51
|
Waldschmidt JM, Anand P, Knoechel B, Lohr JG. Comprehensive characterization of circulating and bone marrow-derived multiple myeloma cells at minimal residual disease. Semin Hematol 2018; 55:33-37. [PMID: 29759150 DOI: 10.1053/j.seminhematol.2018.02.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 02/21/2018] [Indexed: 01/04/2023]
Abstract
The presence or absence of minimal residual disease (MRD) in patients with multiple myeloma (MM) has emerged as a useful marker to determine the depth of remission. MRD negativity as an endpoint has been shown to be associated with improved progression-free survival in many studies. MRD detection is therefore part of numerous clinical trial protocols for MM. At the present time, two methodologies are most widely accepted for MRD detection: (1) multicolor flow cytometry and (2) next-generation sequencing-based clonotype detection. While both of those methodologies enable accurate quantification of MRD in the bone marrow (BM), with sensitivity as low as 10-5 to 10-6, there are several limitations to these methods. First, these approaches reveal the presence or absence of MRD but provide limited molecular information about MM. More comprehensive characterization of MM cells at the MRD stage may identify molecular mechanisms of drug resistance. Second, MRD detection in the BM is typically performed at one time point only, but more frequent detection may define the duration of the MRD status and thus refine its prognostic value. Third, less-invasive approaches that avoid the discomfort and risk associated with BM biopsy would be highly desirable, especially in elderly or frail patients. "Liquid biopsy" for the detection and characterization of circulating MM cells may address these issues. Although MRD detection in the peripheral blood at the same sensitivity as in the BM may be challenging, the identification of patients who do not achieve MRD negativity might reduce the need for BM biopsies. Here, we give an overview of approaches that have been described to detect and characterize MM cells when they occur at very low frequencies in the peripheral blood or in the BM, emphasizing recently described next-generation sequencing approaches for more comprehensive characterization of circulating MM cells.
Collapse
Affiliation(s)
- Johannes M Waldschmidt
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Praveen Anand
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Birgit Knoechel
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Jens G Lohr
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA.
| |
Collapse
|
52
|
Oliva S, Gambella M, Gilestro M, Muccio VE, Gay F, Drandi D, Ferrero S, Passera R, Pautasso C, Bernardini A, Genuardi M, Patriarca F, Saraci E, Petrucci MT, Pescosta N, Liberati AM, Caravita T, Conticello C, Rocci A, Musto P, Boccadoro M, Palumbo A, Omedè P. Minimal residual disease after transplantation or lenalidomide-based consolidation in myeloma patients: a prospective analysis. Oncotarget 2018; 8:5924-5935. [PMID: 27779105 PMCID: PMC5351601 DOI: 10.18632/oncotarget.12641] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 09/21/2016] [Indexed: 11/25/2022] Open
Abstract
We analyzed 50 patients who achieved at least a very good partial response in the RV-MM-EMN-441 study. Patients received consolidation with autologous stem-cell transplantation (ASCT) or cyclophosphamide-lenalidomide-dexamethasone (CRD), followed by Lenalidomide-based maintenance. We assessed minimal residual disease (MRD) by multi-parameter flow cytometry (MFC) and allelic-specific oligonucleotide real-time quantitative polymerase chain reaction (ASO-RQ-PCR) after consolidation, after 3 and 6 courses of maintenance, and thereafter every 6 months until progression. By MFC analysis, 19/50 patients achieved complete response (CR) after consolidation, and 7 additional patients during maintenance. A molecular marker was identified in 25/50 patients, 4/25 achieved molecular-CR after consolidation, and 3 additional patients during maintenance. A lower MRD value by MFC was found in ASCT patients compared with CRD patients (p=0.0134). Tumor burden reduction was different in patients with high-risk vs standard-risk cytogenetics (3.4 vs 5.2, ln-MFC; 3 vs 6 ln-PCR, respectively) and in patients who relapsed vs those who did not (4 vs 5, ln-MFC; 4.4 vs 7.8 ln-PCR). MRD progression anticipated clinical relapse by a median of 9 months while biochemical relapse by a median of 4 months. MRD allows the identification of a low-risk group, independently of response, and a better characterization of the activity of treatments.
Collapse
Affiliation(s)
- Stefania Oliva
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospeadliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Manuela Gambella
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospeadliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Milena Gilestro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospeadliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Vittorio Emanuele Muccio
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospeadliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Francesca Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospeadliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Daniela Drandi
- Division of Hematology, Department of Molecular Biotechnologies and Health Sciences, University of Torino, Torino, Italy
| | - Simone Ferrero
- Division of Hematology, Department of Molecular Biotechnologies and Health Sciences, University of Torino, Torino, Italy
| | - Roberto Passera
- Division of Nuclear Medicine, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Chiara Pautasso
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospeadliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Annalisa Bernardini
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospeadliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Mariella Genuardi
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospeadliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Francesca Patriarca
- Azienda Ospedaliera-Universitaria di Udine, DISM Università di Udine, Udine, Italy
| | - Elona Saraci
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospeadliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Maria Teresa Petrucci
- Division of Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Rome, Italy
| | - Norbert Pescosta
- Ematologia e Centro TMO, Ospedale Centrale Bolzano, Bozen, Italy
| | | | | | - Concetta Conticello
- Divisione di Ematologia, Azienda Policlinico-OVE, Università di Catania, Catania, Italy
| | - Alberto Rocci
- Department of Haematology, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Pellegrino Musto
- Scientific Direction, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture (Pz), Italy
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospeadliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Antonio Palumbo
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospeadliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Paola Omedè
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospeadliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| |
Collapse
|
53
|
Zajec M, Jacobs JFM, Groenen PJTA, de Kat Angelino CM, Stingl C, Luider TM, De Rijke YB, VanDuijn MM. Development of a Targeted Mass-Spectrometry Serum Assay To Quantify M-Protein in the Presence of Therapeutic Monoclonal Antibodies. J Proteome Res 2018; 17:1326-1333. [DOI: 10.1021/acs.jproteome.7b00890] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Marina Zajec
- Department
of Neurology, Erasmus MC University Medical Center, Rotterdam 3015 GE, The Netherlands
- Department
of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam 3015 GE, The Netherlands
| | - Joannes F. M. Jacobs
- Department
of Laboratory Medicine, Radboud University Medical Center, Nijmegen 6525 GA, The Netherlands
| | | | - Corrie M. de Kat Angelino
- Department
of Laboratory Medicine, Radboud University Medical Center, Nijmegen 6525 GA, The Netherlands
| | - Christoph Stingl
- Department
of Neurology, Erasmus MC University Medical Center, Rotterdam 3015 GE, The Netherlands
| | - Theo M. Luider
- Department
of Neurology, Erasmus MC University Medical Center, Rotterdam 3015 GE, The Netherlands
| | - Yolanda B. De Rijke
- Department
of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam 3015 GE, The Netherlands
| | - Martijn M. VanDuijn
- Department
of Neurology, Erasmus MC University Medical Center, Rotterdam 3015 GE, The Netherlands
| |
Collapse
|
54
|
Wu T, Zhou J, Wang C, Wang B, Zhang S, Bai H. Bortezomib overcomes the negative prognostic impact of renal impairment in a newly diagnosed elderly patient with multiple myeloma: A case report. Oncol Lett 2018; 14:7318-7322. [PMID: 29344169 PMCID: PMC5754884 DOI: 10.3892/ol.2017.7151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 07/14/2017] [Indexed: 11/22/2022] Open
Abstract
Multiple myeloma (MM) is a common B-cell hematological malignancy in the clinic. Bortezomib is the first-in-class proteasome inhibitor that has been approved for the treatment of patients with MM in the bone marrow. The present study report the case of an 83-year-old man who showed marked weakness, fatigue and a poor appetite. The patient was admitted to the Department of Nephrology due to severe renal impairment (RI). Immunofixation electrophoresis indicated a λ light chain-positive status. There were 19.2% plasmablasts and proplasmacytes in the bone marrow. Positivity for the cell surface markers cluster of differentiation (CD)13, CD33, CD38 and human leukocyte antigen-antigen D-related was detected by flow cytometry. The patient was diagnosed with MM, λ light chain type, stage IIIB, and received bortezomib and dexamethasone regimen chemotherapy. RI was improved following the chemotherapy, and plasmablasts and proplasmacytes were almost eliminated. The Hb level was maintained at ~90 g/l. Overall, the present case report suggests that bortezomib may be safe and effective for elderly patients, even those >80 years of age, with severe RI.
Collapse
Affiliation(s)
- Tao Wu
- Department of Hematology, Lanzhou General Hospital, Lanzhou Command, Lanzhou, Gansu 730050, P.R. China
| | - Jinmao Zhou
- Department of Hematology, Lanzhou General Hospital, Lanzhou Command, Lanzhou, Gansu 730050, P.R. China
| | - Cunbang Wang
- Department of Hematology, Lanzhou General Hospital, Lanzhou Command, Lanzhou, Gansu 730050, P.R. China
| | - Binbin Wang
- Department of Hematology, Lanzhou General Hospital, Lanzhou Command, Lanzhou, Gansu 730050, P.R. China
| | - Shuting Zhang
- Department of Hematology, Lanzhou General Hospital, Lanzhou Command, Lanzhou, Gansu 730050, P.R. China
| | - Hai Bai
- Department of Hematology, Lanzhou General Hospital, Lanzhou Command, Lanzhou, Gansu 730050, P.R. China
| |
Collapse
|
55
|
Ho C, Arcila ME. Minimal residual disease detection of myeloma using sequencing of immunoglobulin heavy chain gene VDJ regions. Semin Hematol 2018; 55:13-18. [DOI: 10.1053/j.seminhematol.2018.02.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 02/21/2018] [Indexed: 01/29/2023]
|
56
|
Abstract
Multiple myeloma (MM) is an incurable hematopoietic cancer that is characterized by malignant plasma cell infiltration of the bone marrow and/or extramedullary sites. Multi-modality approaches including "novel agents," traditional chemotherapy, and/or stem cell transplantation are used in MM therapy. Drug resistance, however, ultimately develops and the disease remains incurable for the vast majority of patients. In this chapter, we review both tumor cell-autonomous and non-autonomous (microenvironment-dependent) mechanisms of drug resistance. MM provides an attractive paradigm highlighting a number of current concepts and challenges in oncology. Firstly, identification of MM cancer stem cells and their unique drug resistance attributes may provide rational avenues towards MM eradication and cure. Secondly, the oligoclonal evolution of MM and alternation of "clonal tides" upon therapy challenge our current understanding of treatment responses. Thirdly, the success of MM "novel agents" provides exemplary evidence for the impact of therapies that target the immune and non-immune microenvironment. Fourthly, the rapid pace of drug approvals for MM creates an impetus for development of precision medicine strategies and biomarkers that promote efficacy and mitigate toxicity and cost. While routine cure of the disease remains the ultimate and yet unattainable prize, MM advances in the last 10-15 years have provided an astounding paradigm for the treatment of blood cancers in the modern era and have radically transformed patient outcomes.
Collapse
Affiliation(s)
- Athanasios Papadas
- Division of Hematology and Oncology, Department of Medicine, University of Wisconsin-Madison, Madison, WI, 53705, USA.
