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Abstract
Multiple myeloma continues to be an incurable illness. Improvement in our understanding of the disease is leading to new therapeutic modalities and the definition of new targeted therapy. Several pathways have been identified as areas for targeted therapy, and this review will discuss key molecules in some detail. New agents and molecules with biologic modulator activity appear to be changing the natural history of the disease. Agents such as thalidomide or its analogs, arsenic trioxide or bortezomib, hold great promise; however, much is yet to be learned on how to integrate these agents into disease management.
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Affiliation(s)
- Mohamed A Hussein
- Cleveland Clinic, Multidisciplinary Multiple Myeloma Research Program, Cleveland, OH 44195, USA.
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53
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Yaqub S, Ballester G, Ballester O. Frontline therapy for multiple myeloma: a concise review of the evidence based on randomized clinical trials. Cancer Invest 2013; 31:529-37. [PMID: 24083815 DOI: 10.3109/07357907.2013.840382] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The past decade has seen significant progress in the development of new and effective therapies for multiple myeloma. Stem cell transplantation and the introduction of novel agents, such as thalidomide, lenalidomide, and bortezomib, have significantly improved outcomes of myeloma patients. In the current review, we analyzed the available data provided by published randomized clinical trials for the frontline therapy of myeloma patients. We attempted to assess the relative contribution and impact of these new therapies in the setting of both, transplant eligible and transplant ineligible patients.
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Affiliation(s)
- Sobia Yaqub
- 1Division of Medical Oncology, Edwards Comprehensive Cancer Center , Huntington, WV , USA
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Mangan PA, Gleason CL, Miceli T. Autologous hematopoietic stem cell transplantation for multiple myeloma: frequently asked questions. Clin J Oncol Nurs 2013; 17 Suppl:43-7. [PMID: 24280458 DOI: 10.1188/13.cjon.43-47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
When caring for patients with multiple myeloma, questions often arise about the role and timing of autologous hematopoietic stem cell transplantation. As a complement to the other articles in this supplement, as well as to ensure that readers are provided with the insight needed to feel comfortable speaking to patients and other practitioners about this topic, the authors address eight frequently asked questions about common decision points in the process of autologous hematopoietic stem cell transplantation as a treatment for patients with multiple myeloma.
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Sanchorawala V, Hoering A, Seldin DC, Finn KT, Fennessey SA, Sexton R, Mattar B, Safah HF, Holmberg LA, Dean RM, Orlowski RZ, Barlogie B. Modified high-dose melphalan and autologous SCT for AL amyloidosis or high-risk myeloma: analysis of SWOG trial S0115. Bone Marrow Transplant 2013; 48:1537-42. [PMID: 23852321 PMCID: PMC3855173 DOI: 10.1038/bmt.2013.98] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 06/04/2013] [Accepted: 06/12/2013] [Indexed: 12/22/2022]
Abstract
We designed a trial using two sequential cycles of modified high-dose melphalan at 100 mg/m(2) and autologous SCT (mHDM/SCT) in AL amyloidosis (light-chain amyloidosis, AL), AL with myeloma (ALM) and host-based high-risk myeloma (hM) patients through SWOG-0115. The primary objective was to evaluate OS. From 2004 to 2010, 93 eligible patients were enrolled at 17 centers in the United States (59 with AL, 9 with ALM and 25 with hM). The median OS for patients with AL and ALM was 68 months and 47 months, respectively, and has not been reached for patients with hM. The median PFS for patients with AL and ALM was 38 months and 16 months, respectively, and has not been reached for patients with hM. The treatment-related mortality (TRM) was 12% (11/93) and was observed only in patients with AL after SCT. Grade 3 and higher non-hematologic adverse events were experienced by 81%, 67% and 57% of patients with AL, ALM and hM, respectively, during the first and second HDM/SCT. This experience demonstrates that with careful selection of patients and use of mHDM for SCT in patients with AL, ALM and hM, even in the setting of a multicenter study, OS can be improved with acceptable TRM and morbidity.
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Affiliation(s)
| | - A Hoering
- SWOG Statistical Center, Seattle, WA, USA
| | - DC Seldin
- Boston Medical Center, Boston, MA, USA
| | - KT Finn
- Boston Medical Center, Boston, MA, USA
| | | | - R Sexton
- SWOG Statistical Center, Seattle, WA, USA
| | | | - HF Safah
- Tulane University Health Science Center, New Orleans, LA, USA
| | - LA Holmberg
- Puget Sound Oncology Consortium, Seattle, WA, USA
| | - RM Dean
- Cleveland Clinic, Cleveland, OH, USA
| | - RZ Orlowski
- MD Anderson Cancer Center/University of Texas, Houston, TX, USA
| | - B Barlogie
- University of Arkansas, Little Rock, AR, USA
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Ye X, Huang J, Pan Q, Li W. Maintenance therapy with immunomodulatory drugs after autologous stem cell transplantation in patients with multiple myeloma: a meta-analysis of randomized controlled trials. PLoS One 2013; 8:e72635. [PMID: 23977334 PMCID: PMC3747129 DOI: 10.1371/journal.pone.0072635] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 07/11/2013] [Indexed: 12/03/2022] Open
Abstract
Background Although high-dose therapy (HDT) with autologous stem cell transplantation (ASCT) has been confirmed to result in longer remission time than conventional chemotherapy, multiple myeloma (MM) remains incurable. Post-ASCT maintenance is considered as a strategy for obtaining durable remissions and preventing tumor progression. Randomized controlled trials (RCTs) studying maintenance therapy with immunomodulatory drugs (IMiDs) after ASCT have shown some valuable survival improvements. This meta-analysis of RCTs therefore assesses the effect of post-ASCT IMiDs maintenance on MM patients. Methods We performed a meta-analysis to evaluate the impact of IMiDs (thalidomide or lenalidomide) as post-ASCT maintenance therapy on the survival of newly diagnosed MM patients. The outcomes for this meta-analysis were progression-free survival (PFS) and overall survival (OS). Results Eight RCTs enrolling 3514 patients were included for analysis. An obvious improvement in Os (hazard ratio [HR] 0.75) and a significant PFS advantage (HR 0.58) with post-ASCT IMiDs maintenance was revealed. Thalidomide maintenance after ASCT can result in significant benefit in Os (HR 0.72), particularly combined with corticosteroids (HR 0.66). Conclusions MM patients after ASCT have a significant overall survival benefit with IMiDs maintenance. IMiDs maintenance was justified for MM patients who received HDT with ASCT.
