51
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Qian Y, Qian Z, Zhao X, Pan W, Wei X, Meng H, Yang L, Xiao H. Successful Treatment of Relapsed/Refractory Extramedullary Multiple Myeloma With Anti-BCMA CAR-T Cell Therapy Followed by Haploidentical Hematopoietic Stem Cell Transplantation: A Case Report and a Review of the Contemporary Literature. Front Med (Lausanne) 2021; 8:649824. [PMID: 34026784 PMCID: PMC8138324 DOI: 10.3389/fmed.2021.649824] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/22/2021] [Indexed: 01/23/2023] Open
Abstract
Extramedullary multiple myeloma (EMM) is an aggressive sub-entity of multiple myeloma (MM). Despite an excellent improvement in survival for most patients with MM over recent decades, the overall survival (OS) of patients with EMM was usually not longer than 3 years. Standard treatment for patients with EMM has not been established, and their management is particularly challenging. We presented a heavily pretreated young patient with relapsed EMM and refractoriness to a proteasome inhibitor (PI; bortezomib), a next-generation PI (ixazomib), immunomodulatory drugs (IMiDs; lenalidomide), autologous hematopoietic stem cell transplantation (ASCT), and monoclonal antibody (directed against CD38: daratumumab) and indicated that myeloablative haploidentical hematopoietic stem cell transplantation (haploidentical-HSCT) as a salvage treatment of relapse after a chimeric antigen receptor (CAR)-T cell therapy that targeted B-cell maturation antigen (BCMA) (NCT04650724) is feasible. Taken together of the contemporary literature, the promising results on the effect of anti-BCMA CAR-T cell therapy and allogeneic HSCT might present a proof-of-principle for patients with EMM, and therefore, patients with the disease need to be included in future studies.
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Affiliation(s)
- Ying Qian
- Department of Hematology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zijun Qian
- Department of Hematology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiujie Zhao
- Department of Hematology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wenjue Pan
- Department of Hematology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xinzheng Wei
- Hangzhou Integrative Medicine Hospital, Hangzhou, China
| | - Huimin Meng
- PersonGen BioTherapeutics (Suzhou) Co., Ltd., Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Collaborative Innovation Center of Hematology, CyrusTang Medical Institute, Soochow University, Suzhou, China
| | - Lin Yang
- PersonGen BioTherapeutics (Suzhou) Co., Ltd., Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Collaborative Innovation Center of Hematology, CyrusTang Medical Institute, Soochow University, Suzhou, China
| | - Haowen Xiao
- Department of Hematology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China
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52
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Pulmonary Lymphangitic Spread of Multiple Myeloma as Early Relapse after Autologous Stem Cell Transplantation. Case Rep Hematol 2021; 2021:5590975. [PMID: 33884207 PMCID: PMC8041536 DOI: 10.1155/2021/5590975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 11/19/2022] Open
Abstract
Clinical relapses early after autologous stem cell transplantation portrays an inferior clinical outcome. Early relapse in this setting with extramedullary disease (EMD) of lung involvement in multiple myeloma is rare. To our knowledge, this is the first reported case of lymphangitic spread of myeloma with pulmonary parenchymal and pleural involvement occurring at first relapse.
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53
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Rosiñol L, Beksac M, Zamagni E, Van de Donk NWCJ, Anderson KC, Badros A, Caers J, Cavo M, Dimopoulos MA, Dispenzieri A, Einsele H, Engelhardt M, Fernández de Larrea C, Gahrton G, Gay F, Hájek R, Hungria V, Jurczyszyn A, Kröger N, Kyle RA, Leal da Costa F, Leleu X, Lentzsch S, Mateos MV, Merlini G, Mohty M, Moreau P, Rasche L, Reece D, Sezer O, Sonneveld P, Usmani SZ, Vanderkerken K, Vesole DH, Waage A, Zweegman S, Richardson PG, Bladé J. Expert review on soft-tissue plasmacytomas in multiple myeloma: definition, disease assessment and treatment considerations. Br J Haematol 2021; 194:496-507. [PMID: 33724461 DOI: 10.1111/bjh.17338] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
In this review, two types of soft-tissue involvement in multiple myeloma are defined: (i) extramedullary (EMD) with haematogenous spread involving only soft tissues and (ii) paraskeletal (PS) with tumour masses arising from skeletal lesions. The incidence of EMD and PS plasmacytomas at diagnosis ranges from 1·7% to 4·5% and 7% to 34·4% respectively. EMD disease is often associated with high-risk cytogenetics, resistance to therapy and worse prognosis than in PS involvement. In patients with PS involvement a proteasome inhibitor-based regimen may be the best option followed by autologous stem cell transplantation (ASCT) in transplant eligible patients. In patients with EMD disease who are not eligible for ASCT, a proteasome inhibitor-based regimen such as lenalidomide-bortezomib-dexamethasone (RVD) may be the best option, while for those eligible for high-dose therapy a myeloma/lymphoma-like regimen such as bortezomib, thalidomide and dexamethasone (VTD)-RVD/cisplatin, doxorubicin, cyclophosphamide and etoposide (PACE) followed by SCT should be considered. In both EMD and PS disease at relapse many strategies have been tried, but this remains a high-unmet need population.