- UW Carbone Cancer Center, Madison, WI, 53705, USA.
| | - Fotis Asimakopoulos
- Division of Hematology and Oncology, Department of Medicine, University of Wisconsin-Madison, Madison, WI, 53705, USA
- UW Carbone Cancer Center, Madison, WI, 53705, USA
| |
Collapse
|
57
|
Takamatsu H, Wee RK, Zaimoku Y, Murata R, Zheng J, Moorhead M, Carlton VEH, Kong KA, Takezako N, Ito S, Miyamoto T, Yokoyama K, Matsue K, Sato T, Kurokawa T, Yagi H, Terasaki Y, Ohata K, Matsumoto M, Yoshida T, Faham M, Nakao S. A comparison of minimal residual disease detection in autografts among ASO-qPCR, droplet digital PCR, and next-generation sequencing in patients with multiple myeloma who underwent autologous stem cell transplantation. Br J Haematol 2017; 183:664-668. [PMID: 29270982 DOI: 10.1111/bjh.15002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Hiroyuki Takamatsu
- Haematology/Respiratory Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Rachel K Wee
- Haematology/Respiratory Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Yoshitaka Zaimoku
- Haematology/Respiratory Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Ryoichi Murata
- Division of Internal Medicine, Keiju Kanazawa Hospital, Kanazawa, Japan
| | | | | | | | | | - Naoki Takezako
- Department of Haematology, National Hospital Organization Disaster Medical Centre of Japan, Tachikawa, Japan
| | - Shigeki Ito
- Department of Clinical Oncology, Iwate Medical University School of Medicine, Morioka, Japan
| | - Toshihiro Miyamoto
- Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenji Yokoyama
- Department of Haematology/Oncology, Tokai University Hachioji Hospital, Hachioji, Japan
| | - Kosei Matsue
- Division of Haematology/Oncology, Department of Internal Medicine, Kameda Medical Centre, Kamogawa, Japan
| | - Tsutomu Sato
- Department of Medical Oncology and Haematology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Toshiro Kurokawa
- Department of Haematology, Toyama Red Cross Hospital, Toyama, Japan
| | - Hideo Yagi
- Department of Haematology, Kinki University School of Medicine Nara Hospital, Ikoma, Japan
| | - Yasushi Terasaki
- Division of Internal Medicine, Toyama City Hospital, Toyama, Japan
| | - Kinya Ohata
- Haematology/Respiratory Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Morio Matsumoto
- Department of Haematology, National Hospital Organization Shibukawa Medical Center, Shibukawa, Japan
| | - Takashi Yoshida
- Department of Haematology, Shizuoka City Shimizu Hospital, Shizuoka, Japan
| | - Malek Faham
- Adaptive Biotechnologies Corp, Seattle, WA, USA
| | - Shinji Nakao
- Haematology/Respiratory Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| |
Collapse
|
58
|
Bai Y, Orfao A, Chim CS. Molecular detection of minimal residual disease in multiple myeloma. Br J Haematol 2017; 181:11-26. [PMID: 29265356 DOI: 10.1111/bjh.15075] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Despite the significantly higher complete remission rates and improved survival achieved in the last decade, multiple myeloma (MM) patients continue to relapse due to persistence of minimal residual disease (MRD). Generally, MRD refers to persistence of low levels of disease in the order of one tumour cell in ≥105 normal cells. Currently, molecular and immunophenotypic techniques are employed for MRD detection. This review focuses on MRD detection by molecular techniques, including allele-specific oligonucleotide polymerase chain reaction (ASO-PCR), next-generation sequencing (NGS) and digital PCR (dPCR), in addition to a brief description of, and comparison with, multiparameter flow cytometry. The basic principles, technical advantages and limitations, and the clinical impact of all three molecular techniques are reviewed and compared. They all have a sensitivity of at least 10-5 , among which ASO real-time quantitative PCR is the most well-standardized, and NGS carries the highest sensitivity and applicability, while dPCR is still under investigation. Furthermore, molecular MRD negativity is a favourable prognostic factor for survival of patients with MM. However, several challenges inherent to molecular detection of MRD still remain to be overcome, particularly false negativity and failure to detect extramedullary disease. Finally, detection of MRD from peripheral blood remains challenging.
Collapse
Affiliation(s)
- Yinlei Bai
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Spain
| | - Alberto Orfao
- Department of Medicine, University of Salamanca and University Hospital of Salamanca-IBSAL, Salamanca, Spain
| | - Chor Sang Chim
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Spain
| |
Collapse
|
59
|
Holstein SA, Avet-Loiseau H, Hahn T, Ho CM, Lohr JG, Munshi NC, Paiva B, Pasquini MC, Tario JD, Usmani SZ, Wallace PK, Weisel K, McCarthy PL. BMT CTN Myeloma Intergroup Workshop on Minimal Residual Disease and Immune Profiling: Summary and Recommendations from the Organizing Committee. Biol Blood Marrow Transplant 2017; 24:641-648. [PMID: 29242112 DOI: 10.1016/j.bbmt.2017.12.774] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 12/05/2017] [Indexed: 12/21/2022]
Abstract
The Blood and Marrow Transplant Clinical Trials Network Myeloma Intergroup Workshop on Minimal Residual Disease and Immune Profiling was convened on December 1, 2016 at the American Society of Hematology meeting to discuss the emerging data and technologies for minimal residual disease assessment and immune profiling in myeloma. Particular emphasis was placed on developing strategies to incorporate these techniques into clinical trial design. This document reviews the literature, summarizes the topics discussed in the workshop, and provides recommendations for integration of these techniques into future clinical trial design.
Collapse
Affiliation(s)
- Sarah A Holstein
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska.
| | - Hervé Avet-Loiseau
- Centre de Recherches en Cancerologie de Toulouse CRCT, Institut National de la Sante et de la Recherche Medicale, University Cancer Center of Toulouse, Toulouse, France
| | - Theresa Hahn
- Department of Medicine, Blood & Marrow Transplant Center, Roswell Park Cancer Institute, Buffalo, New York
| | - Christine M Ho
- Department of Medicine, Blood & Marrow Transplant Center, Roswell Park Cancer Institute, Buffalo, New York
| | - Jens G Lohr
- Department of Medicine, Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Nikhil C Munshi
- Department of Medicine, Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Bruno Paiva
- Centro de Investigación Medica Aplicadas, Instituto de Investigación Sanitaria de Navarra, Centro de Investigacion Biomedica en Red Cancer, Clínica Universidad de Navarra, Pamplona, Spain
| | - Marcelo C Pasquini
- Department of Medicine, Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Milwaukee
| | - Joseph D Tario
- Department of Medicine, Blood & Marrow Transplant Center, Roswell Park Cancer Institute, Buffalo, New York
| | - Saad Z Usmani
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Charlotte, North Carolina
| | - Paul K Wallace
- Department of Medicine, Blood & Marrow Transplant Center, Roswell Park Cancer Institute, Buffalo, New York
| | - Katja Weisel
- Department of Hematology and Oncology, Universitatsklinikum Tubingen, Tubingen, Germany
| | - Philip L McCarthy
- Department of Medicine, Blood & Marrow Transplant Center, Roswell Park Cancer Institute, Buffalo, New York
| |
Collapse
|
60
|
Davies FE. Is molecular remission the goal of multiple myeloma therapy? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:205-211. [PMID: 29222257 PMCID: PMC6142553 DOI: 10.1182/asheducation-2017.1.205] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
The increased number of effective therapies and the wider use of combinations that give deeper remissions have resulted in a reassessment of the goals of myeloma therapy. With the advent of new therapeutic strategies and diagnostic tools, achievement of minimal residual disease (MRD)-negative status has become increasingly important, with some even considering it as the primary endpoint for therapy. The level of MRD that is aimed for is a continuous, rather than an absolute variable, with studies in both transplant-eligible and -noneligible patients showing that the level of MRD achieved is predictive of progression-free survival and overall survival, with an improvement in survival of approximately 1 year for each log-depletion in MRD level. The most widely used methods to assess MRD status include flow cytometry and clonality detection, using next-generation sequencing technologies with sensitivity limits of 1:10-3 to 1:10-6 The timing of when to assess MRD depends on the treatment used, as well as the molecular and cytogenetic subgroup of the myeloma itself. It is also becoming clear that the level of MRD negativity, as well as microenvironmental factors, are important prognostically, including the regeneration of normal plasma cells, and the normalization of the immune repertoire. With advances in antibody-based therapy and immunotherapy, the achievement of stable MRD states is now possible for a significant proportion of patients, and is a prerequisite for myeloma cure.
Collapse
Affiliation(s)
- Faith E Davies
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| |
Collapse
|
61
|
Rosko A, Giralt S, Mateos MV, Dispenzieri A. Myeloma in Elderly Patients: When Less Is More and More Is More. Am Soc Clin Oncol Educ Book 2017; 37:575-585. [PMID: 28561667 DOI: 10.1200/edbk_175171] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Multiple myeloma is a plasma cell malignancy that occurs among older adults and accounts for 15% of all hematologic malignancies in the United States. Thirty-five percent of patients are diagnosed at age 75 or older. Novel therapeutics and routine use of autologous stem cell transplantation (ASCT) have led to substantial improvements in patient survival, although improvements have been more impressive among patients younger than age 65. Finding the balance between under- and overtreating elderly patients is one of the biggest challenges specific to them as a subgroup of patients with MM. Decision making about which therapies and their dose intensity and duration should be influenced by a patient's functional status, personal preferences, disease characteristics, and ability to tolerate therapy. ASCT should be considered for all patients younger than age 80, assuming that they are not frail. The attainment of a stringent complete response and minimal residual disease negativity is associated with improved progression-free and overall survival. Again, consideration of quality of life for these patients is paramount. Although there is a growing list of tools to sort through these issues, a fully integrated approach has not yet been finely tuned, leaving additional work to be done for the treatment of elderly patients with MM.
Collapse
Affiliation(s)
- Ashley Rosko
- From The Ohio State University, Columbus, OH; Memorial Sloan Kettering Cancer Center, New York, NY; University Hospital of Salamanca, Salamanca, Spain; Mayo Clinic, Rochester, MN
| | - Sergio Giralt
- From The Ohio State University, Columbus, OH; Memorial Sloan Kettering Cancer Center, New York, NY; University Hospital of Salamanca, Salamanca, Spain; Mayo Clinic, Rochester, MN
| | - Maria-Victoria Mateos
- From The Ohio State University, Columbus, OH; Memorial Sloan Kettering Cancer Center, New York, NY; University Hospital of Salamanca, Salamanca, Spain; Mayo Clinic, Rochester, MN
| | - Angela Dispenzieri
- From The Ohio State University, Columbus, OH; Memorial Sloan Kettering Cancer Center, New York, NY; University Hospital of Salamanca, Salamanca, Spain; Mayo Clinic, Rochester, MN
| |
Collapse
|
62
|
Bustoros M, Mouhieddine TH, Detappe A, Ghobrial IM. Established and Novel Prognostic Biomarkers in Multiple Myeloma. Am Soc Clin Oncol Educ Book 2017; 37:548-560. [PMID: 28561668 DOI: 10.1200/edbk_175175] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Multiple myeloma (MM) is an incurable plasma cell malignancy characterized by notable interpatient heterogeneity. There have been important advances in therapy and overall survival, but some patients with high-risk features still have poor survival rates. Therefore, accurate identification of this subset of patients has been integral to improvement of patient outcome. During the last few years, cytogenetics, gene expression profiling, MRI and PET/CT, as well as serum free light chain assays have been used as accurate biomarkers to better characterize the diverse course and outcome of the disease. With the recent advances of massive parallel sequencing techniques, the development of new models that better stratify high-risk groups are beginning to be developed. The use of multiparameter flow cytometry and next-generation sequencing have paved the way for assessment of minimal residual disease and better prognostication of post-therapeutic outcomes. Circulating tumor cells and circulating tumor DNA are promising potential biomarkers that demonstrate the spatial and temporal heterogeneity of MM. Finally, more prognostic markers are being developed that are specific to immunotherapeutic agents. In this review, we discuss these traditional and novel biomarkers that have been developed for MM and also those that can predict disease progression from precursor stages. Together, these biomarkers will help improve our understanding of the intrapatient and interpatient variabilities and help develop precision medicine for patients with high-risk MM.
Collapse
Affiliation(s)
- Mark Bustoros
- From the Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Tarek H Mouhieddine
- From the Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Alexandre Detappe
- From the Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Irene M Ghobrial
- From the Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| |
Collapse
|
63
|
Galtseva IV, Davydova YO, Kapranov NM, Julhakyan HL, Mendeleeva LP. Minimal residual disease in multiple myeloma: Benefits of flow cytometry. Int J Lab Hematol 2017; 40:12-20. [PMID: 29058372 DOI: 10.1111/ijlh.12757] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 09/04/2017] [Indexed: 12/25/2022]
Abstract
Over the last 20 years, the approaches to the treatment of multiple myeloma (MM) have changed considerably, which led to an increase in remission rate. Using new diagnostic methods has made it possible to assess the response to treatment more reliably and forecast disease recurrence: allele-specific polymerase chain reaction, new-generation sequencing and multicolor flow cytometry enable minimal residual disease (MRD) detection of with sensitivity of 10-5 to 10-6 . MRD assessment with flow cytometry using is a rapidly developing area of research. The goal of multicenter groups that use flow cytometry as a tool to detect MRD in patients with MM is achieving standardization and increasing sensitivity and specificity of this method. This article provides data about the methods used for MRD monitoring and describes the advances in the field of flow cytometry.
Collapse
Affiliation(s)
- I V Galtseva
- Federal State-Funded Institution National Research Center for Hematology of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Y O Davydova
- Federal State-Funded Institution National Research Center for Hematology of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - N M Kapranov
- Federal State-Funded Institution National Research Center for Hematology of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - H L Julhakyan
- Federal State-Funded Institution National Research Center for Hematology of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - L P Mendeleeva
- Federal State-Funded Institution National Research Center for Hematology of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| |
Collapse
|
64
|
Jelinek T, Bezdekova R, Zatopkova M, Burgos L, Simicek M, Sevcikova T, Paiva B, Hajek R. Current applications of multiparameter flow cytometry in plasma cell disorders. Blood Cancer J 2017; 7:e617. [PMID: 29053157 PMCID: PMC5678219 DOI: 10.1038/bcj.2017.90] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 07/30/2017] [Accepted: 08/07/2017] [Indexed: 12/12/2022] Open
Abstract
Multiparameter flow cytometry (MFC) has become standard in the management of patients with plasma cell (PC) dyscrasias, and could be considered mandatory in specific areas of routine clinical practice. It plays a significant role during the differential diagnostic work-up because of its fast and conclusive readout of PC clonality, and simultaneously provides prognostic information in most monoclonal gammopathies. Recent advances in the treatment and outcomes of multiple myeloma led to the implementation of new response criteria, including minimal residual disease (MRD) status as one of the most relevant clinical endpoints with the potential to act as surrogate for survival. Recent technical progress led to the development of next-generation flow (NGF) cytometry that represents a validated, highly sensitive, cost-effective and widely available technique for standardized MRD evaluation, which also could be used for the detection of circulating tumor cells. Here we review current applications of MFC and NGF in most PC disorders including the less frequent solitary plasmocytoma, light-chain amyloidosis or Waldenström macroglobulinemia.