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Affiliation(s)
- Xueshi Ye
- Department of Hematology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jinwen Huang
- Department of Hematology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qin Pan
- Department of Oncology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wanli Li
- Department of Orthopedics, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- * E-mail:
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Yang B, Yu RL, Chi XH, Lu XC. Lenalidomide treatment for multiple myeloma: systematic review and meta-analysis of randomized controlled trials. PLoS One 2013; 8:e64354. [PMID: 23691202 PMCID: PMC3653900 DOI: 10.1371/journal.pone.0064354] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 04/11/2013] [Indexed: 01/12/2023] Open
Abstract
Background In recent years, a number of randomized controlled trials (RCTs) have reported on lenalidomide as a treatment for multiple myeloma (MM). Herein, we report results of a meta-analysis of RCTs examining the efficacy and safety of lenalidomide for MM. Patients and Methods Databases were searched using the terms “lenalidomide or revlimid AND multiple myeloma.”RCTs evaluating initial or maintenance therapeutic outcomes were included. Main outcome measures were response rates, progression-free survival (PFS), overall survival, and adverse events. Results Seven trials were included (N = 192–614 participants). Lenalidomide doses and treatment regimens differed between trials. Complete response (CR) and very good partial response (VGPR) risk ratios (RR) favored lenalidomide over placebo (CR = 2.54, 95% confidence interval [CI] = 1.29–5.02; VGPR = 2.82, 95% CI = 1.30–6.09). The PFS hazard ratio favored lenalidomide over placebo (0.37, 95% CI = 0.33–0.41). For adverse events, neutropenia, deep vein thrombosis (DVT), infection, and hematologic cancer RR favored placebo over lenalidomide (neutropenia: 4.74, 95% CI = 2.96–7.57; DVT: 2.52; 95% CI: 1.60–3.98; infection: 1.98; 95% CI: 1.50–2.62; hematologic cancer: 3.20; 95% CI: 1.28–7.98). Conclusions Lenalidomide is an effective treatment for MM; however, treatment-related adverse events must be considered and appropriate adjustments and/or prophylactic treatment should be initiated where possible.
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Affiliation(s)
- Bo Yang
- Department of Geriatric Hematology, Chinese PLA General Hospital, Beijing, China
| | - Rui-li Yu
- Institute of Otorhinolaryngology, Chinese PLA General Hospital, Beijing, China
| | - Xiao-hua Chi
- Department of Pharmacy, the Second Artillery General Hospital, Beijing, China
| | - Xue-chun Lu
- Department of Geriatric Hematology, Chinese PLA General Hospital, Beijing, China
- * E-mail:
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Bortezomib consolidation after autologous stem cell transplantation in multiple myeloma: a Nordic Myeloma Study Group randomized phase 3 trial. Blood 2013; 121:4647-54. [PMID: 23616624 DOI: 10.1182/blood-2012-11-464503] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The Nordic Myeloma Study Group conducted an open randomized trial to compare bortezomib as consolidation therapy given after high-dose therapy and autologous stem cell transplantation (ASCT) with no consolidation in bortezomib-naive patients with newly diagnosed multiple myeloma. Overall, 370 patients were centrally randomly assigned 3 months after ASCT to receive 20 doses of bortezomib given during 21 weeks or no consolidation. The hypothesis was that consolidation therapy would prolong progression-free survival (PFS). The PFS after randomization was 27 months for the bortezomib group compared with 20 months for the control group (P = .05). Fifty-one of 90 patients in the treatment group compared with 32 of 90 controls improved their response after randomization (P = .007). No difference in overall survival was seen. Fatigue was reported more commonly by the bortezomib-treated patients in self-reported quality-of-life (QOL) questionnaires, whereas no other major differences in QOL were recorded between the groups. Consolidation therapy seemed to be beneficial for patients not achieving at least a very good partial response (VGPR) but not for patients in the ≥ VGPR category at randomization. Consolidation with bortezomib after ASCT in bortezomib-naive patients improves PFS without interfering with QOL. This trial was registered at www.clinicaltrials.gov as #NCT00417911.
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Zou Y, Sheng Z, Niu S, Wang H, Yu J, Xu J. Lenalidomide versus thalidomide based regimens as first-line therapy for patients with multiple myeloma. Leuk Lymphoma 2013; 54:2219-25. [PMID: 23394458 DOI: 10.3109/10428194.2013.774393] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Thalidomide (T) and lenalidomide (R) have been used as first-line therapy for previously untreated myeloma. However, direct head-to-head comparison between them is lacking. We performed an indirect meta-analysis to assess the treatment effects of lenalidomide- versus thalidomide-based regimens using common comparators. A comprehensive literature search was undertaken. The initial search yielded 1345 citations, of which 11 randomized controlled trials (RCTs) enrolling 4162 patients met the inclusion criteria. Indirect comparison of lenalidomide versus thalidomide maintenance after autologous stem cell transplant (ASCT) showed a progression-free survival (PFS) benefit (hazard ratio [HR] 0.75, 95% confidence interval [CI] [0.67, 0.85], p < 0.001) but no survival difference (HR 0.83, [0.63, 1.09], p = 0.19) when using observation/placebo as the common comparator. Similarly, the indirect comparison of melphalan-prednisone plus lenalidomide followed by lenalidomide maintenance (MPR-R) versus melphalan-prednisone-thalidomide induction followed by thalidomide maintenance (MPT-T) showed a statistically significant PFS advantage for MPR-R (HR 0.53, 95% CI [0.46, 0.60], p < 0.001), but no difference for overall survival (OS) (HR 0.97, [0.81, 1.17], p = 0.74). Additionally, the significant heterogeneity among pooled studies for the outcome of discontinuation rate due to treatment-related adverse events between MPT-T and MPR-R subgroups (p = 0.007) indicated that the discontinuation rate from thalidomide trials seems to be higher than that from lenalidomide trials. In conclusion, lenalidomide seems to be a more potent and less toxic agent than thalidomide in the treatment of patients with multiple myeloma. Further, a direct head-to-head trial comparing lenalidomide versus thalidomide is clearly warranted.
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Affiliation(s)
- Yandun Zou
- Internal Medicine, GuangDong Women and Children Hospital , GuangZhou , China
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García-Muñoz R, Robles-de-Castro D, Muñoz-Rodríguez A, Rabasa P. Acute lymphoblastic leukemia developing during maintenance therapy with lenalidomide in a patient with multiple myeloma. Leuk Lymphoma 2013; 54:2753-5. [DOI: 10.3109/10428194.2013.786072] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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McCarthy PL, Owzar K, Hahn T. Autologous hematopoietic stem cell transplantation and maintenance therapy for multiple myeloma. Int J Hematol Oncol 2013. [DOI: 10.2217/ijh.13.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Multiple myeloma is highly treatable with novel agents such as proteasome inhibitors (bortezomib) and the immunomodulatory drugs thalidomide and lenalidomide. However, it remains an incurable disease. Induction regimens incorporating novel agents, as well as autologous hematopoietic stem cell transplantation (AHSCT), have deepened response. Following AHSCT, consolidation and maintenance therapy strategies have been developed to improve response, delay progression and improve overall survival (OS). Maintenance therapy should be effective with minimal toxicity and easily administered. The bisphosphonate zoledronate, thalidomide, lenalidomide and bortezomib improve time to progression and OS when used for maintenance therapy after AHSCT, although it is uncertain whether this improvement in OS can be attributed to the maintenance phase in the case of zoledronate. It is also important to note that few data are available regarding the exact role of bortezomib in the maintenance phase. New therapies alone or in combination with existing agents may lead to further improvement of multiple myeloma disease control after AHSCT for transplant-eligible patients.