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Affiliation(s)
- Laura Rosiñol
- Department of Hematology, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Meral Beksac
- Department of Hematology, Ankara University, Ankara, Turkey
| | - Elena Zamagni
- Istituto di Ematologia "Seràgnoli", Dipartamento di Medicina Specialistica Diagnostica e Sperimentale, Università degli Studi, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | | | - Ashraf Badros
- University of Maryland at Baltimore, Baltimore, MD, USA
| | - Jo Caers
- Department of Clinical Hematology, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Michele Cavo
- Istituto di Ematologia "Seràgnoli", Dipartamento di Medicina Specialistica Diagnostica e Sperimentale, Università degli Studi, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Meletios-Athanasios Dimopoulos
- Hematology and Medical Oncology, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | | | - Hermann Einsele
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Monika Engelhardt
- Interdisciplinary Tumor Center, University of Freiburg, Freiburg, Germany
| | | | - Gösta Gahrton
- Department of Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden
| | - Francesca Gay
- Myeloma Unit, Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Roman Hájek
- Department of Haematooncology, University of Ostrava, Ostrava, Czech Republic
| | | | - Artur Jurczyszyn
- Medical College Department of Hematology, Jagiellanian University, Krakow, Poland
| | - Nicolaus Kröger
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Robert A Kyle
- Division of Hematology, Mayo Clínic, Rochester, MN, USA
| | | | | | - Suzanne Lentzsch
- Multiple Myeloma and Amyloidosis Service, Columbia University, New York, NY, USA
| | - Maria V Mateos
- IBSAL, Cancer Research Center, University Hospital of Salamanca, Salamanca, Spain
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Department of molecular Medicine, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, Hospital Saint-Antoine, Sorbonne University, París, France
| | - Philippe Moreau
- Hematology Department, University Hospital Hotel-Dieu, Nantes, France
| | - Leo Rasche
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Donna Reece
- Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
| | | | - Pieter Sonneveld
- Erasmus MC Cancer Institute, Erasmus University of Rotterdam, Rotterdam, the Netherlands
| | - Saad Z Usmani
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer institute/Atrium Health, Charlotte, NC, USA
| | - Karin Vanderkerken
- Department Hematology and Immunology, Vriji Universiteit Brussel, Brussels, Belgium
| | - David H Vesole
- John Theurer Cancer, Hackensack Meridian School of Medicine, Hackensat, NJ, USA
| | - Anders Waage
- Department of Clinical Molecular Medicine, St. Olavs Hospital, NTNU Trondheim, Trondheim, Norway
| | - Sonja Zweegman
- Department of Hematology, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Paul G Richardson
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Joan Bladé
- Department of Hematology, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
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Abstract
PURPOSE OF REVIEW Extramedullary disease (EMD) is a rare but recognized manifestation of multiple myeloma (MM), characterized by involvement of several organs including skin, liver, lymphatic system, pleura, and central nervous system. The incidence is about 3-5% in newly diagnosed MM patients, but has been reported in up to 20% patients in the relapsed MM setting. RECENT FINDINGS Presence of EMD has been associated with more aggressive phenotype of MM, elevated serum lactate dehydrogenase (LDH) enzyme, and high-risk cytogenetics [deletion 17p, translocation (4;14), translocation (14;16)]. There are several hypotheses of how EMD occurs, including factors leading to bone marrow emancipation and hematogenous spread. The treatment schema usually follows that of high-risk MM. The current review summarizes the disease characterization data, along with available data on clinical activity of available anti-MM agents for this entity.
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Affiliation(s)
- Megan H Jagosky
- Plasma Cell Disorders, Department of Hematologic Oncology & Blood Disorders, Levine Cancer Institute/Atrium Health UNC School of Medicine, Charlotte, NC, USA
| | - Saad Z Usmani
- Plasma Cell Disorders, Department of Hematologic Oncology & Blood Disorders, Levine Cancer Institute/Atrium Health UNC School of Medicine, Charlotte, NC, USA.
