101
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Gupta S, Abouzaid S, Liebert R, Parikh K, Ung B, Rosenberg AS. Assessing the Effect of Adherence on Patient-reported Outcomes and Out of Pocket Costs Among Patients With Multiple Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:210-218. [PMID: 29429817 DOI: 10.1016/j.clml.2018.01.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 01/04/2018] [Accepted: 01/24/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND The present study characterized the effect of multiple myeloma (MM) on work productivity, health care resource usage, and out of pocket costs (OOPCs) and examined the association of adherence with quality of life (QoL) and productivity loss. MATERIALS AND METHODS The present cross-sectional study included 162 patients categorized by their 4-item Morisky Medication Adherence Scale (MMAS-4) score (4 vs. ≤ 3). Online surveys included the Work Productivity and Activity Impairment questionnaire, Functional Assessment of Cancer Therapy-Multiple Myeloma (FACT-MM), and MM-specific questions. RESULTS On average, patients reported FACT-MM scores of 98.5 ± 29.3, absenteeism of 18.3% ± 17.8%, presenteeism of 51.8% ± 30.2%, overall work productivity impairment of 57.3% ± 31.7%, and activity impairment of 49.9% ± 29.5% in the previous 7 days. During the previous 3 months, the mean OOPCs were $709 ± $1307; prescription medications accounted for 55% of these costs. Patients attended 4.1 ± 4.6 visits to oncologists or hematologists during that time, which accounted for 45% of the OOPCs. Patients spent an average of 6.8 ± 8.3 hours at MM-related monthly appointments, and 35.2% reported frustration while at the doctor's office. Patients with an MMAS-4 score of 4 reported higher FACT-MM scores (106.9 vs. 89.2; P < .001). Patients with an MMAS-4 score of ≤ 3 reported greater activity impairment (56.5% vs. 39.8%; P = .015) and feeling overwhelmed or frustrated with rescheduling MM appointments (64.0% vs. 26.0%; P = .002). CONCLUSION MM was associated with significant workplace and functional impairment, high OOPCs, and frequent office visits. High medication adherence was associated with better outcomes across these domains. As survival for patients with MM improves, patient QoL should be considered to enhance these outcomes.
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Affiliation(s)
- Shaloo Gupta
- Health Outcomes Practice, Kantar Health, New York, NY.
| | - Safiya Abouzaid
- US Health Economics and Outcomes Research, Celgene Corporation, Summit, NJ
| | - Ryan Liebert
- Health Outcomes Practice, Kantar Health, New York, NY
| | - Kejal Parikh
- US Health Economics and Outcomes Research, Celgene Corporation, Summit, NJ
| | - Brian Ung
- US Health Economics and Outcomes Research, Celgene Corporation, Summit, NJ
| | - Aaron S Rosenberg
- Division of Hematology and Oncology, Davis Comprehensive Cancer Center, University of California, Sacramento, CA
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102
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Bieghs L, Johnsen HE, Maes K, Menu E, Van Valckenborgh E, Overgaard MT, Nyegaard M, Conover CA, Vanderkerken K, De Bruyne E. The insulin-like growth factor system in multiple myeloma: diagnostic and therapeutic potential. Oncotarget 2018; 7:48732-48752. [PMID: 27129151 PMCID: PMC5217049 DOI: 10.18632/oncotarget.8982] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 04/16/2016] [Indexed: 12/14/2022] Open
Abstract
Multiple myeloma (MM) is a highly heterogeneous plasma cell malignancy. The MM cells reside in the bone marrow (BM), where reciprocal interactions with the BM niche foster MM cell survival, proliferation, and drug resistance. As in most cancers, the insulin-like growth factor (IGF) system has been demonstrated to play a key role in the pathogenesis of MM. The IGF system consists of IGF ligands, IGF receptors, IGF binding proteins (IGFBPs), and IGFBP proteases and contributes not only to the survival, proliferation, and homing of MM cells, but also MM-associated angiogenesis and osteolysis. Furthermore, increased IGF-I receptor (IGF-IR) expression on MM cells correlates with a poor prognosis in MM patients. Despite the prominent role of the IGF system in MM, strategies targeting the IGF-IR using blocking antibodies or small molecule inhibitors have failed to translate into the clinic. However, increasing preclinical evidence indicates that IGF-I is also involved in the development of drug resistance against current standard-of-care agents against MM, including proteasome inhibitors, immunomodulatory agents, and corticoids. IGF-IR targeting has been able to overcome or revert this drug resistance in animal models, enhancing the efficacy of standard-of-care agents. This finding has generated renewed interest in the therapeutic potential of IGF-I targeting in MM. The present review provides an update of the impact of the different IGF system components in MM and discusses the diagnostic and therapeutic potentials.
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Affiliation(s)
- Liesbeth Bieghs
- Department of Hematology and Immunology, Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium.,Department of Hematology, Aalborg Hospital, Aalborg University, Denmark.,Department of Biomedicin, Aarhus University, Aarhus, Denmark
| | - Hans E Johnsen
- Department of Hematology, Aalborg Hospital, Aalborg University, Denmark.,Clinical Cancer Research Center, Aalborg University Hospital, Denmark.,Department of Clinical Medicine, Aalborg University, Denmark
| | - Ken Maes
- Department of Hematology and Immunology, Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Eline Menu
- Department of Hematology and Immunology, Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Els Van Valckenborgh
- Department of Hematology and Immunology, Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Mette Nyegaard
- Department of Biomedicin, Aarhus University, Aarhus, Denmark
| | - Cheryl A Conover
- Division of Endocrinology, Metabolism and Nutrition, Endocrine Research Unit, Mayo Clinic, Rochester, NY, USA
| | - Karin Vanderkerken
- Department of Hematology and Immunology, Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Elke De Bruyne
- Department of Hematology and Immunology, Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
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103
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Elsayed HG, Alabdulwahab AS. Upfront treatment of elderly myeloma patients: an overview and update. Expert Rev Hematol 2018; 11:99-108. [DOI: 10.1080/17474086.2018.1419861] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Hussein G. Elsayed
- Haematology Department, King Abdulla Medical City HC, Saudi Arabia
- Medical Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
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104
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Yaccoby S. Two States of Myeloma Stem Cells. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:38-43. [DOI: 10.1016/j.clml.2017.09.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 07/31/2017] [Accepted: 09/25/2017] [Indexed: 01/08/2023]
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105
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Davies FE. Is molecular remission the goal of multiple myeloma therapy? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:205-211. [PMID: 29222257 PMCID: PMC6142553 DOI: 10.1182/asheducation-2017.1.205] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
The increased number of effective therapies and the wider use of combinations that give deeper remissions have resulted in a reassessment of the goals of myeloma therapy. With the advent of new therapeutic strategies and diagnostic tools, achievement of minimal residual disease (MRD)-negative status has become increasingly important, with some even considering it as the primary endpoint for therapy. The level of MRD that is aimed for is a continuous, rather than an absolute variable, with studies in both transplant-eligible and -noneligible patients showing that the level of MRD achieved is predictive of progression-free survival and overall survival, with an improvement in survival of approximately 1 year for each log-depletion in MRD level. The most widely used methods to assess MRD status include flow cytometry and clonality detection, using next-generation sequencing technologies with sensitivity limits of 1:10-3 to 1:10-6 The timing of when to assess MRD depends on the treatment used, as well as the molecular and cytogenetic subgroup of the myeloma itself. It is also becoming clear that the level of MRD negativity, as well as microenvironmental factors, are important prognostically, including the regeneration of normal plasma cells, and the normalization of the immune repertoire. With advances in antibody-based therapy and immunotherapy, the achievement of stable MRD states is now possible for a significant proportion of patients, and is a prerequisite for myeloma cure.