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Affiliation(s)
- Philip L McCarthy
- Blood & Marrow Transplant Program, Roswell Park Cancer Institute Buffalo, NY 14263, USA.
| | - Kouros Owzar
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, USA
| | - Theresa Hahn
- Blood & Marrow Transplant Program, Roswell Park Cancer Institute Buffalo, NY 14263, USA
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Abstract
PURPOSE OF REVIEW Nearly all patients with multiple myeloma will eventually relapse; and, thus, it is critical to identify new treatments that increase therapeutic options for these patients. This review highlights the newest approaches with already approved drugs for treating this common B-cell malignancy. RECENT FINDINGS Most patients with multiple myeloma in both the frontline and relapsed/refractory settings are now treated with a combination of dexamethasone with the proteasome inhibitor bortezomib and/or an immunomodulatory agent thalidomide or lenalidomide. However, alkylating agents including melphalan, cyclophosphamide and most recently bendamustine as well as anthracyclines, especially the pegylated liposomal doxorubicin, have shown high response rates and prolonged remissions when combined with these agents. There are emerging data showing the importance of maintenance therapy especially with lenalidomide. Because of the marked improvement in survival of multiple myeloma during the past decade, there has been a renewed emphasis on developing therapies that are not only effective but also well tolerated. Alternative dosing, scheduling and routes of administration of already approved drugs have proven effective in accomplishing these goals. SUMMARY The availability of drugs with different mechanisms that produce anti-multiple myeloma effects and also show synergistic effects has paved the way for more effective and safer combinations and led to multiple myeloma patients living longer with improved quality of lives.
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Hari PN, McCarthy PL. Multiple Myeloma: Future Directions in Autologous Transplantation and Novel Agents. Biol Blood Marrow Transplant 2013; 19:S20-5. [DOI: 10.1016/j.bbmt.2012.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Update on the role of autologous hematopoietic stem cell transplantation in multiple myeloma. Mediterr J Hematol Infect Dis 2012. [PMID: 23205257 PMCID: PMC3507530 DOI: 10.4084/mjhid.2012.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Autologous stem cell transplantation is considered the standard of care for multiple myeloma patients aged < 65 years with no relevant comorbidities. The addition of drugs acting both on bone marrow microenvironment and on neoplastic plasma cells has significantly increased the proportion of patients achieving a complete remission after induction therapy, and these results are mantained after high-dose melphalan, leading to a prolonged disease control. Studies are being carried out in order to evaluate whether short term consolidation or long-term maintenance therapy can result into disease eradication at the molecular level thus increasing also patients survival. The efficacy of these new drugs has raised the issue of deferring the transplant after achiving a second response upon relapse. Another controversial point is the optimal treatment strategy for high-risk patients, that do not benefit from autologous stem cell transplantation and for whom the efficacy of new drugs is still matter of debate.
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67
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Moreau P, Giralt SA. Optimizing therapy for transplant-eligible patients with newly diagnosed multiple myeloma. Leuk Res 2012. [DOI: 10.1016/s0145-2126(12)70004-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Petrucci MT, Levi A, Bringhen S, Scotti S, Gentilini F, Russo S, Siniscalchi A, Larocca A, Grammatico S, Boccadoro M, Foà R, Palumbo A. Bortezomib, melphalan, and prednisone in elderly patients with relapsed/refractory multiple myeloma. Cancer 2012; 119:971-7. [DOI: 10.1002/cncr.27820] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 08/09/2012] [Accepted: 08/13/2012] [Indexed: 11/09/2022]
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Cherry BM, Korde N, Kwok M, Roschewski M, Landgren O. Evolving therapeutic paradigms for multiple myeloma: back to the future. Leuk Lymphoma 2012; 54:451-63. [PMID: 22880935 DOI: 10.3109/10428194.2012.717277] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Multiple myeloma (MM) is an ancient disease, but until the alkylating agent melphalan was found to have anti-myeloma properties in the 1950s there was virtually no effective therapy. By the late 1960s, extended dosing with melphalan and prednisone tripled survival from diagnosis and became the standard of care for newly diagnosed MM. "Maintenance therapy" to prolong survival through sustained disease control following induction chemotherapy was sought by 1970, but early strategies were ineffective and toxic. Subsequent applications of high-dose therapy (HDT)/autologous stem cell transplant (ASCT) changed the treatment paradigm for MM from extended dosing to an intensive strategy designed to eradicate the malignant cells in a single course of treatment. Although HDT-ASCT resulted in prolonged duration of remission and improved survival, the vast majority of patients still relapsed. Interferon (IFN) and glucocorticoid maintenance therapies demonstrated marginal improvements in outcomes but significant adverse effects. Novel agents introduced over the last decade have prolonged survival when given for maintenance following HDT-ASCT, but have also challenged the HDT-ASCT paradigm by achieving comparable remission rates when used alone as extended frontline therapy. This article reviews the evolution of therapeutic strategies for MM and discusses future questions facing MM investigators.
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Affiliation(s)
- Benjamin M Cherry
- Multiple Myeloma Section, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
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Secondary primary malignancies in multiple myeloma: an old NEMESIS revisited. Adv Hematol 2012; 2012:801495. [PMID: 22851973 PMCID: PMC3407607 DOI: 10.1155/2012/801495] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 05/25/2012] [Accepted: 06/03/2012] [Indexed: 12/22/2022] Open
Abstract
The treatment of myeloma has undergone extraordinary improvements in the past half century. These advances have been accompanied by a concern for secondary primary malignancies (SPMs). It has been known for decades that extended therapy with alkylating chemotherapy agents, such as melphalan, carries an increased risk of therapy-related myelodysplastic syndrome and/or acute myeloid leukemia (t-MDS/AML), with a cumulative risk as high as 10–15%. High-dose chemotherapy with autologous stem cell support became widely accepted for myeloma in the 1990s. Despite the use of high doses of melphalan, the risk of t-MDS/AML with this procedure is estimated to be less than 5%, with much of this risk attributable to pretransplant therapy. Recently, lenalidomide has come under scrutiny for its possible association with SPMs. It is too soon to declare a causal relationship at this time, but there appears to be an increased number of SPMs in reports from several studies using lenalidomide maintenance. Current studies should be amended and future studies planned to better define the risk of SPMs and the risk factors and mechanisms for its development. Patients should be educated regarding this potential concern but the current use of lenalidomide should not generally be altered until further data are available.
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Abidi MH, Gul Z, Abrams J, Ayash L, Deol A, Ventimiglia M, Lum L, Mellon-Reppen S, Al-Kadhimi Z, Ratanatharathorn V, Zonder J, Uberti J. Phase I trial of bortezomib during maintenance phase after high dose melphalan and autologous stem cell transplantation in patients with multiple myeloma. J Chemother 2012; 24:167-72. [PMID: 22759762 PMCID: PMC3815645 DOI: 10.1179/1973947812y.0000000004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
We enrolled 15 patients in this phase I dose de-escalation trial. Twelve patients are evaluable. The primary objective was to determine the safest and best tolerated maintenance dosing (MD) of bortezomib (B). The secondary endpoints were to evaluate complete response (CR), overall response (OR) and response duration. All patients receiving autologous stem cell transplant (ASCT) were eligible and registered between D+30 to D+120 after ASCT. A maximum number of 8 cycles of B was planned. Two evaluable patients in level (L) 1 received therapeutic dose of B 1.3 mg/m(2) intravenously on days (D) 1, 4, 8, and 11 in a 21 day cycle. Both these patients experienced dose limiting toxicities (DLTs). Four evaluable patients were then enrolled in dose L2 utilizing B 1.3 mg/m(2) on D 1, 4, 8, and 11 in a 28 day cycle. Two patients in L2 developed DLTs. Six evaluable patients were thereafter enrolled in L3 utilizing B 1 mg/m(2) on D 1, 8, and 15 in a 28 day cycle. Median 8 cycles of B were administered (2-8). No DLTs were observed in L3. The median duration of follow up for the entire cohort is 33 months (12-62). The median duration of response in L3 is 29.1 months (12-33). We conclude that B 1 mg/m(2) administered intravenously and may be subcutaneously on D 1, 8, and 15 in a 28 day cycle is the best tolerated MD and can be safely given beginning around D+100 post-ASCT.