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55
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Harding WC, Marcoux M, Casal RF, Bashoura L, Stewart J, Lee HC, Faiz SA. Lung Nodule in a Patient with Multiple Myeloma. Am J Respir Crit Care Med 2020; 202:1458-1459. [PMID: 32730097 DOI: 10.1164/rccm.202005-2019im] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- William C Harding
- Division of Critical Care, Pulmonary and Sleep Medicine, Department of Internal Medicine, McGovern Medical School at University of Texas Health, Houston, Texas; and
| | | | | | | | | | - Hans C Lee
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
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56
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Liu Y, Jelloul F, Zhang Y, Bhavsar T, Ho C, Rao M, Lewis NE, Cimera R, Baik J, Sigler A, Sen F, Yabe M, Roshal M, Landgren O, Dogan A, Xiao W. Genetic Basis of Extramedullary Plasmablastic Transformation of Multiple Myeloma. Am J Surg Pathol 2020; 44:838-848. [PMID: 32118627 DOI: 10.1097/pas.0000000000001459] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
In patients with multiple myeloma, plasmablastic transformation in the bone marrow is rare and associated with poor outcomes. The significance of discordant extramedullary plasmablastic transformation in patients with small, mature clonal plasma cells in the bone marrow has not been well studied. Here, we report the clinicopathologic, cytogenetic, and molecular features of 10 such patients (male/female: 6/4, median age: 65 y, range: 48 to 76 y) with an established diagnosis of multiple myeloma in the bone marrow composed of small, mature plasma cells in parallel with a concurrent or subsequent extramedullary plasmablastic transformation. Eight patients with available survival data showed an overall aggressive clinical course with a median survival of 4.5 months after the diagnosis of extramedullary plasmablastic transformation, despite aggressive treatment and even in patients with low-level bone marrow involvement. Pathologically, the extramedullary plasmablastic myeloma were clonally related to the corresponding bone marrow plasma cells, showed high levels of CMYC and/or P53 expression with a high Ki-67 proliferation index by immunohistochemistry and harbored more complex genomic aberrations including frequent mutations in the RAS pathway and MYC rearrangements compared with their bone marrow counterparts. In summary, although genetic and immunohistochemical studies were not uniformly performed on all cases due to the retrospective nature of this study, our data suggest that discordant extramedullary plasmablastic transformation of multiple myeloma has an aggressive clinical course and is characterized by frequent mutations in the RAS pathway and more complex genomic abnormalities.
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Affiliation(s)
- Ying Liu
- Department of Pathology, Hematopathology Service
| | | | | | - Tapan Bhavsar
- Department of Pathology, Wayne State University School of Medicine, Detroit Receiving Hospital, Detroit, MI
| | - Caleb Ho
- Department of Pathology, Hematopathology Service.,Department of Pathology, Diagnostic Molecular Pathology Service
| | - Mamta Rao
- Department of Pathology, Cytogenetic Laboratory
| | | | | | - Jeeyeon Baik
- Department of Pathology, Hematopathology Service
| | | | - Filiz Sen
- Department of Pathology, Hematopathology Service
| | - Mariko Yabe
- Department of Pathology, Hematopathology Service
| | | | - Ola Landgren
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ahmet Dogan
- Department of Pathology, Hematopathology Service
| | - Wenbin Xiao
- Department of Pathology, Hematopathology Service
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57
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Yeoh KW, Thitsar SM, Master Z, Loh Y, Chen Y, Nagarajan C, Tin KM, Cutter D, Mikhaeel G. Pleural plasmacytomas - the role of radiotherapy. Br J Haematol 2020; 190:e160-e162. [PMID: 32519756 DOI: 10.1111/bjh.16770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | | | | | | | | | | | | | - David Cutter
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - George Mikhaeel
- Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
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58
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Development of CAR-T cell therapies for multiple myeloma. Leukemia 2020; 34:2317-2332. [PMID: 32572190 DOI: 10.1038/s41375-020-0930-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/29/2020] [Accepted: 06/12/2020] [Indexed: 12/15/2022]
Abstract
Currently available data on chimeric antigen receptor (CAR)-T cell therapy has demonstrated efficacy and manageable toxicity in heavily pretreated multiple myeloma (MM) patients. The CAR-T field in MM is rapidly evolving with >50 currently ongoing clinical trials across all phases, different CAR-T design, or targets. Most of the CAR-T trials are performed in China and the United States, while European centers organize or participate in only a small fraction of current clinical investigations. Autologous CAR-T cell therapy against B cell maturation antigen shows the best evidence of efficacy so far but main issues remain to be addressed: duration of response, longer follow-up, prolonged cytopenia, patients who may benefit the most such as those with extramedullary disease, outcome prediction, and the integration of CAR-T cell therapy within the MM treatment paradigm. Other promising targets are, i.a.,: CD38, SLAMF7/CS1, or GPRC5D. Although no product has been approved to date, cost and production time for autologous products are expected to be the main obstacles for broad use, for which reason allogeneic CAR-T cells are currently explored. However, the inherent risk of graft-versus-host disease requires additional modification which still need to be validated. This review aims to present the current status of CAR-T cell therapy in MM with an overview on current targets, designs, and stages of CAR-T cell development. Main challenges to CAR-T cell therapy will be highlighted as well as strategies to structurally improve the CAR-T cell product, and thereby its efficacy and safety. The need for comparability of the most promising therapies will be emphasized to balance risks and benefits in an evidence-based but personalized approach to further improve outcome of patients with MM.