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Affiliation(s)
- Faith E Davies
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR
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106
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Li J, Pan Q, Rowan PD, Trotter TN, Peker D, Regal KM, Javed A, Suva LJ, Yang Y. Heparanase promotes myeloma progression by inducing mesenchymal features and motility of myeloma cells. Oncotarget 2017; 7:11299-309. [PMID: 26849235 PMCID: PMC4905474 DOI: 10.18632/oncotarget.7170] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 01/21/2016] [Indexed: 11/25/2022] Open
Abstract
Bone dissemination and bone disease occur in approximately 80% of patients with multiple myeloma (MM) and are a major cause of patient mortality. We previously demonstrated that MM cell-derived heparanase (HPSE) is a major driver of MM dissemination to and progression in new bone sites. However the mechanism(s) by which HPSE promotes MM progression remains unclear. In the present study, we investigated the involvement of mesenchymal features in HPSE-promoted MM progression in bone. Using a combination of molecular, biochemical, cellular, and in vivo approaches, we demonstrated that (1) HPSE enhanced the expression of mesenchymal markers in both MM and vascular endothelial cells; (2) HPSE expression in patient myeloma cells positively correlated with the expression of the mesenchymal markers vimentin and fibronectin. Additional mechanistic studies revealed that the enhanced mesenchymal-like phenotype induced by HPSE in MM cells is due, at least in part, to the stimulation of the ERK signaling pathway. Finally, knockdown of vimentin in HPSE expressing MM cells resulted in significantly attenuated MM cell dissemination and tumor growth in vivo. Collectively, these data demonstrate that the mesenchymal features induced by HPSE in MM cells contribute to enhanced tumor cell motility and bone-dissemination.
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Affiliation(s)
- Juan Li
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Hematology, The First Affiliated Hospital of Sun Yat-Sen University, Guangdong, China
| | - Qianying Pan
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Hematology, The First Affiliated Hospital of Sun Yat-Sen University, Guangdong, China
| | - Patrick D Rowan
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Timothy N Trotter
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Deniz Peker
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kellie M Regal
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Amjad Javed
- Comprehensive Cancer Center and The Center for Metabolic Bone Disease, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Oral and Maxillofacial Surgery, School of Dentistry, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Larry J Suva
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A & M University, College Station, TX, USA
| | - Yang Yang
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA.,Comprehensive Cancer Center and The Center for Metabolic Bone Disease, University of Alabama at Birmingham, Birmingham, AL, USA
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107
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Bolomsky A, Heusschen R, Schlangen K, Stangelberger K, Muller J, Schreiner W, Zojer N, Caers J, Ludwig H. Maternal embryonic leucine zipper kinase is a novel target for proliferation-associated high-risk myeloma. Haematologica 2017; 103:325-335. [PMID: 29122991 PMCID: PMC5792277 DOI: 10.3324/haematol.2017.172973] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 10/27/2017] [Indexed: 01/14/2023] Open
Abstract
Treatment of high-risk patients is a major challenge in multiple myeloma. This is especially true for patients assigned to the gene expression profiling-defined proliferation subgroup. Although recent efforts have identified some key players of proliferative myeloma, genetic interactions and players that can be targeted with clinically effective drugs have to be identified in order to overcome the poor prognosis of these patients. We therefore examined maternal embryonic leucine zipper kinase (MELK) for its implications in hyper-proliferative myeloma and analyzed the activity of the MELK inhibitor OTSSP167 both in vitro and in vivoMELK was found to be significantly overexpressed in the proliferative subgroup of myeloma. This finding translated into poor overall survival in patients with high vs low MELK expression. Enrichment analysis of upregulated genes in myeloma cells of MELKhigh patients confirmed the strong implications in myeloma cell proliferation. Targeting MELK with OTSSP167 impaired the growth and survival of myeloma cells, thereby affecting central survival factors such as MCL-1 and IRF4 This activity was also observed in the 5TGM.1 murine model of myeloma. OTSSP167 reduced bone marrow infiltration and serum paraprotein levels in a dose-dependent manner. In addition, we revealed a strong link between MELK and other proliferation-associated high-risk genes (PLK-1, EZH2, FOXM1, DEPDC1) and MELK inhibition also impaired the expression of those genes. We therefore conclude that MELK is an essential component of a proliferative gene signature and that pharmacological inhibition of MELK represents an attractive novel approach to overcome the poor prognosis of high-risk patients with a proliferative expression pattern.
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Affiliation(s)
- Arnold Bolomsky
- Wilhelminen Cancer Research Institute, Department of Medicine I, Wilhelminenspital, Vienna, Austria
| | - Roy Heusschen
- Laboratory of Hematology, GIGA-I3, University of Liège, Belgium
| | - Karin Schlangen
- Center for Medical Statistics, Informatics and Intelligent Systems, Section for Biosimulation and Bioinformatics, Medical University of Vienna, Austria and
| | - Kathrin Stangelberger
- Wilhelminen Cancer Research Institute, Department of Medicine I, Wilhelminenspital, Vienna, Austria
| | | | - Wolfgang Schreiner
- Center for Medical Statistics, Informatics and Intelligent Systems, Section for Biosimulation and Bioinformatics, Medical University of Vienna, Austria and
| | - Niklas Zojer
- Wilhelminen Cancer Research Institute, Department of Medicine I, Wilhelminenspital, Vienna, Austria
| | - Jo Caers
- Laboratory of Hematology, GIGA-I3, University of Liège, Belgium .,Division of Hematology, Department of Medicine, University and CHU of Liège, Belgium
| | - Heinz Ludwig
- Wilhelminen Cancer Research Institute, Department of Medicine I, Wilhelminenspital, Vienna, Austria
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108
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Ghosh A, Mailankody S, Giralt SA, Landgren CO, Smith EL, Brentjens RJ. CAR T cell therapy for multiple myeloma: where are we now and where are we headed? Leuk Lymphoma 2017; 59:2056-2067. [PMID: 29105517 DOI: 10.1080/10428194.2017.1393668] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
While recent progress has been made in the management of multiple myeloma, it remains a highly fatal malignancy especially among patients with relapsed-refractory disease. Immunotherapy with adoptive T cells targeting myeloma-associated antigens are at various stages of development and have brought about a new hope for cure. This is a review on the emerging field of adoptively transferred engineered T cell based approaches, with an in-depth focus on chimeric antigen receptors (CAR) targeting multiple myeloma. The recent results from CAR T cells targeting B cell maturation antigen are encouraging but eventual resistance to the CAR T cell therapies remain problematic. With newer approaches in therapies for multiple myeloma, the role of transplantation is evolved to form a platform for T cell therapies.