Collapse
Affiliation(s)
- T Jelinek
- Department of Haematooncology, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,Faculty of Science, University of Ostrava, Ostrava, Czech Republic.,Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), IDISNA, Pamplona, Spain
| | - R Bezdekova
- Department of Clinical Haematology, University Hospital Brno, Brno, Czech Republic
| | - M Zatopkova
- Faculty of Science, University of Ostrava, Ostrava, Czech Republic
| | - L Burgos
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), IDISNA, Pamplona, Spain
| | - M Simicek
- Faculty of Science, University of Ostrava, Ostrava, Czech Republic
| | - T Sevcikova
- Faculty of Science, University of Ostrava, Ostrava, Czech Republic
| | - B Paiva
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), IDISNA, Pamplona, Spain
| | - R Hajek
- Department of Haematooncology, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,Faculty of Science, University of Ostrava, Ostrava, Czech Republic
| |
Collapse
|
65
|
Abstract
The primary hurdle in the path to curing multiple myeloma (MM) is defining a validated minimal residual disease (MRD) and its utility in the therapeutic decision making. A better definition of MRD will aid in tailoring MM therapy further to address the clonal heterogeneity and genomic instability and overcome patient's ineffective immune surveillance. MRD analysis can define the logical endpoint for maintenance therapy, in addition also aids in providing a better clinical end point for studies comparing novel agents in myeloma. MRD is a surrogate for the survival in MM. Guidelines for global incorporation of MRD in myeloma are fraught with lack of standardization, universal availability and abridged physicians' understanding of MRD modalities. We aimed at addressing some of the frequently asked questions in the MRD assessment and will also place in perspective some arguments in favor of MRD assessment in routine practice and clinical trial scenario.
Collapse
Affiliation(s)
- Uday Yanamandra
- a Department of Hematology and Stem Cell Transplant , Army Hospital - Research and Referral , New Delhi , India
| | - Shaji K Kumar
- b Department of Internal Medicine, Division of Hematology , Mayo Clinic , Rochester , MN , USA
| |
Collapse
|
66
|
Takamatsu H. Comparison of Minimal Residual Disease Detection by Multiparameter Flow Cytometry, ASO-qPCR, Droplet Digital PCR, and Deep Sequencing in Patients with Multiple Myeloma Who Underwent Autologous Stem Cell Transplantation. J Clin Med 2017; 6:jcm6100091. [PMID: 28946710 PMCID: PMC5664006 DOI: 10.3390/jcm6100091] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 09/17/2017] [Accepted: 09/20/2017] [Indexed: 12/28/2022] Open
Abstract
Multiple myeloma (MM) is a hematological malignancy with a poor prognosis, characterized by clonal proliferation of plasma cells in the bone marrow (BM). Relapse due to undetected minimal residual disease (MRD) is the leading cause of death among patients with MM. This review summarizes the methods and prognostic value of MRD assessment in BM and autografts from MM patients who underwent autologous stem cell transplantation (ASCT) by multiparameter flow cytometry (MFC), allele-specific oligonucleotide real-time quantitative PCR (ASO-qPCR), droplet digital PCR (ddPCR), and next-generation sequencing (NGS)-based detection methods. MRD assessment using NGS-based approaches has clear prognostic value and better sensitivity compared to traditional methods.
Collapse
Affiliation(s)
- Hiroyuki Takamatsu
- Hematology/Respiratory Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, Ishikawa 920-8641, Japan.
| |
Collapse
|
67
|
Alaterre E, Raimbault S, Garcia JM, Rème T, Requirand G, Klein B, Moreaux J. Automated and simplified identification of normal and abnormal plasma cells in Multiple Myeloma by flow cytometry. CYTOMETRY PART B-CLINICAL CYTOMETRY 2017; 94:484-492. [DOI: 10.1002/cyto.b.21590] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 07/28/2017] [Accepted: 08/30/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Elina Alaterre
- HORIBA Medical; Montpellier France
- Institute of Human Genetics, UMR 9002 CNRS, University of Montpellier; Montpellier F-34396 France
| | | | | | - Thierry Rème
- Department of Biological Hematology; CHU Montpellier; Montpellier France
| | - Guilhem Requirand
- Department of Biological Hematology; CHU Montpellier; Montpellier France
| | - Bernard Klein
- Institute of Human Genetics, UMR 9002 CNRS, University of Montpellier; Montpellier F-34396 France
- Department of Biological Hematology; CHU Montpellier; Montpellier France
- University of Montpellier 1, UFR de Médecine; Montpellier France
| | - Jérôme Moreaux
- Institute of Human Genetics, UMR 9002 CNRS, University of Montpellier; Montpellier F-34396 France
- Department of Biological Hematology; CHU Montpellier; Montpellier France
- University of Montpellier 1, UFR de Médecine; Montpellier France
| |
Collapse
|
68
|
Innao V, Allegra A, Russo S, Gerace D, Vaddinelli D, Alonci A, Allegra AG, Musolino C. Standardisation of minimal residual disease in multiple myeloma. Eur J Cancer Care (Engl) 2017; 26. [PMID: 28671297 DOI: 10.1111/ecc.12732] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2017] [Indexed: 12/16/2022]
Abstract
The assessment of the effectiveness of chemotherapy in oncology cannot disregard the concept of minimal residual disease (MRD). In fact, the efforts of numerous scientific groups all over the world are currently focusing on this issue, with the sole purpose of defining sensitive, effective assessment criteria that are, above all, able to give acceptable, easily repeatable results worldwide. Regarding this issue, especially with the advent of new drugs, multiple myeloma is one of the haematologic malignancies for which a consensus has not yet been reached. In this review, we analyse various techniques that have been used to improve the sensitivity of response, aimed at reducing the cut-off values previously allowed, as well as serological values like serum-free light chain, or immunophenotypic tools on bone marrow or peripheral blood, like multi-parameter flow cytometry, or molecular ones such as allele-specific oligonucleotide (ASO)-qPCR and next-generation/high-throughput sequencing technologies (NGS). Moreover, our discussion makes a brief reference to promising techniques, such as mass spectrometry for identifying Ig light chain (LC) in peripheral blood, and the assessment of gene expression profile not only in defining prognostic risk at the diagnosis but also as a tool for evaluation of response.
Collapse
Affiliation(s)
- V Innao
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - A Allegra
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - S Russo
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - D Gerace
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - D Vaddinelli
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - A Alonci
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - A G Allegra
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - C Musolino
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| |
Collapse
|
69
|
Michallet M, Chapuis-Cellier C, Dejoie T, Lombard C, Caillon H, Sobh M, Moreau P, Attal M, Avet-Loiseau H. Heavy+light chain monitoring correlates with clinical outcome in multiple myeloma patients. Leukemia 2017; 32:376-382. [PMID: 28663581 PMCID: PMC5808078 DOI: 10.1038/leu.2017.209] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/23/2017] [Accepted: 06/20/2017] [Indexed: 01/09/2023]
Abstract
Novel anti-myeloma agents have improved patient response rates, which are historically based on reductions of the M-protein. These methods can be inaccurate for quantifying M-proteins at low concentrations. We compared the consistency and clinical impact of response assignment by electrophoretic and heavy+light chain (HLC) immunoassays post-consolidation in 463 newly diagnosed patients. The two methods gave similar assignments in patients with partial (PR; 79% agreement) or complete response (⩾CR; 92%). However, in patients achieving very good PR (VGPR) there was poor concordance between methods (45%). Median progression-free survival (PFS) for standard VGPR patients was 34.5 months; HLC responses stratified these patients further into PR, VGPR and ⩾CR, with median PFS of 21.3, 28.9 months and not reached, respectively; P<0.001. At this time, abnormal HLC ratios had better concordance with multiparametric flow cytometry (sensitivity 10−4) (37 and 34% positive, respectively), compared to immunofixation (62% positive). In addition, HLC-pair suppression was identified in 38% of patients and associated with shorter PFS (30.6 months vs not reached; P<0.001). We conclude that HLC monitoring could augment electrophoretic assessments in patients achieving VGPR. The prognostic significance of HLC responses might partly depend on the patients’ ability to recover their immune system, as determined by normalisation of HLC measurements.
Collapse
Affiliation(s)
- M Michallet
- Department of Hematology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Lyon, France
| | - C Chapuis-Cellier
- Immunological Laboratory, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Lyon, France
| | - T Dejoie
- Biochemistry Laboratory, University Hospital Nantes, Nantes, France
| | - C Lombard
- Immunological Laboratory, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Lyon, France
| | - H Caillon
- Biochemistry Laboratory, University Hospital Nantes, Nantes, France
| | - M Sobh
- Department of Hematology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Lyon, France
| | - P Moreau
- Department of Hematology, Nantes University Hospital, Nantes, France
| | - M Attal
- Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - H Avet-Loiseau
- Institut Universitaire du Cancer de Toulouse-Oncopole, Unite de Genomique du Myelome, Toulouse, France
| |
Collapse
|
70
|
Kumar S, Paiva B, Anderson KC, Durie B, Landgren O, Moreau P, Munshi N, Lonial S, Bladé J, Mateos MV, Dimopoulos M, Kastritis E, Boccadoro M, Orlowski R, Goldschmidt H, Spencer A, Hou J, Chng WJ, Usmani SZ, Zamagni E, Shimizu K, Jagannath S, Johnsen HE, Terpos E, Reiman A, Kyle RA, Sonneveld P, Richardson PG, McCarthy P, Ludwig H, Chen W, Cavo M, Harousseau JL, Lentzsch S, Hillengass J, Palumbo A, Orfao A, Rajkumar SV, Miguel JS, Avet-Loiseau H. International Myeloma Working Group consensus criteria for response and minimal residual disease assessment in multiple myeloma. Lancet Oncol 2017; 17:e328-e346. [PMID: 27511158 DOI: 10.1016/s1470-2045(16)30206-6] [Citation(s) in RCA: 1690] [Impact Index Per Article: 241.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/21/2016] [Accepted: 05/24/2016] [Indexed: 12/16/2022]
Abstract
Treatment of multiple myeloma has substantially changed over the past decade with the introduction of several classes of new effective drugs that have greatly improved the rates and depth of response. Response criteria in multiple myeloma were developed to use serum and urine assessment of monoclonal proteins and bone marrow assessment (which is relatively insensitive). Given the high rates of complete response seen in patients with multiple myeloma with new treatment approaches, new response categories need to be defined that can identify responses that are deeper than those conventionally defined as complete response. Recent attempts have focused on the identification of residual tumour cells in the bone marrow using flow cytometry or gene sequencing. Furthermore, sensitive imaging techniques can be used to detect the presence of residual disease outside of the bone marrow. Combining these new methods, the International Myeloma Working Group has defined new response categories of minimal residual disease negativity, with or without imaging-based absence of extramedullary disease, to allow uniform reporting within and outside clinical trials. In this Review, we clarify several aspects of disease response assessment, along with endpoints for clinical trials, and highlight future directions for disease response assessments.