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Affiliation(s)
- Muneer H Abidi
- Department of Bone Marrow Transplantation, Karmanos Cancer Institute, Wayne State University, Detroit, MI 48201, USA.
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McCarthy PL, Owzar K, Hofmeister CC, Hurd DD, Hassoun H, Richardson PG, Giralt S, Stadtmauer EA, Weisdorf DJ, Vij R, Moreb JS, Callander NS, Van Besien K, Gentile T, Isola L, Maziarz RT, Gabriel DA, Bashey A, Landau H, Martin T, Qazilbash MH, Levitan D, McClune B, Schlossman R, Hars V, Postiglione J, Jiang C, Bennett E, Barry S, Bressler L, Kelly M, Seiler M, Rosenbaum C, Hari P, Pasquini MC, Horowitz MM, Shea TC, Devine SM, Anderson KC, Linker C. Lenalidomide after stem-cell transplantation for multiple myeloma. N Engl J Med 2012; 366:1770-81. [PMID: 22571201 PMCID: PMC3744390 DOI: 10.1056/nejmoa1114083] [Citation(s) in RCA: 859] [Impact Index Per Article: 71.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Data are lacking on whether lenalidomide maintenance therapy prolongs the time to disease progression after autologous hematopoietic stem-cell transplantation in patients with multiple myeloma. METHODS Between April 2005 and July 2009, we randomly assigned 460 patients who were younger than 71 years of age and had stable disease or a marginal, partial, or complete response 100 days after undergoing stem-cell transplantation to lenalidomide or placebo, which was administered until disease progression. The starting dose of lenalidomide was 10 mg per day (range, 5 to 15). RESULTS The study-drug assignments were unblinded in 2009, when a planned interim analysis showed a significantly longer time to disease progression in the lenalidomide group. At unblinding, 20% of patients who received lenalidomide and 44% of patients who received placebo had progressive disease or had died (P<0.001); of the remaining 128 patients who received placebo and who did not have progressive disease, 86 crossed over to lenalidomide. At a median follow-up of 34 months, 86 of 231 patients who received lenalidomide (37%) and 132 of 229 patients who received placebo (58%) had disease progression or had died. The median time to progression was 46 months in the lenalidomide group and 27 months in the placebo group (P<0.001). A total of 35 patients who received lenalidomide (15%) and 53 patients who received placebo (23%) died (P=0.03). More grade 3 or 4 hematologic adverse events and grade 3 nonhematologic adverse events occurred in patients who received lenalidomide (P<0.001 for both comparisons). Second primary cancers occurred in 18 patients who received lenalidomide (8%) and 6 patients who received placebo (3%). CONCLUSIONS Lenalidomide maintenance therapy, initiated at day 100 after hematopoietic stem-cell transplantation, was associated with more toxicity and second cancers but a significantly longer time to disease progression and significantly improved overall survival among patients with myeloma. (Funded by the National Cancer Institute; ClinicalTrials.gov number, NCT00114101.).
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Affiliation(s)
- Philip L McCarthy
- Blood and Marrow Transplant Program, Roswell Park Cancer Institute, Buffalo, NY 14263, USA.
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Thalidomide maintenance therapy for patients with multiple myeloma: meta-analysis. Leuk Res 2012; 36:1016-21. [PMID: 22579366 DOI: 10.1016/j.leukres.2012.04.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 03/19/2012] [Accepted: 04/01/2012] [Indexed: 11/22/2022]
Abstract
We performed a meta-analysis of randomized controlled trials comparing thalidomide maintenance with other regimens after induction chemotherapy for multiple myeloma. Overall, 6 trials including 2786 patients were identified. Patients treated with thalidomide maintenance had marginally better overall survival (hazard ratio HR 0.83, P=0.07). The improvement was especially prominent in a subgroup of studies using corticosteroids with thalidomide (HR 0.70, P=0.02). Thalidomide improved progression-free survival (HR 0.65, P<0.01), but had more frequent venous thrombosis (risk difference 0.024, P<0.05) and peripheral neuropathy (risk difference 0.072, P<0.01). These results suggest that thalidomide maintenance with corticosteroids is effective in prolonging survival for multiple myeloma.
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74
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Ludwig H, Durie BGM, McCarthy P, Palumbo A, San Miguel J, Barlogie B, Morgan G, Sonneveld P, Spencer A, Andersen KC, Facon T, Stewart KA, Einsele H, Mateos MV, Wijermans P, Waage A, Beksac M, Richardson PG, Hulin C, Niesvizky R, Lokhorst H, Landgren O, Bergsagel PL, Orlowski R, Hinke A, Cavo M, Attal M. IMWG consensus on maintenance therapy in multiple myeloma. Blood 2012; 119:3003-15. [PMID: 22271445 PMCID: PMC3321864 DOI: 10.1182/blood-2011-11-374249] [Citation(s) in RCA: 138] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 01/06/2012] [Indexed: 12/23/2022] Open
Abstract
Maintaining results of successful induction therapy is an important goal in multiple myeloma. Here, members of the International Myeloma Working Group review the relevant data. Thalidomide maintenance therapy after autologous stem cell transplantation improved the quality of response and increased progression-free survival (PFS) significantly in all 6 studies and overall survival (OS) in 3 of them. In elderly patients, 2 trials showed a significant prolongation of PFS, but no improvement in OS. A meta-analysis revealed a significant risk reduction for PFS/event-free survival and death. The role of thalidomide maintenance after melphalan, prednisone, and thalidomide is not well established. Two trials with lenalidomide maintenance treatment after autologous stem cell transplantation and one study after conventional melphalan, prednisone, and lenalidomide induction therapy showed a significant risk reduction for PFS and an increase in OS in one of the transplant trials. Maintenance therapy with single-agent bortezomib or in combination with thalidomide or prednisone has been studied. One trial revealed a significantly increased OS with a bortezomib-based induction and bortezomib maintenance therapy compared with conventional induction and thalidomide maintenance treatment. Maintenance treatment can be associated with significant side effects, and none of the drugs evaluated is approved for maintenance therapy. Treatment decisions for individual patients must balance potential benefits and risks carefully, as a widely agreed-on standard is not established.
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Affiliation(s)
- Heinz Ludwig
- Department of Medicine I, Center for Oncology and Hematology, Wilhelminenspital, Vienna, Austria.