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Affiliation(s)
- Arnab Ghosh
- a Hematology/Oncology/BMT Fellowship Program, Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Sham Mailankody
- b Myeloma Service, Division of Hematologic Oncology, Department of Medicine , Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Sergio A Giralt
- c Adult BMT Service, Memorial Sloan Kettering Cancer Center , New York , NY , USA.,d Cellular Therapeutics Center, Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - C Ola Landgren
- b Myeloma Service, Division of Hematologic Oncology, Department of Medicine , Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Eric L Smith
- b Myeloma Service, Division of Hematologic Oncology, Department of Medicine , Memorial Sloan Kettering Cancer Center , New York , NY , USA.,d Cellular Therapeutics Center, Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Renier J Brentjens
- d Cellular Therapeutics Center, Memorial Sloan Kettering Cancer Center , New York , NY , USA.,e Leukemia Service, Department of Medicine , Memorial Sloan Kettering Cancer Center , New York , NY , USA
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109
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Vangsted AJ, Helm-Petersen S, Cowland JB, Jensen PB, Gimsing P, Barlogie B, Knudsen S. Drug response prediction in high-risk multiple myeloma. Gene 2017; 644:80-86. [PMID: 29122646 DOI: 10.1016/j.gene.2017.10.071] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/30/2017] [Accepted: 10/25/2017] [Indexed: 01/05/2023]
Abstract
A Drug Response Prediction (DRP) score was developed based on gene expression profiling (GEP) from cell lines and tumor samples. Twenty percent of high-risk patients by GEP70 treated in Total Therapy 2 and 3A have a progression-free survival (PFS) of more than 10years. We used available GEP data from high-risk patients by GEP70 at diagnosis from Total Therapy 2 and 3A to predict the response by the DRP score of drugs used in the treatment of myeloma patients. The DRP score stratified patients further. High-risk myeloma with a predicted sensitivity to melphalan by the DRP score had a prolonged PFS, HR=2.4 (1.2-4.9, P=0.014) and those with predicted sensitivity to bortezomib had a HR 5.7 (1.2-27, P=0.027). In case of predicted sensitivity to bortezomib, a better response to treatment was found (P=0.022). This method may provide us with a tool for identifying candidates for effective personalized medicine and spare potential non-responders from suffering toxicity.
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Affiliation(s)
- A J Vangsted
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - S Helm-Petersen
- Granulocyte Research Laboratory, Copenhagen University Hospital, Copenhagen, Denmark
| | - J B Cowland
- Granulocyte Research Laboratory, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Genetics, Copenhagen University Hospital, Copenhagen, Denmark
| | - P B Jensen
- Medical Prognosis Institute, Hørsholm, Hematology-Oncology, Denmark
| | - P Gimsing
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - S Knudsen
- Medical Prognosis Institute, Hørsholm, Hematology-Oncology, Denmark
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110
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Lancman G, Tremblay D, Barley K, Barlogie B, Cho HJ, Jagannath S, Madduri D, Moshier E, Parekh S, Chari A. The effect of novel therapies in high-molecular-risk multiple myeloma. CLINICAL ADVANCES IN HEMATOLOGY & ONCOLOGY : H&O 2017; 15:870-879. [PMID: 29200420 PMCID: PMC5993678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Multiple myeloma is a heterogeneous disease with a prognosis that varies with patient factors, disease burden, tumor biology, and treatments. Certain molecular abnormalities confer a worse prognosis and thus are considered high-risk. These include t(4;14), del(17p), t(14;16), t(14;20), hypodiploidy, and gain(1q)/del(1p). In our previous review in 2013, we discussed the effect of available therapies on prognosis in these high-risk patients. Since then, seven phase 3 clinical trials in relapsed myeloma with 1 to 3 lines of therapy have been conducted, resulting in the approval of panobinostat, ixazomib, daratumumab, and elotuzumab, as well as additional data on carfilzomib. In our current review of these studies, all the novel therapies resulted in an improvement in progression-free survival for high-risk patients, but none of the trials provided clear statistical evidence that they overcame high-risk status. Moreover, there are several limitations in the currently available data. For example, the patient's Revised International Staging System score is generally not reported, and even when it is reported, it is usually at the time of initial diagnosis rather than at the time of study entry. Furthermore, the methodology used to determine risk suffers from technologic issues. Finally, the clonal and allele burden and concurrent molecular abnormalities can affect risk status and prognosis. To determine the optimal therapy for high-risk patients, future clinical trials should provide standardized risk assessments for all patients in addition to hazard ratios for Kaplan-Meier survival curves of high-risk patients vs those of standard-risk patients to determine if high-risk status has truly been overcome by a novel agent.
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Affiliation(s)
- Guido Lancman
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Kevin Barley
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bart Barlogie
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hearn Jay Cho
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Deepu Madduri
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Erin Moshier
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samir Parekh
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ajai Chari
- Icahn School of Medicine at Mount Sinai, New York, New York
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111
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Jelinek T, Bezdekova R, Zatopkova M, Burgos L, Simicek M, Sevcikova T, Paiva B, Hajek R. Current applications of multiparameter flow cytometry in plasma cell disorders. Blood Cancer J 2017; 7:e617. [PMID: 29053157 PMCID: PMC5678219 DOI: 10.1038/bcj.2017.90] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 07/30/2017] [Accepted: 08/07/2017] [Indexed: 12/12/2022] Open
Abstract
Multiparameter flow cytometry (MFC) has become standard in the management of patients with plasma cell (PC) dyscrasias, and could be considered mandatory in specific areas of routine clinical practice. It plays a significant role during the differential diagnostic work-up because of its fast and conclusive readout of PC clonality, and simultaneously provides prognostic information in most monoclonal gammopathies. Recent advances in the treatment and outcomes of multiple myeloma led to the implementation of new response criteria, including minimal residual disease (MRD) status as one of the most relevant clinical endpoints with the potential to act as surrogate for survival. Recent technical progress led to the development of next-generation flow (NGF) cytometry that represents a validated, highly sensitive, cost-effective and widely available technique for standardized MRD evaluation, which also could be used for the detection of circulating tumor cells. Here we review current applications of MFC and NGF in most PC disorders including the less frequent solitary plasmocytoma, light-chain amyloidosis or Waldenström macroglobulinemia.