Collapse
Affiliation(s)
- Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
| | - Bruno Paiva
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), Pamplona, Spain
| | | | - Brian Durie
- Cedars-Sinai Comprehensive Cancer Center, Los Angeles, CA, USA
| | - Ola Landgren
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Sagar Lonial
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Meletios Dimopoulos
- Department of Clinical Therapeutics, University of Athens, School of Medicine, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, University of Athens, School of Medicine, Athens, Greece
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Citta della Salute e della Scienza di Torino, Torino, Italy; Mount Sinai Cancer Institute, New York, NY, USA
| | | | - Hartmut Goldschmidt
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | | | - Jian Hou
- Chang Zheng Hospital, Shanghai, China
| | | | - Saad Z Usmani
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA
| | - Elena Zamagni
- Seragnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
| | | | | | - Hans E Johnsen
- Department of Hematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Evangelos Terpos
- Department of Clinical Therapeutics, University of Athens, School of Medicine, Athens, Greece
| | - Anthony Reiman
- Dalhousie University Medical School, Dalhousie, Nova Scotia, Canada
| | - Robert A Kyle
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Heinz Ludwig
- Wilhelminenspital Der Stat Wien, Vienna, Austria
| | | | - Michele Cavo
- Seragnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
| | | | | | - Jens Hillengass
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Antonio Palumbo
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Citta della Salute e della Scienza di Torino, Torino, Italy
| | - Alberto Orfao
- University Hospital of Salamanca/IBSAL, Salamanca, Spain
| | | | - Jesus San Miguel
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), Pamplona, Spain
| | | |
Collapse
|
71
|
Lahuerta JJ, Paiva B, Vidriales MB, Cordón L, Cedena MT, Puig N, Martinez-Lopez J, Rosiñol L, Gutierrez NC, Martín-Ramos ML, Oriol A, Teruel AI, Echeveste MA, de Paz R, de Arriba F, Hernandez MT, Palomera L, Martinez R, Martin A, Alegre A, De la Rubia J, Orfao A, Mateos MV, Blade J, San-Miguel JF. Depth of Response in Multiple Myeloma: A Pooled Analysis of Three PETHEMA/GEM Clinical Trials. J Clin Oncol 2017; 35:2900-2910. [PMID: 28498784 DOI: 10.1200/jco.2016.69.2517] [Citation(s) in RCA: 213] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Purpose To perform a critical analysis on the impact of depth of response in newly diagnosed multiple myeloma (MM). Patients and Methods Data were analyzed from 609 patients who were enrolled in the GEM (Grupo Español de Mieloma) 2000 and GEM2005MENOS65 studies for transplant-eligible MM and the GEM2010MAS65 clinical trial for elderly patients with MM who had minimal residual disease (MRD) assessments 9 months after study enrollment. Median follow-up of the series was 71 months. Results Achievement of complete remission (CR) in the absence of MRD negativity was not associated with prolonged progression-free survival (PFS) and overall survival (OS) compared with near-CR or partial response (median PFS, 27, 27, and 29 months, respectively; median OS, 59, 64, and 65 months, respectively). MRD-negative status was strongly associated with prolonged PFS (median, 63 months; P < .001) and OS (median not reached; P < .001) overall and in subgroups defined by prior transplantation, disease stage, and cytogenetics, with prognostic superiority of MRD negativity versus CR particularly evident in patients with high-risk cytogenetics. Accordingly, Harrell C statistics showed higher discrimination for both PFS and OS in Cox models that included MRD (as opposed to CR) for response assessment. Superior MRD-negative rates after different induction regimens anticipated prolonged PFS. Among 34 MRD-negative patients with MM and a phenotypic pattern of bone marrow involvement similar to monoclonal gammopathy of undetermined significance at diagnosis, the probability of "operational cure" was high; median PFS was 12 years, and the 10-year OS rate was 94%. Conclusion Our results demonstrate that MRD-negative status surpasses the prognostic value of CR achievement for PFS and OS across the disease spectrum, regardless of the type of treatment or patient risk group. MRD negativity should be considered as one of the most relevant end points for transplant-eligible and elderly fit patients with MM.
Collapse
Affiliation(s)
- Juan-Jose Lahuerta
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Bruno Paiva
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Maria-Belen Vidriales
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Lourdes Cordón
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Maria-Teresa Cedena
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Noemi Puig
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Joaquin Martinez-Lopez
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Laura Rosiñol
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Norma C Gutierrez
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - María-Luisa Martín-Ramos
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Albert Oriol
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Ana-Isabel Teruel
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - María-Asunción Echeveste
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Raquel de Paz
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Felipe de Arriba
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Miguel T Hernandez
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Luis Palomera
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Rafael Martinez
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Alejandro Martin
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Adrian Alegre
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Javier De la Rubia
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Alberto Orfao
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - María-Victoria Mateos
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Joan Blade
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Jesus F San-Miguel
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | | |
Collapse
|
72
|
Anderson KC, Auclair D, Kelloff GJ, Sigman CC, Avet-Loiseau H, Farrell AT, Gormley NJ, Kumar SK, Landgren O, Munshi NC, Cavo M, Davies FE, Di Bacco A, Dickey JS, Gutman SI, Higley HR, Hussein MA, Jessup JM, Kirsch IR, Little RF, Loberg RD, Lohr JG, Mukundan L, Omel JL, Pugh TJ, Reaman GH, Robbins MD, Sasser AK, Valente N, Zamagni E. The Role of Minimal Residual Disease Testing in Myeloma Treatment Selection and Drug Development: Current Value and Future Applications. Clin Cancer Res 2017; 23:3980-3993. [PMID: 28428191 DOI: 10.1158/1078-0432.ccr-16-2895] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 01/10/2017] [Accepted: 04/13/2017] [Indexed: 01/22/2023]
Abstract
Treatment of myeloma has benefited from the introduction of more effective and better tolerated agents, improvements in supportive care, better understanding of disease biology, revision of diagnostic criteria, and new sensitive and specific tools for disease prognostication and management. Assessment of minimal residual disease (MRD) in response to therapy is one of these tools, as longer progression-free survival (PFS) is seen consistently among patients who have achieved MRD negativity. Current therapies lead to unprecedented frequency and depth of response, and next-generation flow and sequencing methods to measure MRD in bone marrow are in use and being developed with sensitivities in the range of 10-5 to 10-6 cells. These technologies may be combined with functional imaging to detect MRD outside of bone marrow. Moreover, immune profiling methods are being developed to better understand the immune environment in myeloma and response to immunomodulatory agents while methods for molecular profiling of myeloma cells and circulating DNA in blood are also emerging. With the continued development and standardization of these methodologies, MRD has high potential for use in gaining new drug approvals in myeloma. The FDA has outlined two pathways by which MRD could be qualified as a surrogate endpoint for clinical studies directed at obtaining accelerated approval for new myeloma drugs. Most importantly, better understanding of MRD should also contribute to better treatment monitoring. Potentially, MRD status could be used as a prognostic factor for making treatment decisions and for informing timing of therapeutic interventions. Clin Cancer Res; 23(15); 3980-93. ©2017 AACR.
Collapse
Affiliation(s)
- Kenneth C Anderson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.
| | - Daniel Auclair
- Multiple Myeloma Research Foundation, Norwalk, Connecticut
| | - Gary J Kelloff
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | | | - Hervé Avet-Loiseau
- Laboratoire d'Hématologie, Pôle Biologie, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Ann T Farrell
- Office of Hematology and Oncology Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Nicole J Gormley
- Office of Hematology and Oncology Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Shaji K Kumar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Ola Landgren
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nikhil C Munshi
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Michele Cavo
- Seragnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
| | - Faith E Davies
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Alessandra Di Bacco
- Translational Medicine, Oncology, Takeda Pharmaceuticals, Cambridge, Massachusetts
| | - Jennifer S Dickey
- Division of Molecular Genetics and Pathology, Office of In Vitro Diagnostics and Radiological Health, Center for Devices and Radiologic Health, U.S. Food and Drug Administration, Silver Spring, Maryland
| | | | | | - Mohamad A Hussein
- Department of Hematology, Morsini College of Medicine, University of South Florida, Tampa, Florida
- Scientific Collaborations, Celgene Corporation, Summit, New Jersey
| | - J Milburn Jessup
- Precision Cancer Care Program, Inova Schar Cancer Institute, Falls Church, Virginia
| | - Ilan R Kirsch
- Translational Medicine, Adaptive Biotechnologies, Seattle, Washington
| | - Richard F Little
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | | | - Jens G Lohr
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | | | - James L Omel
- Central Nebraska Myeloma Support Group, Grand Island, Nebraska
| | - Trevor J Pugh
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Gregory H Reaman
- Office of Hematology and Oncology Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | | | - A Kate Sasser
- Translational Research, Oncology, Janssen Research & Development, Spring House, Pennsylvania
| | - Nancy Valente
- BioOncology, Genentech Inc., South San Francisco, California
| | - Elena Zamagni
- Seragnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
| |
Collapse
|
73
|
Langerak AW, Brüggemann M, Davi F, Darzentas N, van Dongen JJM, Gonzalez D, Cazzaniga G, Giudicelli V, Lefranc MP, Giraud M, Macintyre EA, Hummel M, Pott C, Groenen PJTA, Stamatopoulos K. High-Throughput Immunogenetics for Clinical and Research Applications in Immunohematology: Potential and Challenges. THE JOURNAL OF IMMUNOLOGY 2017; 198:3765-3774. [PMID: 28416603 DOI: 10.4049/jimmunol.1602050] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 01/09/2017] [Indexed: 11/19/2022]
Abstract
Analysis and interpretation of Ig and TCR gene rearrangements in the conventional, low-throughput way have their limitations in terms of resolution, coverage, and biases. With the advent of high-throughput, next-generation sequencing (NGS) technologies, a deeper analysis of Ig and/or TCR (IG/TR) gene rearrangements is now within reach, which impacts on all main applications of IG/TR immunogenetic analysis. To bridge the generation gap from low- to high-throughput analysis, the EuroClonality-NGS Consortium has been formed, with the main objectives to develop, standardize, and validate the entire workflow of IG/TR NGS assays for 1) clonality assessment, 2) minimal residual disease detection, and 3) repertoire analysis. This concerns the preanalytical (sample preparation, target choice), analytical (amplification, NGS), and postanalytical (immunoinformatics) phases. Here we critically discuss pitfalls and challenges of IG/TR NGS methodology and its applications in hemato-oncology and immunology.
Collapse
Affiliation(s)
- Anton W Langerak
- Department of Immunology, Laboratory for Medical Immunology, Erasmus MC, University Medical Center, 3015 CN Rotterdam, the Netherlands;
| | - Monika Brüggemann
- Second Medical Department, University Hospital Schleswig-Holstein, 24105 Kiel, Germany
| | - Frédéric Davi
- Département d'Hématologie, Assistance Publique - Hôpitaux de Paris Hopital Pitié-Salpêtrière and Université Pierre et Marie Curie - Université Paris IV, 75005 Paris, France
| | - Nikos Darzentas
- Molecular Medicine Program, Central European Institute of Technology, Masaryk University, 625 00 Brno, Czech Republic
| | - Jacques J M van Dongen
- Department of Immunology, Laboratory for Medical Immunology, Erasmus MC, University Medical Center, 3015 CN Rotterdam, the Netherlands;
| | - David Gonzalez
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast BT9 7AE, United Kingdom
| | - Gianni Cazzaniga
- Centro Ricerca Tettamanti, Clinica Pediatrica Università Milano-Bicocca, 20900 Monza, Italy
| | | | | | - Mathieu Giraud
- Centre de Recherche en Informatique Signal et Automatique de Lille, CNRS, Université de Lille, 59000 Lille, France
| | - Elizabeth A Macintyre
- Département d'Hématologie, Assistance Publique - Hôpitaux de Paris Necker-Enfants Malades and Paris Descartes, 75015 Paris, France
| | - Michael Hummel
- Institut für Pathologie, Charité - Universitätsmedizin Berlin, D-10117 Berlin, Germany
| | - Christiane Pott
- Second Medical Department, University Hospital Schleswig-Holstein, 24105 Kiel, Germany
| | - Patricia J T A Groenen
- Department of Pathology, Radboud University Nijmegen Medical Center, 6525 GA Nijmegen, the Netherlands; and
| | - Kostas Stamatopoulos
- Institute of Applied Biosciences, Center for Research and Technology Hellas, GR-57001 Thessaloniki, Greece
| | | |
Collapse
|
74
|
Hanbali A, Hassanein M, Rasheed W, Aljurf M, Alsharif F. The Evolution of Prognostic Factors in Multiple Myeloma. Adv Hematol 2017; 2017:4812637. [PMID: 28321258 PMCID: PMC5339490 DOI: 10.1155/2017/4812637] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/22/2017] [Accepted: 02/05/2017] [Indexed: 12/23/2022] Open
Abstract
Multiple myeloma (MM) is a heterogeneous hematologic malignancy involving the proliferation of plasma cells derived by different genetic events contributing to the development, progression, and prognosis of this disease. Despite improvement in treatment strategies of MM over the last decade, the disease remains incurable. All efforts are currently focused on understanding the prognostic markers of the disease hoping to incorporate the new therapeutic modalities to convert the disease into curable one. We present this comprehensive review to summarize the current standard prognostic markers used in MM along with novel techniques that are still in development and highlight their implications in current clinical practice.