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59
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Parrondo RD, Roy V, Sher T, Alegria V, Chanan-Khan AA, Ailawadhi S. Use of KRD-PACE as Salvage Therapy in Aggressive, Relapsed/Bortezomib-Refractory Extramedullary Multiple Myeloma: A Report of Two Cases and Literature Review. Case Rep Hematol 2020; 2020:4360926. [PMID: 32148978 PMCID: PMC7049436 DOI: 10.1155/2020/4360926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/30/2020] [Indexed: 12/19/2022] Open
Abstract
Extramedullary multiple myeloma is defined by the presence of plasma cell infiltration outside of the bone marrow. It is associated with a poor prognosis and resistance to therapy and is often associated with high-risk cytogenetics. Aggressive relapsed and refractory extramedullary multiple myeloma is often treated with salvage infusional chemotherapy to achieve rapid disease control. Commonly used regimens include DCEP, CVAD, and VTD-PACE. While VTD-PACE contains bortezomib and thalidomide which have potent antimyeloma activity, the advent of novel agent therapy with proteasome inhibitors and immunomodulatory agents being used in the first-line setting has resulted in many patients being refractory to bortezomib by the time they are treated with VTD-PACE. Herein, we discuss two cases of aggressive relapsed, high-risk, bortezomib-refractory extramedullary multiple myeloma treated with KRD-PACE and review the available clinical data on salvage chemotherapy regimens used in relapsed refractory myeloma.
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Affiliation(s)
- Ricardo D. Parrondo
- Department of Hematology-Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Vivek Roy
- Department of Hematology-Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Taimur Sher
- Department of Hematology-Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Victoria Alegria
- Department of Hematology-Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Asher A. Chanan-Khan
- Department of Hematology-Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
- Department of Hematology-Oncology, St. Vincent's Riverside, Jacksonville, FL, USA
| | - Sikander Ailawadhi
- Department of Hematology-Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
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60
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Gagelmann N, Ayuk F, Atanackovic D, Kröger N. B cell maturation antigen-specific chimeric antigen receptor T cells for relapsed or refractory multiple myeloma: A meta-analysis. Eur J Haematol 2020; 104:318-327. [PMID: 31883150 DOI: 10.1111/ejh.13380] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/23/2019] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Chimeric antigen receptor (CAR) T cells targeting B cell maturation antigen (BCMA) have shown impressive results in clinical studies for relapsed/refractory multiple myeloma (RRMM). We performed a systematic literature review to summarize the current body of evidence on the role of anti-BCMA CAR T cells for RRMM. OBJECTIVES AND METHODS Fifteen studies comprising a total of 285 patients with heavily pretreated RRMM were included using a conventional meta-analysis. Main efficacy outcomes were response, relapse, and survival. Safety outcomes were cytokine release syndrome (CRS) and neurotoxicity. RESULTS Anti-BCMA CAR T cells resulted in a pooled overall response of 82% (95% confidence interval [CI], 74%-88%) and complete response of 36% (24%-50%). Higher CAR+ cell doses were associated with higher response rates. The pooled relapse rate of responders was 45% (27%-64%), and median progression-free survival was 10 months. Present extramedullary disease did not show worse outcome. Severe CRS grades 3-4 and neurotoxicity occurred in 15% (10%-23%) and 18% (10%-31%). CONCLUSION Anti-BCMA CAR T cells showed high response rates, even in patients with present extramedullary disease, while relapse occurred in half of the patients who achieved a response. Larger studies with longer follow-up especially evaluating the association of response and survival are needed.