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Affiliation(s)
- T Jelinek
- Department of Haematooncology, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,Faculty of Science, University of Ostrava, Ostrava, Czech Republic.,Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), IDISNA, Pamplona, Spain
| | - R Bezdekova
- Department of Clinical Haematology, University Hospital Brno, Brno, Czech Republic
| | - M Zatopkova
- Faculty of Science, University of Ostrava, Ostrava, Czech Republic
| | - L Burgos
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), IDISNA, Pamplona, Spain
| | - M Simicek
- Faculty of Science, University of Ostrava, Ostrava, Czech Republic
| | - T Sevcikova
- Faculty of Science, University of Ostrava, Ostrava, Czech Republic
| | - B Paiva
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), IDISNA, Pamplona, Spain
| | - R Hajek
- Department of Haematooncology, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,Faculty of Science, University of Ostrava, Ostrava, Czech Republic
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112
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Thidemann Andersen K, Klausen T, Abildgaard N, Klarskov Andersen M, Frost Andersen N, Christian Frølund U, Helleberg C, Kjeldsen E, Pedersen P, Helm-Petersen S, Svirskaite A, Preiss B, Gimsing P, Juul Vangsted A. Causes of early death in multiple myeloma patients treated with high-dose therapy followed by autologous stem cell transplantation: A study based on the nationwide Danish Multiple Myeloma Registry. Am J Hematol 2017; 92:E611-E614. [PMID: 28707398 DOI: 10.1002/ajh.24857] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 07/09/2017] [Accepted: 07/11/2017] [Indexed: 12/27/2022]
Affiliation(s)
| | - Tobias Klausen
- Department of Hematology; Herlev Hospital; Herlev Ringvej 75, Herlev 2730 Denmark
| | - Niels Abildgaard
- Department of Hematology; Odense University Hospital; Søndre Boulevard 29, Odense 5000 Denmark
| | | | - Niels Frost Andersen
- Department of Hematology; Aarhus University Hospital; Tage-Hansens Gade 2, Århus C 8000 Denmark
| | | | - Carsten Helleberg
- Department of Hematology; Herlev Hospital; Herlev Ringvej 75, Herlev 2730 Denmark
| | - Eigil Kjeldsen
- HemoDiagnostic Laboratory; Aarhus University Hospital; Tage-Hansens Gade 2, Århus C 8000 Denmark
| | - Per Pedersen
- Department of Hematology; Sydvestjysk Sygehus Esbjerg; Finsensgade 35, Esbjerg 6700 Denmark
| | - Sissel Helm-Petersen
- Department of Hematology; Rigshospitalet; Blegdamsvej 9, København Ø 2100 Denmark
| | - Asta Svirskaite
- Department of Hematology; Aalborg University Hospital; Hobrovej 18, Aalborg 9000 Denmark
| | - Birgitte Preiss
- Department of Clinical Pathology; Odense University Hospital; J. B. Winsløws Vej 15, Odense 5000 Denmark
| | - Peter Gimsing
- Department of Hematology; Rigshospitalet; Blegdamsvej 9, København Ø 2100 Denmark
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113
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Hernández-García S, San-Segundo L, González-Méndez L, Corchete LA, Misiewicz-Krzeminska I, Martín-Sánchez M, López-Iglesias AA, Algarín EM, Mogollón P, Díaz-Tejedor A, Paíno T, Tunquist B, Mateos MV, Gutiérrez NC, Díaz-Rodriguez E, Garayoa M, Ocio EM. The kinesin spindle protein inhibitor filanesib enhances the activity of pomalidomide and dexamethasone in multiple myeloma. Haematologica 2017; 102:2113-2124. [PMID: 28860344 PMCID: PMC5709111 DOI: 10.3324/haematol.2017.168666] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 08/29/2017] [Indexed: 01/20/2023] Open
Abstract
Kinesin spindle protein inhibition is known to be an effective therapeutic approach in several malignancies. Filanesib (ARRY-520), an inhibitor of this protein, has demonstrated activity in heavily pre-treated multiple myeloma patients. The aim of the work herein was to investigate the activity of filanesib in combination with pomalidomide plus dexamethasone backbone, and the mechanisms underlying the potential synergistic effect. The ability of filanesib to enhance the activity of pomalidomide plus dexamethasone was studied in several in vitro and in vivo models. Mechanisms of this synergistic combination were dissected by gene expression profiling, immunostaining, cell cycle and short interfering ribonucleic acid studies. Filanesib showed in vitro, ex vivo, and in vivo synergy with pomalidomide plus dexamethasone treatment. Importantly, the in vivo synergy observed in this combination was more evident in large, highly proliferative tumors, and was shown to be mediated by the impairment of mitosis transcriptional control, an increase in monopolar spindles, cell cycle arrest and the induction of apoptosis in cells in proliferative phases. In addition, the triple combination increased the activation of the proapoptotic protein BAX, which has previously been associated with sensitivity to filanesib, and could potentially be used as a predictive biomarker of response to this combination. Our results provide preclinical evidence for the potential benefit of the combination of filanesib with pomalidomide and dexamethasone, and supported the initiation of a recently activated trial being conducted by the Spanish Myeloma group which is investigating this combination in relapsed myeloma patients.