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75
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Attal M, Roussel M. Maintenance therapy for myeloma: how much, how long, and at what cost? Am Soc Clin Oncol Educ Book 2012:515-522. [PMID: 24451789 DOI: 10.14694/edbook_am.2012.32.21] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Maintenance therapy in multiple myeloma has been under investigation for more than 3 decades and has been without evidence of clear advantage in terms of progression-free survival (PFS) until the mid-2000s. Neither conventional chemotherapy, prednisone, nor interferon-based maintenance regimens offered any benefit after conventional or high-dose therapy. Thalidomide was the first drug, mainly given as maintenance after high dose therapy, to demonstrate clinical benefits in terms of PFS and, in some studies, of overall survival (OS). The role of other novel agents such as lenalidomide and bortezomib as maintenance therapy is emerging. Lenalidomide has been shown to reduce the risk of relapse with longer follow-up needed to see if this will translate into a survival benefit. At present, a number of key questions remain unanswered. What are the optimal dose and duration of those treatments? Is the risk of toxicity and second primary malignancies acceptable? Will the disease be more aggressive at time of relapse? Is the clinical benefit predicted by initial prognostic factors and response to previous therapy? Does maintenance therapy work by further eradication of minimal residual disease or by immunological control of the malignant clone? Ongoing randomized trials are evaluating lenalidomide and bortezomib, both in the transplant and nontransplant settings, to better define the role of these drugs as maintenance in multiple myeloma.
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Affiliation(s)
- Michel Attal
- From the Hematology Department, CHU Purpan, Toulouse, France
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76
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Manier S, Boyle E, Gauthier J, Bories C, Facon T, Leleu X. Renouveau des traitements d’entretien dans le myélome multiple : place des immunomodulateurs (IMiDs). ONCOLOGIE 2011. [DOI: 10.1007/s10269-011-2063-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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77
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Palumbo A, Attal M, Roussel M. Shifts in the therapeutic paradigm for patients newly diagnosed with multiple myeloma: maintenance therapy and overall survival. Clin Cancer Res 2011; 17:1253-63. [PMID: 21411441 DOI: 10.1158/1078-0432.ccr-10-1925] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
High-dose therapy (HDT) with autologous stem cell transplantation (ASCT) is the standard of care for eligible newly diagnosed multiple myeloma (MM) patients. Several randomized studies showed a survival advantage for patients undergoing transplantation, compared with conventional chemotherapy. Introduction of new drugs in this setting has markedly increased survival rates within the last 10 years. Efforts to further improve response rates and survival in those patients are still needed, mainly by increasing the depth of tumor reduction and the duration of response through more effective induction, consolidation, and maintenance therapies. Nevertheless, this approach is currently challenged by the promising results of long-term treatment with novel agents. Recent data suggest that the upfront combination of a proteasome inhibitor plus 1 immunomodulatory compound (IMiD) is highly effective. The combination of bortezomib, thalidomide, and dexamethasone (VTD) has proven to be highly effective as a frontline treatment and is significantly superior to vincristine, doxorubicin, and dexamethasone (VAD) or thalidomide and dexamethasone (Thal-Dex) before and after ASCT with a very manageable toxicity pattern. The most promising 3-drug association might be bortezomib, lenalidomide, and dexamethasone (VRD). Adjunction of a 4th drug has not proven to be more efficient. In patients not eligible for ASCT, the introduction of novel agents has changed the management of multiple myeloma. The combinations of melphalan, prednisone, and thalidomide and of bortezomib, melphalan, and prednisone have shown improved progression-free survival and overall survival in comparison with melphalan and prednisone alone. Melphalan, prednisone, and thalidomide and bortezomib, melphalan, and prednisone are now the new standards of care for elderly patients. Preliminary results also support the role of the combination of melphalan, prednisone, and lenalidomide followed by maintenance therapy with lenalidomide in the treatment of elderly patients. Physicians now have a wider variety of treatment options to tailor the most appropriate and efficacious treatment according to their patients' characteristics.
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Affiliation(s)
- Antonio Palumbo
- Myeloma Unit, Division of Hematology, University of Turin, Turin, Italy.
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78
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Bird JM, Owen RG, D'Sa S, Snowden JA, Pratt G, Ashcroft J, Yong K, Cook G, Feyler S, Davies F, Morgan G, Cavenagh J, Low E, Behrens J. Guidelines for the diagnosis and management of multiple myeloma 2011. Br J Haematol 2011; 154:32-75. [PMID: 21569004 DOI: 10.1111/j.1365-2141.2011.08573.x] [Citation(s) in RCA: 205] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Jennifer M Bird
- Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.
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79
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Chou T, Tobinai K, Uike N, Asakawa T, Saito I, Fukuda H, Mizoroki F, Ando K, Iida S, Ueda R, Tsukasaki K, Hotta T. Melphalan-prednisolone and vincristine-doxorubicin-dexamethasone chemotherapy followed by prednisolone/interferon maintenance therapy for multiple myeloma: Japan Clinical Oncology Group Study, JCOG0112. Jpn J Clin Oncol 2011; 41:586-9. [PMID: 21247967 DOI: 10.1093/jjco/hyq245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A multicenter phase III study for untreated multiple myeloma was conducted to investigate a switch-induction chemotherapy with melphalan-prednisolone and vincristine-doxorubicin-dexamethasone followed by randomization on maintenance therapy for patients achieving plateau. Between November 2002 and November 2005, 34 patients were registered. The study was closed early because of poor accrual. Thirty-three eligible patients, with a median age of 65 years (range: 47-77 years) were analyzed for the secondary purpose. For induction therapy, 16 patients were treated with vincristine-doxorubicin-dexamethasone and 17 with melphalan-prednisolone initially. In eight cases, induction therapy was switched because of a poor response. Both regimens were well tolerated, but neutropenia, anorexia, constipation and infection with neutropenia were more frequent for vincristine-doxorubicin-dexamethasone. Best response rates were 44% (95% confidence interval, 20-70) and 47% (95% confidence interval, 23-72), respectively, for vincristine-doxorubicin-dexamethasone and melphalan-prednisolone. Vincristine-doxorubicin-dexamethasone/melphalan-prednisolone switch-induction therapy might be feasible and effective for Japanese patients with multiple myeloma.
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80
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Roussel M, Facon T, Moreau P, Harousseau JL, Attal M. Firstline treatment and maintenance in newly diagnosed multiple myeloma patients. Recent Results Cancer Res 2011; 183:189-206. [PMID: 21509686 DOI: 10.1007/978-3-540-85772-3_9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
High dose therapy (HDT) with autologous stem cell transplantation (ASCT) is the standard of care for eligible newly diagnosed MM patients. Several randomized studies demonstrated a survival advantage for patients undergoing transplantation, compared with conventional chemotherapy. Introduction of new drugs in this setting have markedly increased survival rates within the last 10 years. Efforts to further improve response rates and survival in those patients are still needed, mainly by increasing the depth of tumor reduction and the duration of response through more effective induction, consolidation and maintenance therapies. Nevertheless, this approach is currently challenged by the promising results of long-term treatment with novel agents. Recent data suggest that the upfront combination of a proteasome inhibitor plus one immunomodulatory drug (IMiD) is highly effective. The most promising 3-drug association might be Bortezomib, Lenalidomide and dexamethasone (VRD). Adjunction of a 4th drug is not proven to be more efficient. Consolidation and maintenance therapies are emerging in all trials with great results. For elderly patients, or not eligible for ASCT, the introduction of novel agents has also changed the management of the disease. Melphalan-prednisone-thalidomide and bortezomib-melphalan-prednisone are the two standards of care. Current trials are challenging the role of alkylators in the frontline setting. Maintenance therapy is also undergoing evaluation.