Collapse
Affiliation(s)
- Amr Hanbali
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mona Hassanein
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Walid Rasheed
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Fahad Alsharif
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| |
Collapse
|
75
|
Munshi NC, Avet-Loiseau H, Rawstron AC, Owen RG, Child JA, Thakurta A, Sherrington P, Samur MK, Georgieva A, Anderson KC, Gregory WM. Association of Minimal Residual Disease With Superior Survival Outcomes in Patients With Multiple Myeloma: A Meta-analysis. JAMA Oncol 2017; 3:28-35. [PMID: 27632282 DOI: 10.1001/jamaoncol.2016.3160] [Citation(s) in RCA: 360] [Impact Index Per Article: 51.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Numerous studies have evaluated the prognostic value of minimal residual disease (MRD) in patients with multiple myeloma (MM). Most studies were small and varied in terms of patient population, treatment, and MRD assessment methods. Objective To evaluate the utility of MRD detection in patients with newly diagnosed MM. Data Sources A Medline search was conducted for articles published in English between January 1990 and January 2016. Study Selection Eligible studies reported MRD status and progression-free survival (PFS) or overall survival (OS) in 20 or more patients following treatment. Among 405 articles identified, 21 met the initial eligibility criteria and were included in the analysis. Data Extraction and Synthesis Information on patient characteristics, treatment, MRD assessment, and outcomes were extracted using a standard form. Main Outcomes and Measures The impact of MRD status on PFS and OS was assessed by pooling data from relevant trials. Data were adjusted to allow for different proportions of patients with MRD in different studies, and analyzed using the Peto method. Forest plots were created based on Cox model analysis. Other prespecified research questions were addressed qualitatively. Results Fourteen studies (n = 1273) provided data on the impact of MRD on PFS, and 12 studies (n = 1100) on OS. Results were reported specifically in patients who had achieved conventional complete response (CR) in 5 studies for PFS (n = 574) and 6 studies for OS (n = 616). An MRD-negative status was associated with significantly better PFS overall (hazard ratio [HR], 0.41; 95% CI, 0.36-0.48; P < .001) and in studies specifically looking at CR patients (HR, 0.44; 95% CI, 0.34-0.56; P < .001). Overall survival was also favorable in MRD-negative patients overall (HR, 0.57; 95% CI, 0.46-0.71; P < .001) and in CR patients (HR, 0.47; 95% CI, 0.33-0.67; P < .001). Tests of heterogeneity found no significant differences among the studies for PFS and OS. Conclusions and Relevance Minimal residual disease-negative status after treatment for newly diagnosed MM is associated with long-term survival. These findings provide quantitative evidence to support the integration of MRD assessment as an end point in clinical trials of MM.
Collapse
Affiliation(s)
- Nikhil C Munshi
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Herve Avet-Loiseau
- Unit for Genomics in Myeloma, Institut Universitaire du Cancer, Toulouse, France
| | | | - Roger G Owen
- St James's University Hospital, Leeds, United Kingdom
| | | | | | | | - Mehmet Kemal Samur
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | | | - Kenneth C Anderson
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | | |
Collapse
|
76
|
Flores-Montero J, Sanoja-Flores L, Paiva B, Puig N, García-Sánchez O, Böttcher S, van der Velden VHJ, Pérez-Morán JJ, Vidriales MB, García-Sanz R, Jimenez C, González M, Martínez-López J, Corral-Mateos A, Grigore GE, Fluxá R, Pontes R, Caetano J, Sedek L, Del Cañizo MC, Bladé J, Lahuerta JJ, Aguilar C, Bárez A, García-Mateo A, Labrador J, Leoz P, Aguilera-Sanz C, San-Miguel J, Mateos MV, Durie B, van Dongen JJM, Orfao A. Next Generation Flow for highly sensitive and standardized detection of minimal residual disease in multiple myeloma. Leukemia 2017; 31:2094-2103. [PMID: 28104919 PMCID: PMC5629369 DOI: 10.1038/leu.2017.29] [Citation(s) in RCA: 411] [Impact Index Per Article: 58.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 12/24/2016] [Accepted: 01/03/2017] [Indexed: 12/20/2022]
Abstract
Flow cytometry has become a highly valuable method to monitor minimal residual disease (MRD) and evaluate the depth of complete response (CR) in bone marrow (BM) of multiple myeloma (MM) after therapy. However, current flow-MRD has lower sensitivity than molecular methods and lacks standardization. Here we report on a novel next generation flow (NGF) approach for highly sensitive and standardized MRD detection in MM. An optimized 2-tube 8-color antibody panel was constructed in five cycles of design-evaluation-redesign. In addition, a bulk-lysis procedure was established for acquisition of ⩾107 cells/sample, and novel software tools were constructed for automatic plasma cell gating. Multicenter evaluation of 110 follow-up BM from MM patients in very good partial response (VGPR) or CR showed a higher sensitivity for NGF-MRD vs conventional 8-color flow-MRD -MRD-positive rate of 47 vs 34% (P=0.003)-. Thus, 25% of patients classified as MRD-negative by conventional 8-color flow were MRD-positive by NGF, translating into a significantly longer progression-free survival for MRD-negative vs MRD-positive CR patients by NGF (75% progression-free survival not reached vs 7 months; P=0.02). This study establishes EuroFlow-based NGF as a highly sensitive, fully standardized approach for MRD detection in MM which overcomes the major limitations of conventional flow-MRD methods and is ready for implementation in routine diagnostics.
Collapse
Affiliation(s)
- J Flores-Montero
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| | - L Sanoja-Flores
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| | - B Paiva
- Clinica Universidad de Navarra; Applied Medical Research Center (CIMA), IDISNA, Pamplona, Spain (UNAV)
| | - N Puig
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - O García-Sánchez
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - S Böttcher
- Second Department of Medicine, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (UNIKIEL)
| | - V H J van der Velden
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (EMC)
| | - J-J Pérez-Morán
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - M-B Vidriales
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - R García-Sanz
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - C Jimenez
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - M González
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | | | - A Corral-Mateos
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| | | | - R Fluxá
- Cytognos SL, Salamanca, Spain
| | - R Pontes
- Faculty of Medicine, Federal University of Rio de Janeiro and Institute of Pediatrics and Childhood Care, Rio de Janeiro, Brazil
| | - J Caetano
- Department of Hematology, Portuguese Institute of Oncology, Lisbon, Portugal (IPOLFG)
| | - L Sedek
- Department of Pediatric Hematology and Oncology, Medical University of Silesia in Katowice, Zabrze, Poland (SUM)
| | - M-C Del Cañizo
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - J Bladé
- Department of Hematology, Hospital Clinic I Provincial, Barcelona, Spain
| | - J-J Lahuerta
- Department of Hematology, Hospital 12 de Octubre, Madrid, Spain
| | - C Aguilar
- Department of Hematology, Hospital General de Santa Bárbara, Soria, Spain
| | - A Bárez
- Department of Hematology, Complejo Asistencial de Ávila, Ávila, Spain
| | - A García-Mateo
- Department of Hematology, Complejo Asistencial de Segovia, Segovia, Spain
| | - J Labrador
- Hematology Department, Hospital Universitario de Burgos, Burgos, Spain
| | - P Leoz
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| | - C Aguilera-Sanz
- Department of Hematology, Hospital El Bierzo, Ponferrada, Spain
| | - J San-Miguel
- Clinica Universidad de Navarra; Applied Medical Research Center (CIMA), IDISNA, Pamplona, Spain (UNAV)
| | - M-V Mateos
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - B Durie
- Cedars-Sinai Samuel Oschin Cancer Center, Los Angeles, CA, USA
| | - J J M van Dongen
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (EMC).,Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
| | - A Orfao
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| |
Collapse
|
77
|
van de Velde H, Londhe A, Ataman O, Johns HL, Hill S, Landers E, Berlin JA. Association between complete response and outcomes in transplant-eligible myeloma patients in the era of novel agents. Eur J Haematol 2016; 98:269-279. [PMID: 27859769 DOI: 10.1111/ejh.12829] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Achieving complete response (CR) has been linked to improved progression-free (PFS) and overall (OS) survival in myeloma. A meta-analysis was conducted to investigate whether this holds true in the era of novel agents (bortezomib, lenalidomide, thalidomide). METHODS A total of 24 studies in newly diagnosed patients undergoing autologous stem cell transplantation (ASCT) that reported associations between responses and long-term outcomes (PFS/OS rates post-ASCT by response, or hazard ratios with 95% confidence intervals from Cox models) were identified and analyzed. RESULTS Achievement of CR vs. <CR post-ASCT reduced risk of progression/death by 38% [risk ratio (RR): 0.62, P < 0.0001]; risk of death was 41% lower (RR: 0.59, P < 0.0001). Subgroup meta-analyses showed significant PFS risk reduction with CR post-ASCT with novel (RR: 0.32, P < 0.006) and non-novel (RR: 0.72, P < 0.0001) agents, and corresponding OS risk reduction with novel (RR: 0.33, P = 0.0013) and non-novel (RR: 0.64, P < 0.0001) agents. Risk reduction was greater with novel vs. non-novel agents (PFS: P = 0.047; OS: P = 0.058). CONCLUSIONS Achieving CR during first-line therapy remains important in the novel-agent era; magnitude of association between achieving CR and outcomes appears higher for CR obtained using novel vs. non-novel agents.
Collapse
Affiliation(s)
- Helgi van de Velde
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Anil Londhe
- Janssen Research and Development, Horsham, PA, USA
| | - Ozlem Ataman
- Janssen Research & Development, High Wycombe, UK
| | - Helen L Johns
- FireKite, an Ashfield Company, part of UDG Healthcare plc, Maidenhead, UK
| | - Stephen Hill
- FireKite, an Ashfield Company, part of UDG Healthcare plc, Maidenhead, UK
| | - Emma Landers
- FireKite, an Ashfield Company, part of UDG Healthcare plc, Maidenhead, UK
| | | |
Collapse
|
78
|
Abstract
This article provides an overview of the role of flow cytometry in the diagnosis and follow-up of plasma cell myeloma. A brief introduction to the general immunophenotypic features of normal and myeloma plasma cells is provided, followed by a discussion of technical issues as they relate to the application of flow cytometry in this entity. The prognostic and therapeutic utility of flow cytometric immunophenotyping in myeloma is also analyzed, with an emphasis on the growing role of minimal residual analysis as potential biomarker for evaluating treatment efficacy and for tailoring risk-adapted treatment, in prospective clinical trials.
Collapse
Affiliation(s)
- Horatiu Olteanu
- Department of Pathology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
| |
Collapse
|
79
|
Jiménez C, Jara-Acevedo M, Corchete LA, Castillo D, Ordóñez GR, Sarasquete ME, Puig N, Martínez-López J, Prieto-Conde MI, García-Álvarez M, Chillón MC, Balanzategui A, Alcoceba M, Oriol A, Rosiñol L, Palomera L, Teruel AI, Lahuerta JJ, Bladé J, Mateos MV, Orfão A, San Miguel JF, González M, Gutiérrez NC, García-Sanz R. A Next-Generation Sequencing Strategy for Evaluating the Most Common Genetic Abnormalities in Multiple Myeloma. J Mol Diagn 2016; 19:99-106. [PMID: 27863261 DOI: 10.1016/j.jmoldx.2016.08.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/04/2016] [Accepted: 08/12/2016] [Indexed: 12/16/2022] Open
Abstract
Identification and characterization of genetic alterations are essential for diagnosis of multiple myeloma and may guide therapeutic decisions. Currently, genomic analysis of myeloma to cover the diverse range of alterations with prognostic impact requires fluorescence in situ hybridization (FISH), single nucleotide polymorphism arrays, and sequencing techniques, which are costly and labor intensive and require large numbers of plasma cells. To overcome these limitations, we designed a targeted-capture next-generation sequencing approach for one-step identification of IGH translocations, V(D)J clonal rearrangements, the IgH isotype, and somatic mutations to rapidly identify risk groups and specific targetable molecular lesions. Forty-eight newly diagnosed myeloma patients were tested with the panel, which included IGH and six genes that are recurrently mutated in myeloma: NRAS, KRAS, HRAS, TP53, MYC, and BRAF. We identified 14 of 17 IGH translocations previously detected by FISH and three confirmed translocations not detected by FISH, with the additional advantage of breakpoint identification, which can be used as a target for evaluating minimal residual disease. IgH subclass and V(D)J rearrangements were identified in 77% and 65% of patients, respectively. Mutation analysis revealed the presence of missense protein-coding alterations in at least one of the evaluating genes in 16 of 48 patients (33%). This method may represent a time- and cost-effective diagnostic method for the molecular characterization of multiple myeloma.