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Affiliation(s)
- Susana Hernández-García
- Centro Investigación del Cáncer-IBMCC (CSIC-USAL) and Hospital Universitario-IBSAL, Salamanca, Spain
| | - Laura San-Segundo
- Centro Investigación del Cáncer-IBMCC (CSIC-USAL) and Hospital Universitario-IBSAL, Salamanca, Spain
| | - Lorena González-Méndez
- Centro Investigación del Cáncer-IBMCC (CSIC-USAL) and Hospital Universitario-IBSAL, Salamanca, Spain
| | - Luis A Corchete
- Centro Investigación del Cáncer-IBMCC (CSIC-USAL) and Hospital Universitario-IBSAL, Salamanca, Spain
| | - Irena Misiewicz-Krzeminska
- Centro Investigación del Cáncer-IBMCC (CSIC-USAL) and Hospital Universitario-IBSAL, Salamanca, Spain.,National Medicines Institute, Warsaw, Poland
| | - Montserrat Martín-Sánchez
- Centro Investigación del Cáncer-IBMCC (CSIC-USAL) and Hospital Universitario-IBSAL, Salamanca, Spain
| | - Ana-Alicia López-Iglesias
- Centro Investigación del Cáncer-IBMCC (CSIC-USAL) and Hospital Universitario-IBSAL, Salamanca, Spain
| | | | - Pedro Mogollón
- Centro Investigación del Cáncer-IBMCC (CSIC-USAL) and Hospital Universitario-IBSAL, Salamanca, Spain
| | - Andrea Díaz-Tejedor
- Centro Investigación del Cáncer-IBMCC (CSIC-USAL) and Hospital Universitario-IBSAL, Salamanca, Spain
| | - Teresa Paíno
- Centro Investigación del Cáncer-IBMCC (CSIC-USAL) and Hospital Universitario-IBSAL, Salamanca, Spain
| | | | - María-Victoria Mateos
- Centro Investigación del Cáncer-IBMCC (CSIC-USAL) and Hospital Universitario-IBSAL, Salamanca, Spain
| | - Norma C Gutiérrez
- Centro Investigación del Cáncer-IBMCC (CSIC-USAL) and Hospital Universitario-IBSAL, Salamanca, Spain
| | - Elena Díaz-Rodriguez
- Centro Investigación del Cáncer-IBMCC (CSIC-USAL) and Hospital Universitario-IBSAL, Salamanca, Spain
| | - Mercedes Garayoa
- Centro Investigación del Cáncer-IBMCC (CSIC-USAL) and Hospital Universitario-IBSAL, Salamanca, Spain
| | - Enrique M Ocio
- Centro Investigación del Cáncer-IBMCC (CSIC-USAL) and Hospital Universitario-IBSAL, Salamanca, Spain
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Abstract
The outcomes for the majority of patients with myeloma have improved over recent decades, driven by treatment advances. However, there is a subset of patients considered to have high-risk disease who have not benefited. Understanding how high-risk disease evolves from more therapeutically tractable stages is crucial if we are to improve outcomes. This can be accomplished by identifying the genetic mechanisms and mutations driving the transition of a normal plasma cell to one with the features of the following disease stages: monoclonal gammopathy of undetermined significance, smouldering myeloma, myeloma and plasma cell leukaemia. Although myeloma initiating events are clonal, subsequent driver lesions often occur in a subclone of cells, facilitating progression by Darwinian selection processes. Understanding the co-evolution of the clones within their microenvironment will be crucial for therapeutically manipulating the process. The end stage of progression is the generation of a state associated with treatment resistance, increased proliferation, evasion of apoptosis and an ability to grow independently of the bone marrow microenvironment. In this Review, we discuss these end-stage high-risk disease states and how new information is improving our understanding of their evolutionary trajectories, how they may be diagnosed and the biological behaviour that must be addressed if they are to be treated effectively.
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Affiliation(s)
- Charlotte Pawlyn
- The Institute of Cancer Research, 15 Cotswold Road, Sutton SM2 5NG, UK
| | - Gareth J Morgan
- The Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA
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115
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Ríos-Tamayo R, Martín-García A, Alarcón-Payer C, Sánchez-Rodríguez D, de la Guardia AMDVD, García Collado CG, Jiménez Morales A, Jurado Chacón M, Cabeza Barrera J. Pomalidomide in the treatment of multiple myeloma: design, development and place in therapy. Drug Des Devel Ther 2017; 11:2399-2408. [PMID: 28860711 PMCID: PMC5574598 DOI: 10.2147/dddt.s115456] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Multiple myeloma is a very heterogeneous disease with variable survival. Despite recent progress and the widespread use of new agents, patients with relapsed and refractory disease have a poor outcome. Immunomodulatory drugs play a key role in both the front-line and the relapsed/refractory setting. The combination of pomalidomide (POM) and dexamethasone is safe and effective in relapsed and refractory patients, even in those with high-risk cytogenetic features. Furthermore, it can be used in most patients without the need to adjust according to the degree of renal failure. In order to further improve the results, POM-based triplet therapies are currently used. This article highlights the most relevant issues of POM and POM-based combinations in the relapsed/refractory multiple myeloma setting, from a pharmacological and clinical point of view.
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Affiliation(s)
- Rafael Ríos-Tamayo
- Monoclonal Gammopathies Unit
- Department of Hematology, University Hospital Virgen de las Nieves, Granada, Spain
- Genomic Oncology Area, GENYO, Center for Genomics and Oncological Research: Pfizer/University of Granada/Andalusian Regional Government, PTS, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (Ibs.GRANADA), Hospitales Universitarios de Granada/Universidad de Granada, Granada, Spain
| | - Agustín Martín-García
- Department of Pharmacy
- Clinical Trials Unit, University Hospital Virgen de las Nieves, Granada, Spain
| | | | | | | | | | | | - Manuel Jurado Chacón
- Monoclonal Gammopathies Unit
- Department of Hematology, University Hospital Virgen de las Nieves, Granada, Spain
- Genomic Oncology Area, GENYO, Center for Genomics and Oncological Research: Pfizer/University of Granada/Andalusian Regional Government, PTS, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (Ibs.GRANADA), Hospitales Universitarios de Granada/Universidad de Granada, Granada, Spain
| | - José Cabeza Barrera
- Instituto de Investigación Biosanitaria de Granada (Ibs.GRANADA), Hospitales Universitarios de Granada/Universidad de Granada, Granada, Spain
- Department of Pharmacy
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116
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Spatial genomic heterogeneity in multiple myeloma revealed by multi-region sequencing. Nat Commun 2017; 8:268. [PMID: 28814763 PMCID: PMC5559527 DOI: 10.1038/s41467-017-00296-y] [Citation(s) in RCA: 251] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 06/20/2017] [Indexed: 12/27/2022] Open
Abstract
In multiple myeloma malignant plasma cells expand within the bone marrow. Since this site is well-perfused, a rapid dissemination of "fitter" clones may be anticipated. However, an imbalanced distribution of multiple myeloma is frequently observed in medical imaging. Here, we perform multi-region sequencing, including iliac crest and radiology-guided focal lesion specimens from 51 patients to gain insight into the spatial clonal architecture. We demonstrate spatial genomic heterogeneity in more than 75% of patients, including inactivation of CDKN2C and TP53, and mutations affecting mitogen-activated protein kinase genes. We show that the extent of spatial heterogeneity is positively associated with the size of biopsied focal lesions consistent with regional outgrowth of advanced clones. The results support a model for multiple myeloma progression with clonal sweeps in the early phase and regional evolution in advanced disease. We suggest that multi-region investigations are critical to understanding intra-patient heterogeneity and the evolutionary processes in multiple myeloma.In multiple myeloma, malignant cells expand within bone marrow. Here, the authors use multi-region sequencing in patient samples to analyse spatial clonal architecture and heterogeneity, providing novel insight into multiple myeloma progression and evolution.
