Diseases Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University Suzhou China
| | - Mingqing Zhu
- National Clinical Research Center for Hematologic Diseases Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University Suzhou China
| | - Huirong Chang
- National Clinical Research Center for Hematologic Diseases Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University Suzhou China
| | - Feiran Gong
- National Clinical Research Center for Hematologic Diseases Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University Suzhou China
| | - Jiazi Zhou
- National Clinical Research Center for Hematologic Diseases Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University Suzhou China
| | - Guanghua Chen
- National Clinical Research Center for Hematologic Diseases Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University Suzhou China
| | - Jinlan Pan
- National Clinical Research Center for Hematologic Diseases Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University Suzhou China
| | - Dandan Liu
- National Clinical Research Center for Hematologic Diseases Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University Suzhou China
| | - Xiaming Zhu
- National Clinical Research Center for Hematologic Diseases Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University Suzhou China
| | - Fang Tang
- National Clinical Research Center for Hematologic Diseases Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University Suzhou China
| | - Minghong Liu
- National Clinical Research Center for Hematologic Diseases Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University Suzhou China
| | - Wei Liu
- Department of Pathology The First Affiliated Hospital of Soochow University Suzhou China
| | - Feirong Yao
- Department of Radiology The First Affiliated Hospital of Soochow University Suzhou China
| | - Lei Yu
- Shanghai Unicar‐Therapy Bio‐medicine Technology Co. Ltd. Shanghai China
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University Suzhou China
- Institute of Blood and Marrow Transplantation Collaborative Innovation Center of Hematology, Soochow University Suzhou China
- State Key Laboratory of Radiation Medicine and Protection Soochow University Suzhou China
| | - Chengcheng Fu
- National Clinical Research Center for Hematologic Diseases Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University Suzhou China
- Institute of Blood and Marrow Transplantation Collaborative Innovation Center of Hematology, Soochow University Suzhou China
- State Key Laboratory of Radiation Medicine and Protection Soochow University Suzhou China
| |
Collapse
|
96
|
Chakraborty R, Siddiqi R, Wilson G, Gupta S, Asghar N, Husnain M, Aljama M, Behera TR, Anwer F, Perrot A, Riaz IB. Impact of autologous transplantation on survival in patients with newly diagnosed multiple myeloma who have high-risk cytogenetics: A meta-analysis of randomized controlled trials. Cancer 2022; 128:2288-2297. [PMID: 35377484 DOI: 10.1002/cncr.34211] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 02/23/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Despite routine evaluation of cytogenetics in myeloma, little is known regarding the impact of high-dose therapy (HDT) consolidation on overall survival (OS) or progression-free survival (PFS) in patients who have high-risk cytogenetics. The authors performed a meta-analysis of randomized controlled trials (RCTs) to assess the heterogeneity of HDT efficacy according to cytogenetic risk. METHODS All RCTs in patients who had newly diagnosed myeloma from 2000 to 2021 that compared upfront HDT versus standard-dose therapy (SDT) consolidation were included. The primary objective was to assess the difference in HDT efficacy between standard-risk and high-risk cytogenetics in terms of the OS or PFS log(hazard ratio) (HR). The pooled OS and PFS HR was calculated according to cytogenetic-risk subgroup using a random-effects model, and heterogeneity (I2 ) (the percentage of total observed variability explained by between-study differences) was assessed using an interaction test. RESULTS After screening 3307 citations, 6 RCTs were included for PFS analysis, and 4 were included for OS analysis. The median follow-up ranged from 3.1 to 7.8 years. The pooled OS HR for HDT versus SDT consolidation in patients with standard-risk and high-risk cytogenetics was 0.90 (95% confidence interval [CI], 0.70-1.17; I2 = 0%) and 0.66 (95% CI, 0.45-0.97; I2 = 0%), respectively. The difference in HDT efficacy in terms of OS between standard-risk and high-risk patients was statistically significant in favor of the high-risk group (P for interaction = .03). The pooled PFS HR for HDT versus SDT was 0.65 (95% CI 0.56-0.76; I2 = 0%) versus 0.52 (95% CI, 0.33-0.83; I2 = 55%), respectively. The difference in HDT efficacy in terms of PFS between standard-risk and high-risk patients was not significant (P for interaction = .25). CONCLUSIONS The magnitude of OS benefit with upfront HDT is cytogenetics-dependent. Patients with high-risk cytogenetics should preferably receive upfront rather than delayed HDT consolidation. LAY SUMMARY Upfront autologous stem cell transplantation improves overall survival in patients with newly diagnosed myeloma harboring high-risk cytogenetics.