Collapse
Affiliation(s)
- Cristina Jiménez
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), Salamanca, Spain
| | - María Jara-Acevedo
- DNA Sequencing Service, University of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), Salamanca, Spain
| | - Luis A Corchete
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), Salamanca, Spain
| | | | | | - María E Sarasquete
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), Salamanca, Spain
| | - Noemí Puig
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), Salamanca, Spain
| | - Joaquín Martínez-López
- Hematology Department, 12 de Octubre Hospital, Unit of Cancer Research Innovation Spain (CRIS), Spanish National Cancer Research Center (CNIO), University of Madrid, Madrid, Spain
| | - María I Prieto-Conde
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), Salamanca, Spain
| | - María García-Álvarez
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), Salamanca, Spain
| | - María C Chillón
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), Salamanca, Spain
| | - Ana Balanzategui
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), Salamanca, Spain
| | - Miguel Alcoceba
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), Salamanca, Spain
| | - Albert Oriol
- Catalan Institute of Oncology, Josep Carreras Institute, Germans Trias i Pujol Hospital, Barcelona, Spain
| | - Laura Rosiñol
- Research Biomedical Institute August Pi i Sunyer, Clinical Hospital of Barcelona, Barcelona, Spain
| | | | | | - Juan J Lahuerta
- Hematology Department, 12 de Octubre Hospital, Unit of Cancer Research Innovation Spain (CRIS), Spanish National Cancer Research Center (CNIO), University of Madrid, Madrid, Spain
| | - Joan Bladé
- Research Biomedical Institute August Pi i Sunyer, Clinical Hospital of Barcelona, Barcelona, Spain
| | - María V Mateos
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), Salamanca, Spain
| | - Alberto Orfão
- DNA Sequencing Service, University of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), Salamanca, Spain
| | - Jesús F San Miguel
- Center for Applied Medical Research, University of Navarra Hospital, Institute of Health Research of Navarra (IDISNA), Pamplona, Spain
| | - Marcos González
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), Salamanca, Spain.
| | - Norma C Gutiérrez
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), Salamanca, Spain
| | - Ramón García-Sanz
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), Salamanca, Spain
| |
Collapse
|
80
|
Towards Stratified Medicine in Plasma Cell Myeloma. Int J Mol Sci 2016; 17:ijms17101760. [PMID: 27775669 PMCID: PMC5085784 DOI: 10.3390/ijms17101760] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 09/26/2016] [Accepted: 10/05/2016] [Indexed: 02/06/2023] Open
Abstract
Plasma cell myeloma is a clinically heterogeneous malignancy accounting for approximately one to 2% of newly diagnosed cases of cancer worldwide. Treatment options, in addition to long-established cytotoxic drugs, include autologous stem cell transplant, immune modulators, proteasome inhibitors and monoclonal antibodies, plus further targeted therapies currently in clinical trials. Whilst treatment decisions are mostly based on a patient’s age, fitness, including the presence of co-morbidities, and tumour burden, significant scope exists for better risk stratification, sub-classification of disease, and predictors of response to specific therapies. Clinical staging, recurring acquired cytogenetic aberrations, and serum biomarkers such as β-2 microglobulin, and free light chains are in widespread use but often fail to predict the disease progression or inform treatment decision making. Recent scientific advances have provided considerable insight into the biology of myeloma. For example, gene expression profiling is already making a contribution to enhanced understanding of the biology of the disease whilst Next Generation Sequencing has revealed great genomic complexity and heterogeneity. Pathways involved in the oncogenesis, proliferation of the tumour and its resistance to apoptosis are being unravelled. Furthermore, knowledge of the tumour cell surface and its interactions with bystander cells and the bone marrow stroma enhance this understanding and provide novel targets for cell and antibody-based therapies. This review will discuss the development in understanding of the biology of the tumour cell and its environment in the bone marrow, the implementation of new therapeutic options contributing to significantly improved outcomes, and the progression towards more personalised medicine in this disorder.
Collapse
|
81
|
Bai Y, Wong KY, Fung TK, Chim CS. High applicability of ASO-RQPCR for detection of minimal residual disease in multiple myeloma by entirely patient-specific primers/probes. J Hematol Oncol 2016; 9:107. [PMID: 27724958 PMCID: PMC5057274 DOI: 10.1186/s13045-016-0336-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 10/04/2016] [Indexed: 11/10/2022] Open
Abstract
Allele-specific oligonucleotide real-time quantitative PCR (ASO-RQPCR) is a standardized technique for detection and monitoring of minimal residual disease (MRD) in acute lymphoblastic leukemia (ALL) but not multiple myeloma (MM) due to a low applicability inherent with presence of somatic hypermutation. Herein, by a staged PCR approach and sequencing, clonality and tumor-specific complementarity-determining region 3 (CDR3) sequence were identified in 13/13 MM by sequential PCR of IgH VDJ (n = 10), IgH DJ (n = 2), or IgK VJ (n = 1). Using consensus primers/probes conventionally employed in ALL, ASO-RQPCR worked in three (23.1 %) cases only. Conversely, using entirely patient-specific primers/probes, ASO-RQPCR was applicable in eight (61.5 %) cases with a sensitivity of 5 × 10−4–10−5. Moreover, using standard curves constructed by serial dilution of plasmids cloned with patient-specific CDR3, ASO-RQPCR was successful in 12 (92.3 %) cases with a sensitivity of 10−4–10−5, but not in a case lacking an N region, in which design of a tumor-specific ASO primer was precluded. Finally, in a patient in complete response (CR), further reduction of MRD after autologous stem cell transplantation (ASCT) was demonstrated. In summary, using entirely patient-specific primers/probes, ASO-RQPCR was applicable in >90 % MM patients and enabled detection of dynamic changes of MRD before and after ASCT despite conventional CR.
Collapse
Affiliation(s)
- Yinlei Bai
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Kwan Yeung Wong
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Tsz Kin Fung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Chor Sang Chim
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong.
| |
Collapse
|
82
|
Shires K, Wienand K. Cancer testis antigen MAGE C1 can be used to monitor levels of circulating malignant stem cells in the peripheral blood of multiple myeloma patients. J Cancer Res Clin Oncol 2016; 142:2383-96. [PMID: 27581737 DOI: 10.1007/s00432-016-2231-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 08/23/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE Monitoring the levels of malignant disease-causing cells in multiple myeloma, as opposed to the clinical symptoms alone, is an important move forward in the management of this disease. While current methods including multiparametric flow cytometry and PCR analysis of the clonal plasma cells can be used in a patient-specific manner, their use is limited and the fundamental malignant progenitor cell is not being monitored. The expression of cancer testis antigen MAGE C1 has been linked to the malignant stem cell in this disease, and thus, we investigated the use of both flow cytometric and qRTPCR approaches to monitor its expression as an alternative monitoring methodology in this pilot study. METHODS We compared the levels of MAGE C1 in the peripheral blood to serum M protein and serum beta 2 microglobulin levels at 3-monthly intervals over a 2-year period, for 12 patients on chemotherapy regimens and 4 patients undergoing stem cell transplantation. RESULTS AND CONCLUSIONS The analysis indicated that the novel flow cytometric analysis of MAGE C1 expression in the peripheral blood was extremely relevant as a potential minimal residual disease-monitoring tool. Expression of this cancer testis antigen was detectable in all patients throughout treatment, with comparable increases and decreases to serum M protein and/or serum beta 2 microglobulin, but with the advantage of being able to detect disease at a more sensitive level. Furthermore, due to the increased sensitivity, the ability to pre-empt disease relapse before clinical changes were evident, was preliminarily indicated. The qRTPCR approach showed potential as a monitoring tool in the chemotherapy patient cohort, with the mRNA MAGE C1 levels following a similar pattern of expression observed in the flow cytometry analysis.
Collapse
Affiliation(s)
- Karen Shires
- 6th Floor Chris Barnard Building, Division of Haematology, Department of Pathology, University of Cape Town Medical School, Anzio Road, Observatory, Cape Town, 7221, South Africa.
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa.
| | - Kirsty Wienand
- 6th Floor Chris Barnard Building, Division of Haematology, Department of Pathology, University of Cape Town Medical School, Anzio Road, Observatory, Cape Town, 7221, South Africa
| |
Collapse
|
83
|
Differentiation stage of myeloma plasma cells: biological and clinical significance. Leukemia 2016; 31:382-392. [PMID: 27479184 DOI: 10.1038/leu.2016.211] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 06/19/2016] [Accepted: 06/21/2016] [Indexed: 02/06/2023]
Abstract
The notion that plasma cells (PCs) are terminally differentiated has prevented intensive research in multiple myeloma (MM) about their phenotypic plasticity and differentiation. Here, we demonstrated in healthy individuals (n=20) that the CD19-CD81 expression axis identifies three bone marrow (BM)PC subsets with distinct age-prevalence, proliferation, replication-history, immunoglobulin-production, and phenotype, consistent with progressively increased differentiation from CD19+CD81+ into CD19-CD81+ and CD19-CD81- BMPCs. Afterwards, we demonstrated in 225 newly diagnosed MM patients that, comparing to normal BMPC counterparts, 59% had fully differentiated (CD19-CD81-) clones, 38% intermediate-differentiated (CD19-CD81+) and 3% less-differentiated (CD19+CD81+) clones. The latter patients had dismal outcome, and PC differentiation emerged as an independent prognostic marker for progression-free (HR: 1.7; P=0.005) and overall survival (HR: 2.1; P=0.006). Longitudinal comparison of diagnostic vs minimal-residual-disease samples (n=40) unraveled that in 20% of patients, less-differentiated PCs subclones become enriched after therapy-induced pressure. We also revealed that CD81 expression is epigenetically regulated, that less-differentiated clonal PCs retain high expression of genes related to preceding B-cell stages (for example: PAX5), and show distinct mutation profile vs fully differentiated PC clones within individual patients. Together, we shed new light into PC plasticity and demonstrated that MM patients harbouring less-differentiated PCs have dismal survival, which might be related to higher chemoresistant potential plus different molecular and genomic profiles.
Collapse
|
84
|
Zamagni E, Tacchetti P, Terragna C, Cavo M. Multiple myeloma: disease response assessment. Expert Rev Hematol 2016; 9:831-7. [DOI: 10.1080/17474086.2016.1212654] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
85
|
Minimal residual disease monitoring and immune profiling in multiple myeloma in elderly patients. Blood 2016; 127:3165-74. [PMID: 27118453 DOI: 10.1182/blood-2016-03-705319] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 04/17/2016] [Indexed: 01/20/2023] Open
Abstract
The value of minimal residual disease (MRD) in multiple myeloma (MM) has been more frequently investigated in transplant-eligible patients than in elderly patients. Because an optimal balance between treatment efficacy and toxicity is of utmost importance in patients with elderly MM, sensitive MRD monitoring might be particularly valuable in this patient population. Here, we used second-generation 8-color multiparameter-flow cytometry (MFC) to monitor MRD in 162 transplant-ineligible MM patients enrolled in the PETHEMA/GEM2010MAS65 study. The transition from first- to second-generation MFC resulted in increased sensitivity and allowed us to identify 3 patient groups according to MRD levels: MRD negative (<10(-5); n = 54, 34%), MRD positive (between <10(-4) and ≥10(-5); n = 20, 12%), and MRD positive (≥10(-4); n = 88, 54%). MRD status was an independent prognostic factor for time to progression (TTP) (hazard ratio [HR], 2.7; P = .007) and overall survival (OS) (HR, 3.1; P = .04), with significant benefit for MRD-negative patients (median TTP not reached, 70% OS at 3 years), and similar poorer outcomes for cases with MRD levels between <10(-4) and ≥10(-5) vs ≥10(-4) (both with a median TTP of 15 months; 63% and 55% OS at 3 years, respectively). Furthermore, MRD negativity significantly improved TTP of patients >75 years (HR, 4.8; P < .001), as well as those with high-risk cytogenetics (HR, 12.6; P = .01). Using second-generation MFC, immune profiling concomitant to MRD monitoring also contributed to identify patients with poor, intermediate, and favorable outcomes (25%, 61%, and 100% OS at 3 years, respectively; P = .01), the later patients being characterized by an increased compartment of mature B cells. Our results show that similarly to transplant candidates, MRD monitoring is one of the most relevant prognostic factors in elderly MM patients, irrespectively of age or cytogenetic risk. This trial was registered at www.clinicaltrials.gov as #NCT01237249.
Collapse
|
86
|
Phenotypic and genomic analysis of multiple myeloma minimal residual disease tumor cells: a new model to understand chemoresistance. Blood 2016; 127:1896-906. [DOI: 10.1182/blood-2015-08-665679] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 12/28/2015] [Indexed: 12/31/2022] Open
Abstract
Key Points
We report for the first time the biological features of MRD cells in MM and unravel that clonal selection is already present at the MRD stage. MRD cells show a singular phenotypic signature that may result from persisting clones with different genetic and gene expression profiles.
Collapse
|
87
|
Nishihori T, Song J, Shain KH. Minimal Residual Disease Assessment in the Context of Multiple Myeloma Treatment. Curr Hematol Malig Rep 2016; 11:118-26. [PMID: 26898557 PMCID: PMC4819726 DOI: 10.1007/s11899-016-0308-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
With contemporary therapeutic strategies in multiple myeloma, heretofore unseen depth and rate of responses are being achieved. These strategies have paralleled improvements in outcome of multiple myeloma patients. The integration of the next generation of proteasome inhibitors and antibody therapeutics promise continued improvements in therapy with the expectation of consistent depth of response not quantifiable by current clinical methods. As such, there is a growing need to develop adequate tools to evaluate deeper disease response after therapy and to refine the response criteria including the minimal residual disease. Several emerging techniques are being evaluated for these purposes including multi-parameter flow cytometry, allele-specific oligonucleotide polymerase chain reaction, next-generation sequencing, and imaging modalities. In this review, we highlight the recent developments and evaluate advantages and limitations of the current technologies to assess minimal residual disease. We also discuss future applications of these methodologies in potentially guiding multiple myeloma treatment decisions.
Collapse
Affiliation(s)
- Taiga Nishihori
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
- Department of Oncologic Sciences, Moffitt Cancer Center/University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Jinming Song
- Department of Oncologic Sciences, Moffitt Cancer Center/University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Department of Hematopathology, Moffitt Cancer Center, Tampa, FL, USA
| | - Kenneth H Shain
- Department of Oncologic Sciences, Moffitt Cancer Center/University of South Florida Morsani College of Medicine, Tampa, FL, USA.
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA.
- Tumor Biology Department, Moffitt Cancer Center, Tampa, FL, USA.