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81
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Benevolo G, Larocca A, Gentile M, Pregno P, Gay F, Botto B, Frairia C, Evangelista A, Morabito F, Boccadoro M, Vitolo U, Palumbo A. The efficacy and safety of bortezomib and dexamethasone as a maintenance therapy in patients with advanced multiple myeloma who are responsive to salvage bortezomib-containing regimens. Cancer 2010; 117:1884-90. [PMID: 21509765 DOI: 10.1002/cncr.25743] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Revised: 09/24/2010] [Accepted: 09/28/2010] [Indexed: 11/06/2022]
Abstract
BACKGROUND Although treatment for multiple myeloma (MM) has considerably improved in the past decade, MM continues to be an incurable hematological malignancy that causes most patients to eventually relapse and die from their illness. Thus, the identification of effective salvage strategies remains a priority. METHODS In this trial, the authors evaluated the safety and efficacy of bortezomib and dexamethasone [V: on days 1 and 15 (1.3 mg/mq); D: on days 1-2 and 15-16, every 28-day cycle until progression (20 mg/d)] as maintenance therapy (MT) in patients with advanced MM who responded to salvage therapy that used a bortezomib-containing regimen. RESULTS Forty-nine MM patients were enrolled in this study between October of 2004 and April of 2008. All patients who were included in this study were responsive to a prior salvage therapy with bortezomib and had a measurable disease. The bortezomib and dexamethasone MT improved the quality of responses to complete remission in 4 patients and very good partial response in 3 patients. In addition, 10 patients experienced at least a 50% improvement in their symptoms. The median time to progression (TTP) was 16 months with a progression-free survival of 61% after 1 year. The overall response after 1 year was 76%, and the cumulative incidence of death due to disease progression, which was adjusted for competitive risk events, was 14%. Non-dose-limiting toxicities included neuropathy (predominantly grade 1), herpes zoster reactivation, pneumonia, and gastrointestinal affections (constipation and diarrhea). Three patients developed grade 2 neuropathy, which required a bortezomib dose reduction to 1.0 mg/mq. No grade 3 or 4 toxicities were recorded. CONCLUSIONS The use of bortezomib and dexamethasone as MT in advanced MM was effective and well tolerated. The twice-monthly bortezomib infusion appeared to reduce the incidence of grade 3 and 4 neuropathies in comparison to similar experiences in other settings.
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82
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Cunningham S, Ranganathan A, Cheson B, Cortés JE, Jagannath S. The annual meeting of the American Society of Clinical Oncology. June 4-8, 2010; Chicago, IL. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2010; 10:323-330. [PMID: 21030344 DOI: 10.3816/clml.2010.n.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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83
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Morabito F, Gentile M, Mazzone C, Bringhen S, Vigna E, Lucia E, Recchia AG, Raimondo FD, Musto P, Palumbo A. Therapeutic approaches for newly diagnosed multiple myeloma patients in the era of novel drugs. Eur J Haematol 2010; 85:181-91. [PMID: 20491882 DOI: 10.1111/j.1600-0609.2010.01472.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Fortunato Morabito
- Divisione di Ematologia, Azienda Ospedaliera di Cosenza, Cosenza, Italy.
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84
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Engelhardt M, Kleber M, Udi J, Wäsch R, Spencer A, Patriarca F, Knop S, Bruno B, Gramatzki M, Morabito F, Kropff M, Neri A, Sezer O, Hajek R, Bunjes D, Boccadoro M, Straka C, Cavo M, Polliack A, Einsele H, Palumbo A. Consensus statement from European experts on the diagnosis, management, and treatment of multiple myeloma: from standard therapy to novel approaches. Leuk Lymphoma 2010; 51:1424-43. [DOI: 10.3109/10428194.2010.487959] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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85
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Total Therapy 3 for multiple myeloma: prognostic implications of cumulative dosing and premature discontinuation of VTD maintenance components, bortezomib, thalidomide, and dexamethasone, relevant to all phases of therapy. Blood 2010; 116:1220-7. [PMID: 20501894 DOI: 10.1182/blood-2010-01-264333] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The impact of cumulative dosing and premature drug discontinuation (PMDD) of bortezomib (V), thalidomide (T), and dexamethasone (D) on overall survival (OS), event-free survival (EFS), time to next therapy, and post-relapse survival in Total Therapy 3 were examined, using time-dependent methodology, relevant to induction, peritransplantation, consolidation, and maintenance phases. Univariately, OS and EFS were longer in case higher doses were used of all agents during induction, consolidation (except T), and maintenance (except V and T). The favorable OS and EFS impact of D induction dosing provided the rationale for examining the expression of glucocorticoid receptor NR3C1, top-tertile levels of which significantly prolonged OS and EFS and rendered outcomes independent of D and T dosing, whereas T and D, but not V, dosing was critical to outcome improvement in the bottom-tertile NR3C1 setting. PMDD of V was an independent highly adverse feature for OS (hazard ratio = 6.44; P < .001), whereas PMDD of both T and D independently imparted shorter time to next therapy. The absence of adverse effects on postrelapse survival of dosing of any VTD components and indeed a benefit from V supports the use up-front of all active agents in a dose-dense and dose-intense fashion, as practiced in Total Therapy 3, toward maximizing myeloma survival.
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86
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Ludwig H, Adam Z, Tóthová E, Hajek R, Labar B, Egyed M, Spicka I, Gisslinger H, Drach J, Kuhn I, Hinke A, Zojer N. Thalidomide maintenance treatment increases progression-free but not overall survival in elderly patients with myeloma. Haematologica 2010; 95:1548-54. [PMID: 20418244 DOI: 10.3324/haematol.2009.020586] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Thalidomide maintenance therapy after stem cell transplantation resulted in increased progression-free survival and overall survival in a few trials, but its role in non-transplant eligible patients with multiple myeloma remains unclear. This study assessed the impact of thalidomide-interferon in comparison to interferon maintenance therapy in elderly patients with multiple myeloma. DESIGN AND METHODS Of 289 elderly patients with multiple myeloma who were randomized to thalidomide-dexamethasone or melphalan-prednisolone induction therapy, 137 finally completed 9 cycles of induction therapy with stable disease or better and thereby qualified for maintenance treatment. Of these, 128 have been randomized to either thalidomide-interferon or interferon alone. Primary study endpoints were progression-free survival and response rates; secondary endpoints were overall survival, toxicity and quality of life. RESULTS Thalidomide-interferon maintenance therapy led to a significantly longer progression-free survival compared to interferon (27.7 vs. 13.2 months, P=0.0068), but overall survival was similar in both groups (52.6 vs. 51.4 months, P=0.81) and did not differ between patients aged 75 years or older, or younger patients (P=0.39). Survival after disease progression tended to be shorter in patients on thalidomide-interferon maintenance therapy (P=0.056). Progression-free survival and overall survival tended to be shorter in patients with adverse cytogenetic (FISH) findings compared to the standard risk group but differences were not significant (P=0.084 and P=0.082, respectively). Patients on thalidomide-interferon presented with more neuropathy (P=0.0015), constipation (P=0.0004), skin toxicity (P=0.0041) and elevated creatinine (P=0.026). CONCLUSIONS Thalidomide plus interferon maintenance therapy increased progression-free survival but not overall survival and was associated with slightly more toxicity than maintenance with interferon alone. (ClinicalTrials.gov Identifier: NCT00205751).
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Affiliation(s)
- Heinz Ludwig
- Department of Medicine I, Center for Oncology and Hematology, Wilhelminenspital, Vienna, Austria.