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Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Djordje Atanackovic
- Multiple Myeloma Program & Cancer Immunotherapy, Hematology and Hematologic Malignancies, University of Utah/Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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61
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Extramedullary multiple myeloma. Leukemia 2019; 34:1-20. [DOI: 10.1038/s41375-019-0660-0] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/31/2019] [Accepted: 08/12/2019] [Indexed: 01/07/2023]
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62
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Avivi I, Cohen YC, Suska A, Shragai T, Mikala G, Garderet L, Seny GM, Glickman S, Jayabalan DS, Niesvizky R, Gozzetti A, Wiśniewska‐Piąty K, Waszczuk‐Gajda A, Usnarska‐Zubkiewicz L, Hus I, Guzicka R, Radocha J, Milunovic V, Davila J, Gentile M, Castillo JJ, Jurczyszyn A. Hematogenous extramedullary relapse in multiple myeloma - a multicenter retrospective study in 127 patients. Am J Hematol 2019; 94:1132-1140. [PMID: 31334859 DOI: 10.1002/ajh.25579] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 07/10/2019] [Accepted: 07/13/2019] [Indexed: 12/19/2022]
Abstract
The current study assesses the characteristics and outcomes of multiple myeloma (MM) patients, treated with novel agents for hematogenous extramedullary (HEMM) relapse. Consecutive patients diagnosed with HEMM between 2010-2018 were included. Patients' characteristics at diagnosis and at HEMM presentation, response to treatment, survival and factors predicting survival were recorded and analyzed. A group of 127 patients, all diagnosed with HEMM by imaging (87.3%) and/or biopsy (79%), were included. Of those, 44% were initially diagnosed with ISS3, 57% presented with plasmacytomas, and 30% had high-risk cytogenetics. Median time to HEMM was 32 months. In multivariate analysis, ISS3 and bone plasmacytoma predicted shorter time to HEMM (P = .005 and P = .008, respectively). Upfront autograft was associated with longer time to HEMM (P = .002). At HEMM, 32% of patients had no BM plasmacytosis, 20% had non-secretory disease and 43% had light-chain disease. Multiple HEMM sites were reported in 52% of patients, mostly involving soft tissue, skin (29%), and pleura/lung (25%). First treatment for HEMM included proteasome inhibitors (50%), immunomodulatory drugs (IMiDs) (39%), monoclonal antibodies (10%), and chemotherapy (53%). Overall response rate (ORR) was 57%. IMiDs were associated with higher ORR (HR 2.2, 95% CI 1.02-4.7, P = .04). Median survival from HEMM was 6 months (CI 95% 4.8-7.2). Failure to achieve ≥VGPR was the only significant factor for worse OS in multivariate analyses (HR = 9.87, CI 95% 2.35 - 39, P = .001). In conclusion, HEMM occurs within 3 years of initial myeloma diagnosis and is associated with dismal outcome. The IMiDs might provide a higher response rate, and achievement of ≥VGPR predicts longer survival.
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Affiliation(s)
- Irit Avivi
- Tel Aviv Medical Center and Sackler Faculty of Medicine Tel Aviv Israel
| | - Yael C. Cohen
- Tel Aviv Medical Center and Sackler Faculty of Medicine Tel Aviv Israel
| | - Anna Suska
- Department of HematologyJagiellonian University Medical College Cracow Poland
| | - Tamir Shragai
- Department of Hematology and Stem Cell TransplantationSouth‐Pest Central Hospital, Natl. Inst. Hematol. Infectol Budapest Hungary
| | - Gabor Mikala
- Department of Hematology and Stem Cell TransplantationSouth‐Pest Central Hospital, Natl. Inst. Hematol. Infectol Budapest Hungary
| | - Laurent Garderet
- Service d'Hématologie et thérapie cellulaireHôpital Saint Antoine Paris France
- Service d'HématologieHôpital Pitié Salpêtrière Paris France
| | - Gueye M. Seny
- Service d'Hématologie et thérapie cellulaireHôpital Saint Antoine Paris France
| | | | | | | | | | | | - Anna Waszczuk‐Gajda
- Department of Hematology, Oncology and Internal DiseasesWarsaw Medical University Warsaw Poland
| | - Lidia Usnarska‐Zubkiewicz
- Department of Hematology, Blood Neoplasms and Bone Marrow TransplantationWroclaw Medical University Poland
| | - Iwona Hus
- Department of Haematology and Bone Marrow TransplantationMedical University of Lublin Lublin Poland
| | - Renata Guzicka
- Department of HaematologyPomeranian Medical University Szczecin Poland
| | - Jakub Radocha
- 4th Department of Medicine – HaematologyCharles University Hospital Hradec Kralove Hradec Kralove Czech Republic
| | - Vibor Milunovic
- Division of HematologyClinical Hospital Merkur Zagreb Croatia
| | | | - Massimo Gentile
- Hematology Unit, Department of Onco‐HematologyAzienda Ospendaliera of Cosenza Cosenza Italy
| | - Jorge J. Castillo
- Dana‐Farber Cancer InstituteHarvard Medical School Boston Massachusetts
| | - Artur Jurczyszyn
- Department of HematologyJagiellonian University Medical College Cracow Poland
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63
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Khan AM, Azar I, Najjar S, Bevington T, Mehdi S. A Case of Aggressive Multiple Myeloma with Extramedullary Involvement of the Female Reproductive System, Thyroid and Breasts. Case Rep Hematol 2019; 2019:7348504. [PMID: 31467739 PMCID: PMC6701299 DOI: 10.1155/2019/7348504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 07/15/2019] [Indexed: 01/06/2023] Open
Abstract
Extramedullary disease at the time of diagnosis of multiple myeloma is a rare finding that portends poor prognosis and necessitates aggressive treatment strategies. We present a case of multiple myeloma with extramedullary plasmacytomas of the female reproductive system, thyroid and breasts. The patient was treated with lenalidomide, bortezomib, cyclophosphamide, and dexamethasone. Follow-up PET-CT scans confirmed clinical complete response, and the patient underwent autologous stem cell transplantation. The patient will be continued on lenalidomide and bortezomib maintenance therapy. To the best of our knowledge, simultaneous involvement of these sites has never been reported. The case highlights that there are no established guidelines on the treatment of multiple myeloma with extramedullary disease leading to great variability based on clinician preference. We will also discuss the treatment options and prognosis of multiple myeloma with extramedullary disease.