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
| |
Collapse
|
88
|
Bhutani M, Landgren O, Usmani SZ. Multiple myeloma: is it time for biomarker-driven therapy? Am Soc Clin Oncol Educ Book 2016:e493-503. [PMID: 25993214 DOI: 10.14694/edbook_am.2015.35.e493] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Remarkable strides have been made in understanding the molecular mechanisms by which multiple myeloma develops, leading to more sophisticated classification that incorporates not only the traditional diagnostic criteria, but also immunophenotype, genetic, and molecular features. However, even with this added information, considerable heterogeneity in clinical outcomes exists within the identified subtypes. The present paradigm for myeloma treatment is built on the basic step of defining transplant eligibility versus noneligibility, as determined by age, performance status, and cumulative burden of comorbidities. An incredibly complex heterogeneous disease is, therefore, treated in a generalized way with the result that large interpatient variability exists in the outcome. As antimyeloma therapeutics continue to expand it is becoming even more crucial to personalize treatment approaches that provide the most value to a specific patient. Development of biomarkers, either individually or as larger sets or patterns and ranging from analysis of blood or bone marrow to biomedical imaging, is a major focus in the field. Biomarkers such as involved serum free light chain ratio and MRI focal lesions have been implemented in the new definition of multiple myeloma and guide clinicians to initiate treatment in otherwise asymptomatic individuals. Currently, however, there is not enough evidence to support intensifying the treatment for high-risk disease or reducing the treatment for low-risk disease. Minimal residual disease-negative status is an important biomarker that holds promise for monitoring the effectiveness of response-adapted strategies. This article sheds light on the forward landscape and rear-mirror view of biomarkers in myeloma.
Collapse
Affiliation(s)
- Manisha Bhutani
- From the Department of Hematologic Oncology & Blood Disorders, Levine Cancer Institute/Carolinas Healthcare System, Charlotte, NC; Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ola Landgren
- From the Department of Hematologic Oncology & Blood Disorders, Levine Cancer Institute/Carolinas Healthcare System, Charlotte, NC; Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Saad Z Usmani
- From the Department of Hematologic Oncology & Blood Disorders, Levine Cancer Institute/Carolinas Healthcare System, Charlotte, NC; Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| |
Collapse
|
89
|
Katodritou E, Papadaki S, Konstantinidou P, Terpos E. Is it possible to cure myeloma without allogeneic transplantation? Transfus Apher Sci 2016; 54:63-70. [PMID: 26850930 DOI: 10.1016/j.transci.2016.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
During the last decades, a better understanding of the biology of multiple myeloma (MM) has led to the application of novel treatment strategies for MM patients. The new anti-myeloma regimens produce higher incidence of durable and of better quality responses and they improve overall survival, challenging the dogma of incurable disease, outside the context of allogeneic transplantation. This review presents all these strategies that aim to cure MM, including continuous treatment i.e. induction, consolidation and maintenance, treatment of asymptomatic MM and monitoring minimal residual disease using modern techniques, such as multi-parameter flow cytometry, molecular assays and advanced imaging.
Collapse
Affiliation(s)
- Eirini Katodritou
- Department of Hematology, Theagenion Cancer Hospital, Thessaloniki, Greece; Greek Myeloma Study Group, Athens, Greece
| | - Sofia Papadaki
- Department of Hematology, Theagenion Cancer Hospital, Thessaloniki, Greece
| | | | - Evangelos Terpos
- Greek Myeloma Study Group, Athens, Greece; Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| |
Collapse
|
90
|
Muz B, de la Puente P, Azab F, Luderer MJ, King J, Vij R, Azab AK. A CD138-independent strategy to detect minimal residual disease and circulating tumour cells in multiple myeloma. Br J Haematol 2016; 173:70-81. [PMID: 26729247 DOI: 10.1111/bjh.13927] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 11/18/2015] [Indexed: 12/26/2022]
Abstract
CD138 (also termed SDC1) has been the gold-standard surface marker to detect multiple myeloma (MM) cells for decades; however, drug-resistant residual and circulating MM cells were shown to have lower expression of this marker. In this study, we have shown that residual MM cells following bortezomib treatment are hypoxic. This combination of drug exposure and hypoxia down-regulates their CD138 expression, thereby making this marker unsuitable for detecting residual or other hypoxic MM cells, such as circulating tumour cells, in MM. Hence, we developed an alternative biomarker set which detects myeloma cells independent of their hypoxic and CD138 expression status in vitro, in vivo and in primary MM patients. The new markers were able to identify a clonal CD138-negative population as minimal residual disease in the bone marrow and peripheral blood of MM patients. Further investigation to characterize the role of this population as a prognostic marker in MM is warranted.
Collapse
Affiliation(s)
- Barbara Muz
- Department of Radiation Oncology, Cancer Biology Division, Washington University School of Medicine, St. Louis, MO, USA
| | - Pilar de la Puente
- Department of Radiation Oncology, Cancer Biology Division, Washington University School of Medicine, St. Louis, MO, USA
| | - Feda Azab
- Department of Radiation Oncology, Cancer Biology Division, Washington University School of Medicine, St. Louis, MO, USA
| | - Micah John Luderer
- Department of Radiation Oncology, Cancer Biology Division, Washington University School of Medicine, St. Louis, MO, USA
| | - Justin King
- Section of Stem Cell Transplant and Leukemia, Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ravi Vij
- Section of Stem Cell Transplant and Leukemia, Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Abdel Kareem Azab
- Department of Radiation Oncology, Cancer Biology Division, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
91
|
Abstract
Assessment of minimal residual disease (MRD) is becoming standard diagnostic care for potentially curable neoplasms such as some acute leukemias as well as chronic myeloid and lymphocytic leukemia. Although multiple myeloma (MM) remains as an incurable disease, around half of the patients achieve complete remission (CR), and recent data suggests increasing rates of curability with "total-therapy-like" programs. This landscape is likely to be improved with the advent of new antibodies and small molecules. Therefore, conventional serological and morphological techniques have become suboptimal for sensitive evaluation of highly effective treatment strategies. Although, existing data suggests that MRD could be used as a biomarker to evaluate treatment efficacy, help on therapeutic decisions, and act as surrogate for overall survival, the role of MRD in MM is still a matter of extensive debate. Here, we review the different levels of remission used to define depth of response in MM and their clinical significance, as well as the prognostic value and unique characteristics of MRD detection using immunophenotypic, molecular, and imaging techniques. Key facts The higher efficacy of new treatment strategies for MM demand the incorporation of highly sensitive techniques to monitor treatment efficacy MRD could be used as a more potent surrogate biomarker for survival than standard CR We need to understand the pros and cons of the different MRD techniques The time has come to incorporate highly sensitive, cost-effective, readily available, and standardized MRD techniques into clinical trials to assess its role in therapeutic decisions.
Collapse
Affiliation(s)
- Bruno Paiva
- Centro de Investigacion Medica Aplicada (CIMA), Clinica Universidad de Navarra, IDISNA, Pamplona, Spain
| | - Ramón García-Sanz
- Hospital Universitario de Salamanca, Centro de Investigación Del Cancer (IBMCC-USAL, CSIC), Instituto de Investigaion Biomedica de Salamanca (IBSAL), Salamanca, Spain
| | - Jesús F San Miguel
- Centro de Investigacion Medica Aplicada (CIMA), Clinica Universidad de Navarra, IDISNA, Pamplona, Spain.
| |
Collapse
|
92
|
Landgren O, Owen RG. Better therapy requires better response evaluation: Paving the way for minimal residual disease testing for every myeloma patient. CYTOMETRY PART B-CLINICAL CYTOMETRY 2015; 90:14-20. [PMID: 26147584 DOI: 10.1002/cyto.b.21273] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 06/26/2015] [Accepted: 06/30/2015] [Indexed: 11/09/2022]
Abstract
In 2015, there is a large body of evidence demonstrating that minimal residual disease (MRD) negativity after therapy is a powerful predictor of progression-free survival and overall survival in multiple myeloma. On the basis of available data, we believe MRD provides a meaningful endpoint for regulatory purposes, academic studies, and a valuable prognostic evaluation of individual patients in the clinical setting. Similar to what has been shown in acute and chronic lymphocytic leukemia, based on emerging data, the prognostic impact of MRD in multiple myeloma appears to be independent of induction therapy received. This fact raises fundamental questions regarding best possible treatment strategies (e.g., fixed number of cycles versus response adapted number of cycles) as well as optimal treatment modalities (e.g., newer effective but less intense combination therapies versus high dose melphalan followed by autologous stem cell transplantation), in particular for patients newly diagnosed with multiple myeloma.
Collapse
Affiliation(s)
- Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Roger G Owen
- Department of Medicine, St James's University Hospital, Leeds, United Kingdom
| |
Collapse
|
93
|
Deep Response in Multiple Myeloma: A Critical Review. BIOMED RESEARCH INTERNATIONAL 2015; 2015:832049. [PMID: 26783530 PMCID: PMC4689894 DOI: 10.1155/2015/832049] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 11/23/2015] [Indexed: 11/17/2022]
Abstract
Novel and more effective treatment strategies against multiple myeloma (MM) have significantly prolonged patients' survival and raised interest in the depth of response and its association with clinical outcome. Minimal residual disease (MRD) has emerged as one of the most relevant prognostic factors in MM and should be included in a new definition of complete response (CR). Although further standardization is still required, MRD monitoring should be applied in prospective clinical trials as a sensitive tool to compare and evaluate the efficacy of different treatment strategies, particularly in the consolidation and maintenance settings, and implement individualized therapy-monitoring approaches. Here, we review current definition of deep response in MM, advantages and limitations of current MRD assessment assays, clinical evidences for MRD monitoring as a prognostic tool for therapeutic decisions in MM, and challenges to develop uniform criteria for MRD monitoring.
Collapse
|
94
|
Clinical efficacy and management of monoclonal antibodies targeting CD38 and SLAMF7 in multiple myeloma. Blood 2015; 127:681-95. [PMID: 26631114 DOI: 10.1182/blood-2015-10-646810] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 11/26/2015] [Indexed: 01/19/2023] Open
Abstract
Immunotherapeutic strategies are emerging as promising therapeutic approaches in multiple myeloma (MM), with several monoclonal antibodies in advanced stages of clinical development. Of these agents, CD38-targeting antibodies have marked single agent activity in extensively pretreated MM, and preliminary results from studies with relapsed/refractory patients have shown enhanced therapeutic efficacy when daratumumab and isatuximab are combined with other agents. Furthermore, although elotuzumab (anti-SLAMF7) has no single agent activity in advanced MM, randomized trials in relapsed/refractory MM have demonstrated significantly improved progression-free survival when elotuzumab is added to lenalidomide-dexamethasone or bortezomib-dexamethasone. Importantly, there has been no significant additive toxicity when these monoclonal antibodies are combined with other anti-MM agents, other than infusion-related reactions specific to the therapeutic antibody. Prevention and management of infusion reactions is important to avoid drug discontinuation, which may in turn lead to reduced efficacy of anti-MM therapy. Therapeutic antibodies interfere with several laboratory tests. First, interference of therapeutic antibodies with immunofixation and serum protein electrophoresis assays may lead to underestimation of complete response. Strategies to mitigate interference, based on shifting the therapeutic antibody band, are in development. Furthermore, daratumumab, and probably also other CD38-targeting antibodies, interfere with blood compatibility testing and thereby complicate the safe release of blood products. Neutralization of the therapeutic CD38 antibody or CD38 denaturation on reagent red blood cells mitigates daratumumab interference with transfusion laboratory serologic tests. Finally, therapeutic antibodies may complicate flow cytometric evaluation of normal and neoplastic plasma cells, since the therapeutic antibody can affect the availability of the epitope for binding of commercially available diagnostic antibodies.
Collapse
|
95
|
Rawstron AC, Paiva B, Stetler-Stevenson M. Assessment of minimal residual disease in myeloma and the need for a consensus approach. CYTOMETRY PART B-CLINICAL CYTOMETRY 2015. [PMID: 26202864 DOI: 10.1002/cyto.b.21272] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Treatment options for myeloma continue to develop at a rapid pace, and it is becoming increasingly challenging to determine the optimal therapeutic approaches because demonstrating a clear survival benefit now requires many years of follow-up. The detection of minimal residual disease (MRD) is recognized as a sensitive and rapid approach to evaluate treatment efficacy that predicts progression-free and overall survival independent of categorical response assessment and patients' biology. The benefit of MRD analysis is reflected in the many different techniques (multiparameter flow cytometry, quantitative polymerase chain reaction, and high-throughput sequencing) and collaborative groups (including EMN, ESCCA, ICCS, EuroFlow, and EuroMRD) that have performed collaborative projects to harmonize quantitative MRD detection. The time has come to adopt a consensus approach, and this report reviews the benefits and disadvantages of different strategies for MRD detection in myeloma and highlights the requirements for a sensitive, reproducible, and clinically meaningful cellular analytical approach.