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87
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The evolution and impact of therapy in multiple myeloma. Med Oncol 2010; 27 Suppl 1:S1-6. [PMID: 20169425 DOI: 10.1007/s12032-010-9442-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 01/28/2010] [Indexed: 01/22/2023]
Abstract
Multiple myeloma is a clonal B-cell malignancy characterized by aberrant expression of plasma cells within the bone marrow, and is associated with the well known clinical manifestations anemia, bone disease, renal dysfunction, hypercalcemia, and recurrent infections. For many years, melphalan and prednisone represented the standard of care in multiple myeloma therapy, with stem cell transplantation reserved for selected patients. Treatment of the disease has evolved rapidly over the past decade, however, with the development and utilization of thalidomide, lenalidomide, and bortezomib. As a result of these developments, clinical outcomes have improved significantly. This review highlights important historic landmarks as well as more recent events that have played an important role in the evolution of myeloma therapy.
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88
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Cunningham S, Muneer S, Ranganathan A, Shrader M, Berenson JR, Cheson B, Cortés JE. The 51st Annual Meeting of the American Society of Hematology. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2010; 10:11-20. [DOI: 10.3816/clml.2010.n.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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89
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Jagannath S, Kyle RA, Palumbo A, Siegel DS, Cunningham S, Berenson J. The Current Status and Future of Multiple Myeloma in the Clinic. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2010; 10:28-43. [DOI: 10.3816/clml.2010.n.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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90
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Jagannath S, Kyle RA, Palumbo A, Siegel DS, Cunningham S, Berenson J. The Current Status and Future of Multiple Myeloma in the Clinic. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2009. [DOI: 10.3816/clm.2010.n.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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91
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92
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Abstract
The adverse prognostic impact of advanced age in multiple myeloma is multi-factorial. In this review we explore the various contributory factors to this phenomenon. These include general biological and psychosocial factors, which impact on cancer in the elderly population such as the presence of multiple co morbidities and poor performance status at diagnosis and variation in patient's expectations of treatment. Factors specific to myeloma include the ability to deliver optimum therapy in older patients and the impact of this on disease response, possible biological differences of myeloma in older patients, and how these various factors impact on the efficacy of conventional-dose, high-dose (HDT) and newer disease modifying therapies. Selected elderly patients can gain equal benefit to younger patients from effective therapies such as HDT. However, the use of specific assessment tools for the elderly, apart from chronological age, should be used to select elderly patients who will benefit. Future testing of newer therapies in patients with myeloma must include older patients, who will make up an increasing proportion of the myeloma population in the future and should incorporate assessment of effect of these therapies on quality of life.
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Affiliation(s)
- Linda Mileshkin
- Division of Haematology and Medical Oncology, Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett St, Victoria 8006, Australia.
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93
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Facon T, San Miguel J, Mateos MV, Hulin C. Frontline treatment in elderly patients with multiple myeloma. Semin Hematol 2009; 46:133-42. [PMID: 19389497 DOI: 10.1053/j.seminhematol.2009.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Melphalan-prednisone-thalidomide (MPT) and melphalan-prednisone-bortezomib (MPV) currently appear to be the treatments of choice for a large proportion of elderly multiple myeloma (MM) patients ineligible for autologous stem cell transplantation (ASCT). It seems certain that in the near future cyclophosphamide-thalidomide-dexamethasone, with an attenuated dose of dexamethasone (CTDa), and melphalan-prednisone-lenalidomide (MPR) will also be proved superior to MP, thus providing four therapeutic options in this patient group. These options could lead to more personalized treatment approaches, based on patient comorbidities, as the three novel agents have somewhat different toxicity profiles. MP would be appropriate for only a minority of patients with poor performance status and/or significant comorbidities. Questions regarding the relative efficacy of different melphalan-based regimens or melphalan-based regimens versus dexamethasone-based regimens with low-dose dexamethasone will require further trials. Additionally, the important issue of maintenance treatment needs to be investigated. These new and emerging therapies provide multiple effective treatment options for MM patients and greatly enhanced treatment strategies for clinicians, all offering promise that has been sorely lacking over the past four decades.
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Affiliation(s)
- Thierry Facon
- Service des Maladies du Sang, Centre Hospitalier Universitaire (CHU), Lille, France.
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94
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Gertz MA. Relevant prognostic features of multiple myeloma and the new International Staging System. Leuk Lymphoma 2009; 48:458-68. [PMID: 17454585 DOI: 10.1080/10428190601059753] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The new International Staging System should be reported in all future studies of multiple myeloma. However, the system fails to account for recent research findings pertaining to mechanisms of disease progression. This review describes development of the International Staging System and details prognostic factors that may further our understanding of the biology of multiple myeloma.
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Affiliation(s)
- Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA.
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95
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Reece DE, Leitch HA, Atkins H, Voralia M, Canning LA, LeBlanc R, Belch AR, White D, Kovacs MJ. Treatment of relapsed and refractory myeloma. Leuk Lymphoma 2009; 49:1470-85. [DOI: 10.1080/10428190802064941] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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96
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Spencer A, Prince HM, Roberts AW, Prosser IW, Bradstock KF, Coyle L, Gill DS, Horvath N, Reynolds J, Kennedy N. Consolidation Therapy With Low-Dose Thalidomide and Prednisolone Prolongs the Survival of Multiple Myeloma Patients Undergoing a Single Autologous Stem-Cell Transplantation Procedure. J Clin Oncol 2009; 27:1788-93. [PMID: 19273705 DOI: 10.1200/jco.2008.18.8573] [Citation(s) in RCA: 274] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Thalidomide is effective in the treatment of newly diagnosed and relapsed/refractory multiple myeloma (MM). However, the role of thalidomide in the post-autologous stem cell transplantation (ASCT) context remains unclear. This study assessed whether the addition of thalidomide consolidation following ASCT would improve the durability of responses achieved and overall survival. Patients and Methods Between January 2002 and March 2005, 269 patients with newly diagnosed MM who achieved disease stabilization or better with conventional induction chemotherapy received a single high-dose melphalan conditioned ASCT. Post-ASCT, 129 patients were randomly assigned to receive indefinite prednisolone maintenance therapy (control group) and 114 to receive the same in addition to 12 months of thalidomide consolidation (thalidomide group). The primary study end points were progression-free survival (PFS) and overall survival (OS). The secondary end point was tolerability. Results After a median follow-up of 3 years, the postrandomization 3-year PFS rates were 42% and 23% (P < .001; hazard ratio [HR], 0.5; 95% CI, 0.35 to 0.71) and the OS rates were 86% and 75% (P = .004; HR, 0.41; 95% CI, 0.22 to 0.76) in the thalidomide and control groups, respectively. There was no difference in survival between groups 12 months after disease progression (79% v 77%; P = .237). Neurological toxicities were more common in the thalidomide arm but there were no differences between arms for thromboembolic events. Conclusion Consolidation therapy with 12 months of thalidomide combined with prednisolone prolongs survival when used after a single high-dose therapy supported ASCT in patients with newly diagnosed MM. Furthermore, thalidomide consolidation therapy did not adversely impact on survival in the subsequent salvage setting.