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Affiliation(s)
- Abdul Moiz Khan
- Department of Internal Medicine, Albany Medical College, Albany, NY, USA
| | - Ibrahim Azar
- Department of Internal Medicine, Albany Medical College, Albany, NY, USA
| | - Saleh Najjar
- Department of Pathology, Albany Medical College, Albany, NY, USA
| | - Travis Bevington
- Department of Radiology, Albany Medical College, Albany, NY, USA
| | - Syed Mehdi
- Section of Hematology/Oncology, Stratton VA Medical Center, Albany, NY, USA
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64
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Gagelmann N, Eikema DJ, Koster L, Caillot D, Pioltelli P, Lleonart JB, Reményi P, Blaise D, Schaap N, Trneny M, Passweg J, Porras RP, Cahn JY, Musso M, Poiré X, Fenk R, Itälä-Remes M, Pavone V, Fouillard L, Maertens J, Bron D, Pouli A, Schroyens W, Schönland S, Garderet L, Yakoub-Agha I, Kröger N. Tandem Autologous Stem Cell Transplantation Improves Outcomes in Newly Diagnosed Multiple Myeloma with Extramedullary Disease and High-Risk Cytogenetics: A Study from the Chronic Malignancies Working Party of the European Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2019; 25:2134-2142. [PMID: 31288095 DOI: 10.1016/j.bbmt.2019.07.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 01/01/2023]
Abstract
Although high-dose therapy and autologous stem cell transplant combined with novel agents continues to be the hallmark of first-line treatment in newly diagnosed transplant-eligible multiple myeloma patients, the impact of tandem autologous or autologous/reduced-intensity allogeneic transplant for patients with extramedullary disease (EMD) and high-risk cytogenetics is not yet defined. Here, we analyzed clinical and cytogenetic data from 488 adult myeloma patients with EMD undergoing single autologous (n = 373), tandem autologous (n = 84), or autologous-allogeneic transplant (n = 31) between 2003 and 2015. At least 1 high-risk abnormality was present in 41% (n = 202), with del(17p) (40%) and t(4;14) (45%) the most frequent. More than 1 high-risk abnormality was found in 54%. High-risk cytogenetics showed worse 4-year overall survival (OS) and progression-free survival (PFS) of 54% and 29%, respectively, versus 78% and 49% for standard-risk cytogenetics (P < .001). Co-segregation of high-risk abnormalities did not seem to affect outcome. Regarding transplant regimen, OS and PFS were 70% and 43% for single autologous versus 83% and 52% for tandem autologous and 88% and 58% for autologous-allogeneic (P = .06 and P = .30). In multivariate analysis high-risk cytogenetics were associated with worse survival (hazard ratio [HR], 2.00; P = .003), whereas tandem autologous significantly improved outcome versus single autologous transplant (HRs, .46 and .64; P = .02 and P = .03). Autologous-allogeneic transplant did not significantly differ in outcome but appeared to improve survival, but results were limited because of small population (HR, .31). In conclusion, high-risk cytogenetics is frequently observed in newly diagnosed myeloma with EMD and significantly worsens outcome after single autologous, whereas a tandem autologous transplant strategy may overcome onset poor prognosis.