Collapse
Affiliation(s)
- Andy C Rawstron
- HMDS, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom; and On Behalf of the European Society for Clinical Cell Analysis (ESCCA)
| | - Bruno Paiva
- Clínica Universidad de Navarra, Pamplona, Spain.,Centro de Investigación Médica Aplicada (CIMA), Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | | |
Collapse
|
96
|
Flores-Montero J, de Tute R, Paiva B, Perez JJ, Böttcher S, Wind H, Sanoja L, Puig N, Lecrevisse Q, Vidriales MB, van Dongen JJM, Orfao A. Immunophenotype of normal vs. myeloma plasma cells: Toward antibody panel specifications for MRD detection in multiple myeloma. CYTOMETRY PART B-CLINICAL CYTOMETRY 2015; 90:61-72. [PMID: 26100534 DOI: 10.1002/cyto.b.21265] [Citation(s) in RCA: 143] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 05/25/2015] [Accepted: 06/17/2015] [Indexed: 01/04/2023]
Abstract
In recent years, several studies on large series of multiple myeloma (MM) patients have demonstrated the clinical utility of flow cytometry monitoring of minimal residual disease (flow-MRD) in bone marrow (BM), for improved assessment of response to therapy and prognostication. However, disturbing levels of variability exist regarding the specific protocols and antibody panels used in individual laboratories. Overall, consensus exists about the utility of combined assessment of CD38 and CD138 for the identification of BM plasma cells (PC); in contrast, more heterogeneous lists of markers are used to further distinguish between normal/reactive PCs and myeloma PCs in the MRD settings. Among the later markers, CD19, CD45, CD27, and CD81, together with CD56, CD117, CD200, and CD307, have emerged as particularly informative; however, no single marker provides enough specificity for clear discrimination between clonal PCs and normal PCs. Accordingly, multivariate analyses of single PCs from large series of normal/reactive vs. myeloma BM samples have shown that combined assessment of CD138 and CD38, together with CD45, CD19, CD56, CD27, CD81, and CD117 would be ideally suited for MRD monitoring in virtually every MM patient. However, the specific antibody clones, fluorochrome conjugates and sources of the individual markers determines its optimal (vs. suboptimal or poor) performance in an eight-color staining. Assessment of clonality, via additional cytoplasmic immunoglobulin (CyIg) κ vs. CyIgλ evaluation, may contribute to further establish the normal/reactive vs. clonal nature of small suspicious PC populations at high sensitivity levels, provided that enough cells are evaluated.
Collapse
Affiliation(s)
- Juan Flores-Montero
- Centro de Investigación del Cáncer (Instituto de Biología Molecular y Celular del Cáncer, CSIC-USAL), Instituto Biosanitario de Salamanca (IBSAL), Servicio de Citometría y Departamento de Medicina-NUCLEUS, Universidad de Salamanca (Salamanca), Spain
| | - Ruth de Tute
- Haematological Malignancy Diagnostic Service, St James Institute of Oncology, Leeds Teaching Hospitals, Leeds, United Kingdom
| | - Bruno Paiva
- Clínica Universidad de Navarra, Centro de Investigaciones Médicas Aplicadas (CIMA), Pamplona, Spain
| | - José Juan Perez
- Department of Hematology, Hospital Universitario de Salamanca, Instituto Biosanitario de Salamanca (IBSAL), Centro de Investigación del Cáncer (Instituto de Biología Molecular y Celular del Cáncer, CSIC-USAL), Salamanca, Spain
| | - Sebastian Böttcher
- Second Department of Medicine, University Hospital of Schleswig Holstein, Campus Kiel (UNIKIEL), Kiel, Germany
| | - Henk Wind
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam (Erasmus MC), Rotterdam, The Netherlands
| | - Luzalba Sanoja
- Centro de Investigación del Cáncer (Instituto de Biología Molecular y Celular del Cáncer, CSIC-USAL), Instituto Biosanitario de Salamanca (IBSAL), Servicio de Citometría y Departamento de Medicina-NUCLEUS, Universidad de Salamanca (Salamanca), Spain
| | - Noemí Puig
- Department of Hematology, Hospital Universitario de Salamanca, Instituto Biosanitario de Salamanca (IBSAL), Centro de Investigación del Cáncer (Instituto de Biología Molecular y Celular del Cáncer, CSIC-USAL), Salamanca, Spain
| | - Quentin Lecrevisse
- Centro de Investigación del Cáncer (Instituto de Biología Molecular y Celular del Cáncer, CSIC-USAL), Instituto Biosanitario de Salamanca (IBSAL), Servicio de Citometría y Departamento de Medicina-NUCLEUS, Universidad de Salamanca (Salamanca), Spain
| | - María Belén Vidriales
- Department of Hematology, Hospital Universitario de Salamanca, Instituto Biosanitario de Salamanca (IBSAL), Centro de Investigación del Cáncer (Instituto de Biología Molecular y Celular del Cáncer, CSIC-USAL), Salamanca, Spain
| | - Jacques J M van Dongen
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam (Erasmus MC), Rotterdam, The Netherlands
| | - Alberto Orfao
- Centro de Investigación del Cáncer (Instituto de Biología Molecular y Celular del Cáncer, CSIC-USAL), Instituto Biosanitario de Salamanca (IBSAL), Servicio de Citometría y Departamento de Medicina-NUCLEUS, Universidad de Salamanca (Salamanca), Spain
| |
Collapse
|
97
|
Cogbill CH, Spears MD, Vantuinen P, Harrington AM, Olteanu H, Kroft SH. Morphologic and cytogenetic variables affect the flow cytometric recovery of plasma cell myeloma cells in bone marrow aspirates. Int J Lab Hematol 2015. [DOI: 10.1111/ijlh.12411] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- C. H. Cogbill
- Department of Pathology; Medical College of Wisconsin; Milwaukee WI USA
| | - M. D. Spears
- Department of Pathology; Medical College of Wisconsin; Milwaukee WI USA
| | - P. Vantuinen
- Department of Pathology; Medical College of Wisconsin; Milwaukee WI USA
| | - A. M. Harrington
- Department of Pathology; Medical College of Wisconsin; Milwaukee WI USA
| | - H. Olteanu
- Department of Pathology; Medical College of Wisconsin; Milwaukee WI USA
| | - S. H. Kroft
- Department of Pathology; Medical College of Wisconsin; Milwaukee WI USA
| |
Collapse
|
98
|
Gormley NJ, Turley DM, Dickey JS, Farrell AT, Reaman GH, Stafford E, Carrington L, Marti GE. Regulatory perspective on minimal residual disease flow cytometry testing in multiple myeloma. CYTOMETRY PART B-CLINICAL CYTOMETRY 2015; 90:73-80. [PMID: 26108351 DOI: 10.1002/cyto.b.21268] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 06/19/2015] [Indexed: 11/06/2022]
Abstract
The FDA has co-sponsored three workshops to address minimal residual disease (MRD) detection in acute lymphocytic leukemia (ALL), chronic lymphocytic leukemia (CLL), and acute myeloid leukemia (AML) as well as an FDA-NCI roundtable symposium on MRD detection and its use as a response biomarker in Multiple Myeloma (MM). As clinical outcomes in MM continue to improve with the introduction of new therapeutics, consideration of biomarkers and their development as validated surrogate endpoints that can be used in the place of traditional clinical trial endpoints of progression-free survival (PFS) will be fundamental to expeditious drug development. This article will describe the FDA drug approval process, the regulatory framework through which a biomarker can be used as a surrogate endpoint for drug approval, and how MRD detection in MM fits within this context. In parallel, this article will also describe the FDA current device clearance process with emphasis on the analytical development as it might apply to an in vitro diagnostic assay for the detection of MRD in MM. It is anticipated that this Special Issue may possibly represent how MRD might serve as a drug development tool in hematological malignancies.
Collapse
Affiliation(s)
- Nicole J Gormley
- Center for Drug Evaluation and Research (CDER) and Center for Devices and Radiologic Health (CDRH), Food and Drug Administration (FDA)
| | - Danielle M Turley
- Center for Drug Evaluation and Research (CDER) and Center for Devices and Radiologic Health (CDRH), Food and Drug Administration (FDA)
| | - Jennifer S Dickey
- Center for Drug Evaluation and Research (CDER) and Center for Devices and Radiologic Health (CDRH), Food and Drug Administration (FDA)
| | - Ann T Farrell
- Center for Drug Evaluation and Research (CDER) and Center for Devices and Radiologic Health (CDRH), Food and Drug Administration (FDA)
| | - Gregory H Reaman
- Center for Drug Evaluation and Research (CDER) and Center for Devices and Radiologic Health (CDRH), Food and Drug Administration (FDA)
| | - Elizabeth Stafford
- Center for Drug Evaluation and Research (CDER) and Center for Devices and Radiologic Health (CDRH), Food and Drug Administration (FDA)
| | - Lea Carrington
- Center for Drug Evaluation and Research (CDER) and Center for Devices and Radiologic Health (CDRH), Food and Drug Administration (FDA)
| | - Gerald E Marti
- Center for Drug Evaluation and Research (CDER) and Center for Devices and Radiologic Health (CDRH), Food and Drug Administration (FDA)
| |
Collapse
|
99
|
Minimal residual disease testing after stem cell transplantation for multiple myeloma. Bone Marrow Transplant 2015; 51:2-12. [DOI: 10.1038/bmt.2015.164] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 05/28/2015] [Accepted: 06/02/2015] [Indexed: 12/21/2022]
|
100
|
Ludwig H, Greil R, Masszi T, Spicka I, Shpilberg O, Hajek R, Dmoszynska A, Paiva B, Vidriales MB, Esteves G, Stoppa AM, Robinson D, Chaturvedi S, Ataman O, Enny C, Feng H, van de Velde H, Viterbo L. Bortezomib, thalidomide and dexamethasone, with or without cyclophosphamide, for patients with previously untreated multiple myeloma: 5-year follow-up. Br J Haematol 2015; 171:344-54. [PMID: 26153365 PMCID: PMC4758383 DOI: 10.1111/bjh.13582] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 06/14/2015] [Indexed: 01/10/2023]
Abstract
This follow-up extension of a randomised phase II study assessed differences in long-term outcomes between bortezomib-thalidomide-dexamethasone (VTD) and VTD-cyclophosphamide (VTDC) induction therapy in multiple myeloma. Newly diagnosed patients (n = 98) were randomised 1:1 to intravenous bortezomib (1·3 mg/m(2); days 1, 4, 8, 11), thalidomide (100 mg; days 1-21), and dexamethasone (40 mg; days 1-4, 9-12), with/without cyclophosphamide (400 mg/m(2); days 1, 8), for four 21-day cycles before stem-cell mobilisation/transplantation. After a median follow-up of 64·8 months, median time-to-next therapy was 51·8 and 47·9 months with VTD and VTDC, respectively. Type of subsequent therapy was similar in both arms. After adjusting for asymmetric censoring, median time to progression was not significantly different between VTD and VTDC [35·7 vs. 34·5 months; Hazard ratio (HR) 1·26, 95% confidence interval: 0·76-2·09; P = 0·370]. Five-year survival was 69·1% and 65·3% with VTD and VTDC, respectively. When analysed by minimal residual disease (MRD) status, overall survival was longer in MRD-negative versus MRD-positive patients with bone marrow-confirmed complete response (HR 3·66, P = 0·0318). VTD induction followed by transplantation provides long-term disease control and, consistent with the primary analysis, there is no additional benefit from adding cyclophosphamide. This study was registered at ClinicalTrials.gov (NCT00531453).
Collapse
Affiliation(s)
- Heinz Ludwig
- c/o First Department of Medicine, Centre for Oncology, Haematology and Palliative Care, Wilhelminen Cancer Research Institute, Wilhelminenspital, Vienna, Austria
| | - Richard Greil
- Landeskrankenhaus, Universitätsklinik für Innere Medizin III, Salzburg, Austria
| | - Tamas Masszi
- Department of Haematology and Stem Cell Transplantation, St István and St László Hospital, Budapest, Hungary
| | - Ivan Spicka
- First Faculty of Medicine, First Medical Department, Clinical Department of Haematology, Charles University in Prague, Prague, Czech Republic
| | - Ofer Shpilberg
- Institute of Haematology, Assuta Medical Centre, Tel-Aviv, Israel
| | - Roman Hajek
- Department of Haemato-oncology, FN Ostrava and Faculty of Medicine, Ostrava, Czech Republic
| | | | - Bruno Paiva
- Centro de Investigación Médica Aplicada (CIMA), Clínica Universidad de Navarra, Pamplona, Spain
| | | | - Graca Esteves
- Hospital de Dia de Hematologia, Hospital de Santa Maria, Lisbon, Portugal
| | | | | | | | - Ozlem Ataman
- Division of Janssen-Cilag Limited, Janssen Research & Development, High Wycombe, UK
| | | | - Huaibao Feng
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - Helgi van de Velde
- Janssen Research & Development, Division of Janssen Pharmaceutica NV, Beerse, Belgium
| | - Luisa Viterbo
- Serviço de Onco-Hematologia, Instituto Português de Oncologia do Porto Francisco Gentil, Entidade Pública Empresarial (IPOPFG, EPE), Porto, Portugal
| |
Collapse
|