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Affiliation(s)
- Andrew Spencer
- From the Alfred Hospital, Victoria; Peter MacCallum Cancer Institute; Royal Melbourne Hospital, Melbourne; The Canberra Hospital, Canberra; Westmead Hospital, Sydney; Royal North Shore, Sydney; Princess Alexandra Hospital, Brisbane; and the Royal Adelaide Hospital, Adelaide, Australia
| | - H. Miles Prince
- From the Alfred Hospital, Victoria; Peter MacCallum Cancer Institute; Royal Melbourne Hospital, Melbourne; The Canberra Hospital, Canberra; Westmead Hospital, Sydney; Royal North Shore, Sydney; Princess Alexandra Hospital, Brisbane; and the Royal Adelaide Hospital, Adelaide, Australia
| | - Andrew W. Roberts
- From the Alfred Hospital, Victoria; Peter MacCallum Cancer Institute; Royal Melbourne Hospital, Melbourne; The Canberra Hospital, Canberra; Westmead Hospital, Sydney; Royal North Shore, Sydney; Princess Alexandra Hospital, Brisbane; and the Royal Adelaide Hospital, Adelaide, Australia
| | - Ian W. Prosser
- From the Alfred Hospital, Victoria; Peter MacCallum Cancer Institute; Royal Melbourne Hospital, Melbourne; The Canberra Hospital, Canberra; Westmead Hospital, Sydney; Royal North Shore, Sydney; Princess Alexandra Hospital, Brisbane; and the Royal Adelaide Hospital, Adelaide, Australia
| | - Kenneth F. Bradstock
- From the Alfred Hospital, Victoria; Peter MacCallum Cancer Institute; Royal Melbourne Hospital, Melbourne; The Canberra Hospital, Canberra; Westmead Hospital, Sydney; Royal North Shore, Sydney; Princess Alexandra Hospital, Brisbane; and the Royal Adelaide Hospital, Adelaide, Australia
| | - Luke Coyle
- From the Alfred Hospital, Victoria; Peter MacCallum Cancer Institute; Royal Melbourne Hospital, Melbourne; The Canberra Hospital, Canberra; Westmead Hospital, Sydney; Royal North Shore, Sydney; Princess Alexandra Hospital, Brisbane; and the Royal Adelaide Hospital, Adelaide, Australia
| | - Devinder S. Gill
- From the Alfred Hospital, Victoria; Peter MacCallum Cancer Institute; Royal Melbourne Hospital, Melbourne; The Canberra Hospital, Canberra; Westmead Hospital, Sydney; Royal North Shore, Sydney; Princess Alexandra Hospital, Brisbane; and the Royal Adelaide Hospital, Adelaide, Australia
| | - Noemi Horvath
- From the Alfred Hospital, Victoria; Peter MacCallum Cancer Institute; Royal Melbourne Hospital, Melbourne; The Canberra Hospital, Canberra; Westmead Hospital, Sydney; Royal North Shore, Sydney; Princess Alexandra Hospital, Brisbane; and the Royal Adelaide Hospital, Adelaide, Australia
| | - John Reynolds
- From the Alfred Hospital, Victoria; Peter MacCallum Cancer Institute; Royal Melbourne Hospital, Melbourne; The Canberra Hospital, Canberra; Westmead Hospital, Sydney; Royal North Shore, Sydney; Princess Alexandra Hospital, Brisbane; and the Royal Adelaide Hospital, Adelaide, Australia
| | - Nola Kennedy
- From the Alfred Hospital, Victoria; Peter MacCallum Cancer Institute; Royal Melbourne Hospital, Melbourne; The Canberra Hospital, Canberra; Westmead Hospital, Sydney; Royal North Shore, Sydney; Princess Alexandra Hospital, Brisbane; and the Royal Adelaide Hospital, Adelaide, Australia
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Cheema PK, Zadeh S, Kukreti V, Reece D, Chen C, Trudel S, Mikhael J. Age 40 years and under does not confer superior prognosis in patients with multiple myeloma undergoing upfront autologous stem cell transmplant. Biol Blood Marrow Transplant 2009; 15:686-93. [PMID: 19450753 DOI: 10.1016/j.bbmt.2009.02.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Accepted: 02/21/2009] [Indexed: 11/25/2022]
Abstract
Multiple myeloma (MM) rarely occurs in patients 40 years of age and younger. This young age has been reported to correlate with improved survival in patients with MM. The objective of this study is to describe presenting features and outcomes of patients < or =40 years of age with MM who undergo autologous stem cell transplantation (ASCT) as first-line treatment, and compare overall survival (OS) and progression free survival (PFS) to patients aged 41-65 years. We performed a retrospective institutional review of all patients < or =40 years of age and 41-65 years of age at the time of diagnosis of MM who had undergone upfront ASCT from January 1, 1990, to July 31, 2007. Thirty-eight patients < or =40 years of age and 608 patients aged 41-65 were identified. There was a high rate of plasma cell leukemia (PCL) in young patients at 11% compared to the reported rate of 2%-4%. At diagnosis, there was an increased rate of renal failure in the young cohort compared to patients aged 41-65 years at 25% versus 16% and Bence Jones proteinuria at 81% versus 51%. The rate of complete or partial response was similar between the groups at 79% and 83% in the young and older cohorts, respectively. Median PFS post-ASCT was 22.0 months (95% confidence interval [CI]: 16.1, 28.0), versus 26.9 months (95% CI: 24.0, 29.8) for patients aged 41-65 years (P = .66). Median OS from date of ASCT was also similar to those over 40 years: 68.1 months (95% CI: 39.0, 97.2) versus 80.7 months (95% CI: 68.1, 93.4); P = .90. Treatment-related mortality (TRM) was low at 2.6% and 2.3% in the young and older cohorts, respectively. Despite previous reports that young age is a positive prognostic marker, our study found OS post-ASCT is equivalent to those aged 41-65 years. This study emphasizes the importance of developing strategies to better the outcomes of young patients with MM.
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Affiliation(s)
- Parneet K Cheema
- Division of Hematology/Oncology, Mayo Clinic Arizona, Scottsdale,AZ 85259, USA
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Patriarca F, Petrucci MT, Bringhen S, Baldini L, Caravita T, Corradini P, Corso A, Di Raimondo F, Falcone A, Ferrara F, Morabito F, Musto P, Offidani M, Petrini M, Rizzi R, Semenzato G, Tosi P, Vacca A, Cavo M, Boccadoro M, Palumbo A. Considerations in the treatment of multiple myeloma: a consensus statement from Italian experts. Eur J Haematol 2009; 82:93-105. [DOI: 10.1111/j.1600-0609.2008.01179.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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100
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ASH evidence-based guidelines: what is the role of maintenance therapy in the treatment of multiple myeloma? Hematology 2009:587-9. [DOI: 10.1182/asheducation-2009.1.587] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
A 51-year-old male was diagnosed with an IgA multiple myeloma (MM) after having back pain for several months. His bone marrow showed 30% involvement with plasma cells and his cytogenetics showed t(4:14). His β2-microglobulin was 6.5 mg/dL at diagnosis and he had multiple lytic lesions, along with a creatinine of 2.3 mg/dL and significant anemia. Induction therapy with lenalidomide, bortezomib and dexamethasone was used, and he was able to achieve complete remission after 4 cycles of therapy. He then went on to receive high-dose chemotherapy with a single autologous stem cell transplant. He tolerated it well and now comes to discuss follow-up treatment plans. He wants to discuss maintenance therapy.
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