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Affiliation(s)
- Nico Gagelmann
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | | | | | - Péter Reményi
- St. István and St. Laszlo Hospital, Budapest, Hungary
| | | | - Nicolaas Schaap
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Marek Trneny
- Charles University Hospital, Prague, Czech Republic
| | | | | | | | | | - Xavier Poiré
- Cliniques Universitaires St. Luc, Brussels, Belgium
| | - Roland Fenk
- Heinrich Heine University, Düsseldorf, Germany
| | | | | | | | | | | | | | | | - Stefan Schönland
- Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | | | - Nicolaus Kröger
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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65
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Beksac M, Seval GC, Kanellias N, Coriu D, Rosiñol L, Ozet G, Goranova-Marinova V, Unal A, Bila J, Ozsan H, Ivanaj A, Balić LI, Kastritis E, Bladé J, Dimopoulos MA. A real world multicenter retrospective study on extramedullary disease from Balkan Myeloma Study Group and Barcelona University: analysis of parameters that improve outcome. Haematologica 2019; 105:201-208. [PMID: 31278209 PMCID: PMC6939516 DOI: 10.3324/haematol.2019.219295] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 07/05/2019] [Indexed: 12/19/2022] Open
Abstract
Here, we report the outcome of 226 myeloma patients presenting with extramedullary plasmacytoma or paraosseous involvement in a retrospective study conducted in 19 centers from 11 countries. Extramedullary disease was detected at diagnosis or relapse between January 2010 and November 2017. Extramedullary plasmacytoma and paraosseous involvement were observed in 130 patients at diagnosis (92 of 38) and in 96 at relapse (84 of 12). The median time from multiple myeloma diagnosis to the development of extramedullary disease was 25.1 months (range 3.1-106.3 months) in the relapse group (median follow up: 15 months). Imaging approach for extramedullary disease was computed tomography (n=133), positron emission tomography combined with computed tomography (n=50), or magnetic resonance imaging (n=35). The entire group received a median two lines of treatment and autologous stem cell transplantation (44%) following the diagnosis of extramedullary disease. Complete response was higher for paraosseous involvement versus extramedullary plasmacytoma at diagnosis (34.2% vs. 19.3%; P=NS.) and relapse (54.5% vs. 9%; P=0.001). Also paraosseous involvement patients had a better progression-free survival (PFS) when recognized at initial diagnosis of myeloma than at relapse (51.7 vs. 38.9 months). In addition, overall survival was better for paraosseous involvement compared to extramedullary plasmacytoma at diagnosis (not reached vs. 46.5 months). Extramedullary plasmacytoma at relapse had the worst prognosis with a PFS of 13.6 months and overall survival of 11.4 months. In the multivariate analysis, paraosseous involvement, extramedullary disease at diagnosis, International Staging System (ISS-I), and undergoing autologous stem cell transplantation improved overall survival independently. This cohort demonstrated that extramedullary disease benefits from front-line autologous stem cell transplantation and extramedullary plasmacytoma differs from paraosseous involvement in terms of rate and duration of response, with even worse outcomes when detected at relapse, constituting an unmet clinical need.
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Affiliation(s)
- Meral Beksac
- Department of Hematology, School of Medicine, Ankara University, Ankara, Turkey
| | | | - Nicholas Kanellias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Daniel Coriu
- University of Medicine and Pharmacy "Carol Davila", Fundeni Clinical Institute, Bucharest, Romania
| | | | - Gulsum Ozet
- Clinic of Hematology, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | | | - Ali Unal
- Department of Hematology, School of Medicine, Erciyes University, Kayseri, Turkey
| | - Jelena Bila
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Hayri Ozsan
- Department of Hematology, School of Medicine, Dokuz Eylül University, Izmir, Turkey
| | | | | | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Joan Bladé
- Hospital Clinic, IDIBAPS, Barcelona, Spain
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66
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Montefusco V, Gay F, Spada S, De Paoli L, Di Raimondo F, Ribolla R, Musolino C, Patriarca F, Musto P, Galieni P, Ballanti S, Nozzoli C, Cascavilla N, Ben-Yehuda D, Nagler A, Hajek R, Offidani M, Liberati AM, Sonneveld P, Cavo M, Corradini P, Boccadoro M. Outcome of paraosseous extra-medullary disease in newly diagnosed multiple myeloma patients treated with new drugs. Haematologica 2019; 105:193-200. [PMID: 31221778 PMCID: PMC6939525 DOI: 10.3324/haematol.2019.219139] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 06/19/2019] [Indexed: 12/16/2022] Open
Abstract
Extramedullary disease is relatively frequent in multiple myeloma, but our knowledge on the subject is limited and mainly relies on small case series or single center experiences. Little is known regarding the role of new drugs in this setting. We performed a meta-analysis of eight trials focused on the description of extramedullary disease characteristics, clinical outcome, and response to new drugs. A total of 2,332 newly diagnosed myeloma patients have been included; 267 (11.4%) had extramedullary disease, defined as paraosseous in 243 (10.4%), extramedullary plasmocytoma in 12 (0.5%), and not classified in 12 (0.5%) patients. Median progression-free survival was 25.3 months and 25.2 in extramedullary disease and non-extramedullary disease patients, respectively. In multivariate analysis the presence of extramedullary disease did not impact on progression-free survival (hazard ratio 1.15, P=0.06), while other known prognostic factors retained their significance. Patients treated with immunomodulatory drugs, mainly lenalidomide, or proteasome inhibitors had similar progression-free survival and progression-free survival-2 regardless of extramedullary disease presence. Median overall survival was 63.5 months and 79.9 months (P=0.01) in extramedullary and non-extramedullary disease patients, respectively, and in multivariate analysis the presence of extramedullary disease was associated with a reduced overall survival (hazard ratio 1.41, P<0.001), in line with other prognostic factors. With the limits of the use of low sensitivity imaging techniques, that lead to an underestimation of extramedullary disease, we conclude that in patients treated with new drugs the detrimental effect of extramedullary disease at diagnosis is limited, that lenalidomide is effective as are proteasome inhibitors, and that these patients tend to acquire a more aggressive disease in later stages. (EUDRACT2005-004714-32, NCT01063179 NCT00551928, NCT01091831, NCT01093196, NCT01190787, NCT01346787, NCT01857115).