Collapse
Affiliation(s)
- Rajshekhar Chakraborty
- Multiple Myeloma and Amyloidosis Program, Columbia University Irving Medical Center, New York, New York
| | - Rabbia Siddiqi
- Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Gloria Wilson
- The Knowledge Center, August C. Long Health Sciences Library, Columbia University Irving Medical Center, New York, New York
| | - Samiksha Gupta
- Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Noureen Asghar
- Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Husnain
- Division of Hematology/Oncology, University of Arizona, Tucson, Arizona
| | - Mohammed Aljama
- Division of Hematology/Oncology, University of Arizona, Tucson, Arizona
| | | | - Faiz Anwer
- Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Aurore Perrot
- Hematology Service, University Cancer Institute Toulouse-Oncopole, Toulouse, France
| | - Irbaz B Riaz
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
97
|
Caro J, Cairns D, Menzies T, Boyle E, Pawlyn C, Cook G, Kaiser M, Walker BA, Owen R, Jackson GH, Morgan GJ, Heaney J, Drayson MT, Davies FE. Impact of Etiological Cytogenetic Abnormalities on the Depth of Immunoparesis and Survival in Newly Diagnosed Multiple Myeloma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e279-e284. [PMID: 34876373 DOI: 10.1016/j.clml.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/13/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION/BACKGROUND Immunoparesis, or low polyclonal immunoglobulin levels, is commonly seen in multiple myeloma (MM), and is associated with poor clinical outcomes. MM can be divided into subgroups with distinct biology and outcomes based on etiologic cytogenetic abnormalities. These include hyperdiploidy and translocations of t(11;14), t(4;14), t(14;16), and t(14;20), with the latter 3 associated with high-risk disease. We hypothesized that the different etiologic cytogenetic abnormalities drive bone marrow microenvironmental changes, resulting in different degrees of immunoparesis, and subgroup-dependent effects on clinical outcomes. MATERIALS AND METHODS We performed a retrospective review of 985 newly diagnosed patients enrolled in the Myeloma IX and XI trials. Immunoglobulin levels, survival outcomes, and infection rates were evaluated for each cytogenetic subgroup. RESULTS A significant proportion of patients with high-risk t(4;14), t(14;16), or t(14;20) had suppressed polyclonal immunoglobulins compared to standard-risk patients with hyperdiploidy or t(11;14). The clinical impact of immunoparesis depended on the cytogenetic subgroup, with the degree of IgM suppression effecting progression-free and overall survival only in the hyperdiploid subgroup. There was no significant difference in infection rates amongst the etiologic subgroups. CONCLUSION These findings demonstrate that the etiologic cytogenetic subgroup influences the degree and clinical impact of immunoparesis. This suggests that the underlying cytogenetic abnormality affects remodeling of the bone marrow plasma cell niche, resulting in suppressed normal plasma cell function, and low immunoglobulin levels.
Collapse
Affiliation(s)
- Jessica Caro
- Perlmutter Cancer Center, NYU Langone Health, New York, NY.
| | - David Cairns
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Tom Menzies
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Eileen Boyle
- Perlmutter Cancer Center, NYU Langone Health, New York, NY
| | | | - Gordon Cook
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Martin Kaiser
- The Institute of Cancer Research, London, United Kingdom
| | | | - Roger Owen
- St James's University Hospital, Leeds, United Kingdom
| | - Graham H Jackson
- Department of Hematology, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Jennifer Heaney
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Mark T Drayson
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Faith E Davies
- Perlmutter Cancer Center, NYU Langone Health, New York, NY
| |
Collapse
|
98
|
Vekemans MC, Doyen C, Caers J, Wu K, Kentos A, Mineur P, Michaux L, Delforge M, Meuleman N. Recommendations on the management of multiple myeloma in 2020. Acta Clin Belg 2022; 77:445-461. [PMID: 33355041 DOI: 10.1080/17843286.2020.1860411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
With the introduction of immunomodulatory drugs, proteasome inhibitors, and anti-CD38 monoclonal antibodies, major improvements have been achieved in the treatment of multiple myeloma (MM), with a significant impact on the outcome of this disease. Different treatment combinations are now in use and other therapies are being developed. Based on an extensive review of the recent literature, we propose practical recommendations on myeloma management, to be used by hematologists as a reference for daily practice.