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117
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Kurtin S. Living with Multiple Myeloma: A Continuum-Based Approach to Cancer Survivorship. Semin Oncol Nurs 2017; 33:348-361. [DOI: 10.1016/j.soncn.2017.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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118
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Abstract
PURPOSE OF REVIEW Although the input of multiparameter flow cytometry (MFC) into the clinical management of multiple myeloma patients has faced some reluctance, continuously growing evidence supports the utility of MFC in this disease. RECENT FINDINGS MFC immunophenotyping of bone marrow and peripheral blood plasma cells affords cost-effective assessment of clonality, and provides prognostic information on the risk of progression in smoldering multiple myeloma, and the identification of active multiple myeloma patients with dismal outcome (e.g., high numbers of circulating tumor cells) or long-term survival despite suboptimal responses through the characterization of monoclonal gammopathy of undetermined significance-like phenotypes. Extensive data indicate that minimal residual disease (MRD) monitoring can be used as biomarker to evaluate treatment efficacy and act as surrogate for survival. The time has come to address within clinical trials the exact role of baseline risk factors and MRD monitoring for tailored therapy in multiple myeloma, which implies systematic usage of highly sensitive cost-effective, readily available, and standardized MRD techniques such as MFC. SUMMARY Next-generation MFC should be considered mandatory in the routine evaluation of multiple myeloma patients both at diagnosis and after therapy, and represents an attractive technique to integrate with high-throughput DNA and RNA-seq methods to help in understanding the mechanisms behind dissemination and chemoresistance of multiple myeloma.
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120
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Abstract
The standard treatment of relapsed multiple myeloma has been either lenalidomide-dexamethasone (RD) or bortezomib-dexamethasone (VD) but it is changing rapidly for 2 reasons. First, lenalidomide and bortezomib are currently used in frontline treatment and many patients become resistant to these agents early in the course of their disease. Second, 6 second-line new agents have been recently developed and offer new possibilities (pomalidomide, carfilzomib and ixazomib, panobinostat, elotuzumab, and daratumumab). Recent randomized studies have shown that triple combinations adding 1 of these new agents (except pomalidomide) to the RD or VD regimens were superior to the double combinations in terms of response rate and progression-free survival (PFS). Their place in the treatment of first relapse is discussed here. Among these agents, daratumumab is clearly a breakthrough and daratumumab-based combinations might become the preferred option in the near future. However, all of these drugs are expensive and are not available or affordable in all countries. We propose a decision algorithm for first relapse in fit patients with the objective of achieving the best PFS. The choice of salvage regimen is based on lenalidomide/bortezomib resistance, daratumumab availability, and cost. Autologous transplantation should be considered in younger patients if not used upfront.
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121
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Innao V, Allegra A, Russo S, Gerace D, Vaddinelli D, Alonci A, Allegra AG, Musolino C. Standardisation of minimal residual disease in multiple myeloma. Eur J Cancer Care (Engl) 2017; 26. [PMID: 28671297 DOI: 10.1111/ecc.12732] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2017] [Indexed: 12/16/2022]
Abstract
The assessment of the effectiveness of chemotherapy in oncology cannot disregard the concept of minimal residual disease (MRD). In fact, the efforts of numerous scientific groups all over the world are currently focusing on this issue, with the sole purpose of defining sensitive, effective assessment criteria that are, above all, able to give acceptable, easily repeatable results worldwide. Regarding this issue, especially with the advent of new drugs, multiple myeloma is one of the haematologic malignancies for which a consensus has not yet been reached. In this review, we analyse various techniques that have been used to improve the sensitivity of response, aimed at reducing the cut-off values previously allowed, as well as serological values like serum-free light chain, or immunophenotypic tools on bone marrow or peripheral blood, like multi-parameter flow cytometry, or molecular ones such as allele-specific oligonucleotide (ASO)-qPCR and next-generation/high-throughput sequencing technologies (NGS). Moreover, our discussion makes a brief reference to promising techniques, such as mass spectrometry for identifying Ig light chain (LC) in peripheral blood, and the assessment of gene expression profile not only in defining prognostic risk at the diagnosis but also as a tool for evaluation of response.
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Affiliation(s)
- V Innao
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - A Allegra
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - S Russo
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - D Gerace
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - D Vaddinelli
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - A Alonci
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - A G Allegra
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - C Musolino
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
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122
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Abstract
There have been major recent advancements in the understanding and management of multiple myeloma which in turn has led to unprecedented survival outcomes for patients. Diagnostic and response criteria have been recently revised. Our understanding of clonal progression, evolution, and clonal tides will inform therapeutic choices and appropriate treatment for patients. Response rates to initial induction with modern triplet therapies containing proteasome inhibitors and immunomodulators have made this approach the global standard for initial treatment. Although the relevance of autologous transplantation has been questioned in the setting of modern induction therapy, we have new data suggesting its continued relevance. Recent studies performed in the context of novel agent induction suggest that autologous transplantation continues to improve response rates and progression-free survival, thus underscoring its role in transplant-eligible patients. Emerging paradigms in the treatment of multiple myeloma include immune approaches, such as adoptive cellular therapies, vaccines, or antibody-based immune manipulations, all of which seem to synergize with a transplant platform. Allogeneic transplantation is limited in scope by the concern of prohibitive toxicity and is applicable mainly to younger patients with high-risk disease. However, the allogeneic approach offers even more options of immunotherapy at relapse, including donor lymphocyte infusions, immunomodulatory drug maintenance, and withdrawal of immune suppression.
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Affiliation(s)
- Parameswaran Hari
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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123
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BTK suppresses myeloma cellular senescence through activating AKT/P27/Rb signaling. Oncotarget 2017; 8:56858-56867. [PMID: 28915637 PMCID: PMC5593608 DOI: 10.18632/oncotarget.18096] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 04/04/2017] [Indexed: 01/22/2023] Open
Abstract
We previously explored the role of BTK in maintaining multiple myeloma stem cells (MMSCs) self-renewal and drug-resistance. Here we investigated the elevation of BTK suppressing MM cellular senescence, a state of irreversible cellular growth arrest. We firstly discovered that an increased expression of BTK in MM samples compared to normal controls by immunohistochemistry (IHC), and significant chromosomal gain in primary samples. In addition, BTK high-expressing MM patients are associated with poor outcome in both Total Therapy 2 (TT2) and TT3 cohorts. Knockdown BTK expression by shRNA induced MM cellular senescence using β-galactosidase (SA-b-gal) staining, cell growth arrest by cell cycle staining and decreased clonogenicity while forcing BTK expression in MM cells abrogated these characteristics. We also validated this feature in mouse embryonic fibroblast cells (MEFs), which showed that elevated BTK expression was resistant to MEF senescence after serial cultivation in vitro. Further mechanism study revealed that BTK activated AKT signaling leading to down-regulation of P27 expression and hindered RB activity while AKT inhibitor, LY294002, overcame BTK-overexpression induced cellular senescence resistance. Eventually we demonstrated that BTK inhibitor, CGI-1746, induced MM cellular senescence, colony reduction and tumorigenecity inhibition in vivo. Summarily, we designate a novel mechanism of BTK in mediating MM growth, and BTK inhibitor is of great potential in vivo and in vitro suggesting BTK is a promising therapeutic target for MM.