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Affiliation(s)
- Vittorio Montefusco
- Division of Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Francesca Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Stefano Spada
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Lorenzo De Paoli
- Division of Hematology, Department of Translational Medicine, Amedeo Avogadro University of Eastern Piedmont and Maggiore Hospital, Novara, Italy
| | - Francesco Di Raimondo
- Division of Hematology, Ospedale Ferrarotto, Azienda Policlinico-Ospedale Vittorio Emanuele, University of Catania, Catania, Italy
| | - Rossella Ribolla
- Department of Hematology, ASST Spedali Civili di Brescia, Brescia, Italy
| | | | | | - Pellegrino Musto
- Hematology and Stem Cell Transplantation Unit, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, Italy
| | - Piero Galieni
- U.O.C. Ematologia e Trapianto di Cellule Staminali Emopoietiche, Ospedale Mazzoni, Ascoli Piceno, Italy
| | - Stelvio Ballanti
- Sezione di Ematologia e Immunologia Clinica, Ospedale Santa Maria della Misericordia di Perugia, Perugia, Italy
| | - Chiara Nozzoli
- Cellular therapies and Transfusion Medicine Unit, Careggi University Hospital, Firenze, Italy
| | - Nicola Cascavilla
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Dina Ben-Yehuda
- Division of Hematology, Hadassah Ein-Kerem Medical Center, Jerusalem, Israel
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel-HaShomer, Israel
| | - Roman Hajek
- Department of Haematooncology, University Hospital Ostrava, Ostrava, Czech Republic and Faculty of Medicine, Ostrava University, Ostrava, Czech Republic
| | | | | | - Pieter Sonneveld
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Michele Cavo
- Institute of Hematology "L. and A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, "S. Orsola-Malpighi" Hospital, Bologna, Italy
| | - Paolo Corradini
- Hemato-Oncology Department, University of Milan, Division of Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
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67
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Extramedullary disease in multiple myeloma - controversies and future directions. Blood Rev 2019; 36:32-39. [PMID: 31005420 DOI: 10.1016/j.blre.2019.04.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 04/10/2019] [Accepted: 04/12/2019] [Indexed: 11/21/2022]
Abstract
Extramedullary disease of multiple myeloma (EM) remains a treatment challenge even in the era of new drugs. While many reports analyzing various aspects of EM have been published, mechanism of EM development has not been clarified yet. This review summarizes current knowledge about this clinical entity, including its history, diagnostics, imaging methods, incidence, prognosis, current treatment options, risk factors and known molecular mechanisms that might be involved in pathogenesis of EM.
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68
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Yang JZ, Wu XD, Meng JB, Zhang JQ, Sun LX. Association of increased microvessel density with skeletal extramedullary disease relapse in multiple myeloma patients who have skeletal extramedullary disease at diagnosis. Pathol Res Pract 2018; 214:1694-1699. [PMID: 30196985 DOI: 10.1016/j.prp.2018.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 08/05/2018] [Accepted: 08/18/2018] [Indexed: 12/25/2022]
Abstract
The aim of the study was to investigate whether microvessel density (MVD) could be associated with skeletal extramedullary disease relapse (skeletal-EMDR) in patients with multiple myeloma (MM) who have skeletal-EMD at diagnosis. Seventy-nine newly diagnosed MM patients who have skeletal-EMD were retrospectively enrolled in this study. The 4-year cumulative incidence of skeletal-EMDR was 35.0%±8.3%. The 4-year probability of overall survival (OS) was 54.0%±7.6%. Multivariate analysis showed that skeletal-EMDR (HR = 4.144; 95% CI: 1.608-10.685; P = 0.003) was independently associated with inferior OS for the MM patients who have skeletal-EMD at diagnosis. The factors associated with skeletal-EMDR were MVD (HR = 3.990, 95%CI:1.136-14.018; P = 0.031), white blood cell (WBC) (HR = 0.262, 95% CI:0.090-0.769; P = 0.015), and the EMD sites involved at onset (HR = 0.263, 95% CI: 0.074-0.937; P = 0.039). The MVD in patients with thoracic and lumbar vertebrae as the involved sites at diagnosis was significantly lower than those with other sites involved (41.59 ± 14.39 vs. 60.82 ± 35.14, P=0.001). Our data suggest that increased MVD could be used to predict skeletal-EMDR, which is associated with inferior survival in patients with MM who have skeletal-EMD at diagnosis.
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Affiliation(s)
- Jian-Zhu Yang
- Department of Pathology, Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xian-Da Wu
- Department of Hematology, Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jian-Bo Meng
- Department of Hematology, Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jin-Qiao Zhang
- Department of Hematology, Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| | - Li-Xia Sun
- Department of Hematology, Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, China.
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