Collapse
Affiliation(s)
| | - Chantal Doyen
- Centre Hospitalier Universitaire de Namur, UCL, Yvoir, Belgium
| | - Jo Caers
- Centre Hospitalier Universitaire de Liège, Ulg, Liège, Belgium
| | - Kalung Wu
- Zienkenhuis Netwerk Antwerpen, Antwerp, Belgium
| | | | | | - Lucienne Michaux
- Universitair Ziekenhuis Leuven Gasthuisberg, KUL, Leuven, Belgium
| | - Michel Delforge
- Universitair Ziekenhuis Leuven Gasthuisberg, KUL, Leuven, Belgium
| | | |
Collapse
|
99
|
Patel KK, Shah JJ, Feng L, Lee HC, Manasanch EM, Olsem J, Morphey A, Huo XJ, Thomas SK, Bashir Q, Qazilbash MH, Weber DM, Orlowski RZ. Safety and Efficacy of Combination Maintenance Therapy with Ixazomib and Lenalidomide in Patients with Posttransplant Myeloma. Clin Cancer Res 2022; 28:1277-1284. [PMID: 34992070 PMCID: PMC9365361 DOI: 10.1158/1078-0432.ccr-21-3420] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/23/2021] [Accepted: 01/04/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE In this study, the addition of ixazomib to lenalidomide maintenance post-autologous stem cell transplant (ASCT) in 64 patients with newly diagnosed multiple myeloma was evaluated on the basis of the observed benefit of lenalidomide-only maintenance in prior studies. PATIENTS AND METHODS Patients were started on maintenance therapy with lenalidomide and ixazomib within 60-180 days of stem cell infusion. RESULTS Response rates deepened over time from baseline post-ASCT for 39 patients. The complete response (CR)/stringent CR rate was 43% and median overall survival was not reached with a median follow-up of 62 months (range, 25-82 months). Median PFS (mPFS) for all patients was 73 months and has not been reached for those with International Staging System (ISS) stage 1 disease. mPFS in 9 patients who had ISS stage 3 disease and 14 patients who had high-risk cytogenetics was 34 and 25 months, respectively. Twenty-two patients had progressive disease, while 19 patients continue to receive dual maintenance. The most common grade 3/4 adverse events included neutropenia, leukopenia, thrombocytopenia, lung infections, diarrhea, and maculopapular rash. Second primary malignancies occurred in 9 patients. Toxicity led to dose reductions in ixazomib and lenalidomide in 20 and 31 patients, respectively. Discontinuation of ixazomib due to toxicity occurred in 4 patients. Grade 1/2 neuropathy occurred in 22 patients and led to reduction or discontinuation of ixazomib in 2 patients. CONCLUSIONS The addition of ixazomib to lenalidomide maintenance demonstrated a better than expected PFS compared with historical data using lenalidomide alone and was safe and tolerable.
Collapse
Affiliation(s)
- Krina K. Patel
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas.,Corresponding Author: Krina K. Patel, Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston TX 77030. Phone: 713-792-6662; Fax: 713-792-1897; E-mail:
| | | | - Lei Feng
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Hans C. Lee
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Elisabet M. Manasanch
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Jasper Olsem
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Ashley Morphey
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Xiao Jiao Huo
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Sheeba K. Thomas
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Qaiser Bashir
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Muzaffar H. Qazilbash
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Donna M. Weber
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas
| | - Robert Z. Orlowski
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston Texas.,Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston Texas
| |
Collapse
|
100
|
Meilhac A, Cautela J, Thuny F. Cancer Therapies and Vascular Toxicities. Curr Treat Options Oncol 2022; 23:333-347. [PMID: 35244888 DOI: 10.1007/s11864-022-00964-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 12/24/2022]
Abstract
OPINION STATEMENT Vascular events have become an important issue in the overall management of cancer patients. They usually result from a combination of (i) direct or indirect toxicity of anticancer treatments, (ii) a higher prevalence of cardiovascular risk factors in cancer patients, and (iii) prolonged exposure to treatments due to an increasing patient survival rate. In addition to conventional chemotherapies and radiotherapy, targeted therapies and immunotherapies have been developed which improve the prognosis of cancer patients but sometimes at the cost of vascular toxicity, which can lead to systemic or pulmonary hypertension and arterial/venous thromboembolic events. Endothelial dysfunction, a procoagulant state and metabolic disorders are the three main pathophysiological patterns leading to cancer treatment-related vascular toxicity. This issue is challenging because serious vascular adverse events can necessitate cancer treatment being put on hold or stopped, which could compromise patient survival. In addition to increasing the risk of thrombotic adverse events, cancer therapies may lead to an increased risk of bleeding, especially in treatments with vascular endothelial growth factor inhibitors. Therefore, we can define vasculo-oncology as a part of the cardio-oncology specialty; its aims are to predict, prevent, screen, and treat vascular toxicity related to cancer treatments. While the level of evidence is low regarding the management of vascular toxicity during cancer therapy, cardiologists and specialists in vascular diseases should closely collaborate with oncologists and hematologists to determine the optimal strategy for each patient.
Collapse
Affiliation(s)
- Alexandra Meilhac
- Department of Cardiology, North Hospital, Assistance Publique - Hôpitaux de Marseille, Centre for CardioVascular and Nutrition Research (C2VN), University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Inserm 1263, Inrae 1260, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France
| | - Jennifer Cautela
- Department of Cardiology, North Hospital, Assistance Publique - Hôpitaux de Marseille, Centre for CardioVascular and Nutrition Research (C2VN), University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Inserm 1263, Inrae 1260, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France
| | - Franck Thuny
- Department of Cardiology, North Hospital, Assistance Publique - Hôpitaux de Marseille, Centre for CardioVascular and Nutrition Research (C2VN), University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Inserm 1263, Inrae 1260, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France.
| |
Collapse
|