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124
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Schinke C, Hoering A, Wang H, Carlton V, Thanandrarajan S, Deshpande S, Patel P, Molnar G, Susanibar S, Mohan M, Mathur P, Radhakrishnan M, Hoque S, Jo Kamimoto J, Grazziutti M, van Rhee F, Zangari M, Insuasti-Beltran G, Alapat D, Post G, Yaccoby S, Epstein J, Rasche L, Johnson S, Moorhead M, Willis T, Barlogie B, Walker B, Weinhold N, Davies FE, Morgan GJ. The prognostic value of the depth of response in multiple myeloma depends on the time of assessment, risk status and molecular subtype. Haematologica 2017; 102:e313-e316. [PMID: 28522572 DOI: 10.3324/haematol.2017.165217] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Carolina Schinke
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Hongwei Wang
- Cancer Resarch and Biostatistics, Seattle, WA, USA
| | | | | | - Shayu Deshpande
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Purvi Patel
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Gabor Molnar
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sandra Susanibar
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Meera Mohan
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Pankaj Mathur
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Shadiqul Hoque
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jorge Jo Kamimoto
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Monica Grazziutti
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Frits van Rhee
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Maurizio Zangari
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Daisy Alapat
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ginell Post
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Shmuel Yaccoby
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Joshua Epstein
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Leo Rasche
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sarah Johnson
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Tom Willis
- Adaptive Biotechnologies, San Francisco, CA, USA
| | | | - Brian Walker
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Niels Weinhold
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Faith E Davies
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Gareth J Morgan
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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125
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Lee HC, Wang H, Baladandayuthapani V, Lin H, He J, Jones RJ, Kuiatse I, Gu D, Wang Z, Ma W, Lim J, O'Brien S, Keats J, Yang J, Davis RE, Orlowski RZ. RNA Polymerase I Inhibition with CX-5461 as a Novel Therapeutic Strategy to Target MYC in Multiple Myeloma. Br J Haematol 2017; 177:80-94. [PMID: 28369725 DOI: 10.1111/bjh.14525] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 09/12/2016] [Indexed: 12/15/2022]
Abstract
Dysregulation of MYC is frequently implicated in both early and late myeloma progression events, yet its therapeutic targeting has remained a challenge. Among key MYC downstream targets is ribosomal biogenesis, enabling increases in protein translational capacity necessary to support the growth and self-renewal programmes of malignant cells. We therefore explored the selective targeting of ribosomal biogenesis with the small molecule RNA polymerase (pol) I inhibitor CX-5461 in myeloma. CX-5461 induced significant growth inhibition in wild-type (WT) and mutant TP53 myeloma cell lines and primary samples, in association with increases in downstream markers of apoptosis. Moreover, Pol I inhibition overcame adhesion-mediated drug resistance and resistance to conventional and novel agents. To probe the TP53-independent mechanisms of CX-5461, gene expression profiling was performed on isogenic TP53 WT and knockout cell lines and revealed reduction of MYC downstream targets. Mechanistic studies confirmed that CX-5461 rapidly suppressed both MYC protein and MYC mRNA levels. The latter was associated with an increased binding of the RNA-induced silencing complex (RISC) subunits TARBP2 and AGO2, the ribosomal protein RPL5, and MYC mRNA, resulting in increased MYC transcript degradation. Collectively, these studies provide a rationale for the clinical translation of CX-5461 as a novel therapeutic approach to target MYC in myeloma.
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Affiliation(s)
- Hans C Lee
- The Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hua Wang
- The Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Heather Lin
- The Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jin He
- The Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard J Jones
- The Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Isere Kuiatse
- The Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dongmin Gu
- The Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhiqiang Wang
- The Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wencai Ma
- The Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John Lim
- Senhwa Biosciences, Inc., San Diego, CA, USA
| | | | - Jonathan Keats
- Integrated Cancer Genomics Division, Translational Genomics Research Institute, Phoenix, AZ, USA
| | - Jing Yang
- The Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard E Davis
- The Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert Z Orlowski
- The Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,The Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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126
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Lahuerta JJ, Paiva B, Vidriales MB, Cordón L, Cedena MT, Puig N, Martinez-Lopez J, Rosiñol L, Gutierrez NC, Martín-Ramos ML, Oriol A, Teruel AI, Echeveste MA, de Paz R, de Arriba F, Hernandez MT, Palomera L, Martinez R, Martin A, Alegre A, De la Rubia J, Orfao A, Mateos MV, Blade J, San-Miguel JF. Depth of Response in Multiple Myeloma: A Pooled Analysis of Three PETHEMA/GEM Clinical Trials. J Clin Oncol 2017; 35:2900-2910. [PMID: 28498784 DOI: 10.1200/jco.2016.69.2517] [Citation(s) in RCA: 222] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Purpose To perform a critical analysis on the impact of depth of response in newly diagnosed multiple myeloma (MM). Patients and Methods Data were analyzed from 609 patients who were enrolled in the GEM (Grupo Español de Mieloma) 2000 and GEM2005MENOS65 studies for transplant-eligible MM and the GEM2010MAS65 clinical trial for elderly patients with MM who had minimal residual disease (MRD) assessments 9 months after study enrollment. Median follow-up of the series was 71 months. Results Achievement of complete remission (CR) in the absence of MRD negativity was not associated with prolonged progression-free survival (PFS) and overall survival (OS) compared with near-CR or partial response (median PFS, 27, 27, and 29 months, respectively; median OS, 59, 64, and 65 months, respectively). MRD-negative status was strongly associated with prolonged PFS (median, 63 months; P < .001) and OS (median not reached; P < .001) overall and in subgroups defined by prior transplantation, disease stage, and cytogenetics, with prognostic superiority of MRD negativity versus CR particularly evident in patients with high-risk cytogenetics. Accordingly, Harrell C statistics showed higher discrimination for both PFS and OS in Cox models that included MRD (as opposed to CR) for response assessment. Superior MRD-negative rates after different induction regimens anticipated prolonged PFS. Among 34 MRD-negative patients with MM and a phenotypic pattern of bone marrow involvement similar to monoclonal gammopathy of undetermined significance at diagnosis, the probability of "operational cure" was high; median PFS was 12 years, and the 10-year OS rate was 94%. Conclusion Our results demonstrate that MRD-negative status surpasses the prognostic value of CR achievement for PFS and OS across the disease spectrum, regardless of the type of treatment or patient risk group. MRD negativity should be considered as one of the most relevant end points for transplant-eligible and elderly fit patients with MM.
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Affiliation(s)
- Juan-Jose Lahuerta
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Bruno Paiva
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Maria-Belen Vidriales
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Lourdes Cordón
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Maria-Teresa Cedena
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Noemi Puig
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Joaquin Martinez-Lopez
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Laura Rosiñol
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Norma C Gutierrez
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - María-Luisa Martín-Ramos
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Albert Oriol
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Ana-Isabel Teruel
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - María-Asunción Echeveste
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Raquel de Paz
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Felipe de Arriba
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Miguel T Hernandez
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Luis Palomera
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Rafael Martinez
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Alejandro Martin
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Adrian Alegre
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Javier De la Rubia
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Alberto Orfao
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - María-Victoria Mateos
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Joan Blade
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Jesus F San-Miguel
- Juan-Jose Lahuerta, Maria-Teresa Cedena, Joaquin Martinez-Lopez, and María-Luisa Martín-Ramos, Hospital 12 de Octubre, CIBERONC; Raquel de Paz, Hospital Universitario La Paz; Rafael Martinez, Hospital Clínico San Carlos; Adrian Alegre, Hospital Universitario La Princesa, Madrid; Bruno Paiva and Jesus F. San-Miguel, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona; Laura Rosiñol, and Joan Blade, Hospital Clínic de Barcelona, Barcelona; Maria-Belen Vidriales, Noemi Puig, Norma C. Gutierrez, Alejandro Martin, and María-Victoria Mateos, Hospital Universitario de Salamanca Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC; Alberto Orfao, Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, CIBERONC, Salamanca; Lourdes Cordón and Javier De la Rubia, Hospital Universitario y Politécnico La Fe; Ana-Isabel Teruel, Hospital Clínico de Valencia, Valencia; Albert Oriol, Hospital Germans Trias i Pujol, Badalona; María-Asunción Echeveste, Hospital de Donostia, San Sebastian; Felipe de Arriba, Hospital Morales Meseguer, Murcia; Miguel T. Hernandez, Hospital Universitario de Canarias, Tenerife; Luis Palomera, Hospital Universitario Lozano Blesa, Zaragoza, Spain
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127
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Kurtin S. Integrating Emerging Data Into Clinical Practice: A Case-Based Approach for Multiple Myeloma. J Adv Pract Oncol 2017; 8:365-377. [PMID: 30018842 PMCID: PMC6040880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Selected Patient Cases From the APSHO Regional Lecture SeriesINTRODUCTION As the official publication of the Advanced Practitioner Society for Hematology and Oncology (APSHO), JADPRO is pleased to offer Part 2 of an accredited educational activity based on the recently concluded APSHO Regional Lecture Series. Hosted in collaboration with major cancer centers around the country, the APSHO Regional Lecture Series brought case-based didactic presentations and skills workshops to advanced practitioners. In the spirit of JADPRO, three accredited Grand Rounds articles by Beth Eaby-Sandy, MSN, CRNP, OCN® (non-small cell lung cancer) and Sandra Kurtin, PhDc, ANP-C, AOCN® (multiple myeloma and chronic lymphocytic leukemia)-program chairs for the regional lecture series-offer the same practice-changing information and strategies for advanced practitioners. In this Grand Rounds article, program chair Sandra Kurtin gives a comprehensive overview of the most recent developments in multiple myeloma research from the 2016 American Society of Hematology (ASH) Annual Meeting and clinical insight in the management of patients with this disease. You can read Part 1 in the March 2017 issue of JADPRO or online at advancedpractitioner.com, and be sure to keep an eye out for Part 3 in a future issue of JADPRO. Check out apsho.org/lectures for information on registering for upcoming JADPRO Regional Lectures this year at a location near you.
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Tuchman SA, Moore JO, DeCastro CD, Li Z, Sellars E, Kang Y, Long G, Gasparetto CG. Phase II study of dose-attenuated bortezomib, cyclophosphamide and dexamethasone (“VCD-Lite”) in very old or otherwise toxicity-vulnerable adults with newly diagnosed multiple myeloma. J Geriatr Oncol 2017; 8:165-169. [DOI: 10.1016/j.jgo.2017.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/11/2017] [Accepted: 02/09/2017] [Indexed: 10/20/2022]
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Anderson KC, Auclair D, Kelloff GJ, Sigman CC, Avet-Loiseau H, Farrell AT, Gormley NJ, Kumar SK, Landgren O, Munshi NC, Cavo M, Davies FE, Di Bacco A, Dickey JS, Gutman SI, Higley HR, Hussein MA, Jessup JM, Kirsch IR, Little RF, Loberg RD, Lohr JG, Mukundan L, Omel JL, Pugh TJ, Reaman GH, Robbins MD, Sasser AK, Valente N, Zamagni E. The Role of Minimal Residual Disease Testing in Myeloma Treatment Selection and Drug Development: Current Value and Future Applications. Clin Cancer Res 2017; 23:3980-3993. [PMID: 28428191 DOI: 10.1158/1078-0432.ccr-16-2895] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 01/10/2017] [Accepted: 04/13/2017] [Indexed: 01/22/2023]
Abstract
Treatment of myeloma has benefited from the introduction of more effective and better tolerated agents, improvements in supportive care, better understanding of disease biology, revision of diagnostic criteria, and new sensitive and specific tools for disease prognostication and management. Assessment of minimal residual disease (MRD) in response to therapy is one of these tools, as longer progression-free survival (PFS) is seen consistently among patients who have achieved MRD negativity. Current therapies lead to unprecedented frequency and depth of response, and next-generation flow and sequencing methods to measure MRD in bone marrow are in use and being developed with sensitivities in the range of 10-5 to 10-6 cells. These technologies may be combined with functional imaging to detect MRD outside of bone marrow. Moreover, immune profiling methods are being developed to better understand the immune environment in myeloma and response to immunomodulatory agents while methods for molecular profiling of myeloma cells and circulating DNA in blood are also emerging. With the continued development and standardization of these methodologies, MRD has high potential for use in gaining new drug approvals in myeloma. The FDA has outlined two pathways by which MRD could be qualified as a surrogate endpoint for clinical studies directed at obtaining accelerated approval for new myeloma drugs. Most importantly, better understanding of MRD should also contribute to better treatment monitoring. Potentially, MRD status could be used as a prognostic factor for making treatment decisions and for informing timing of therapeutic interventions. Clin Cancer Res; 23(15); 3980-93. ©2017 AACR.
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Affiliation(s)
- Kenneth C Anderson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.
| | - Daniel Auclair
- Multiple Myeloma Research Foundation, Norwalk, Connecticut
| | - Gary J Kelloff
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | | | - Hervé Avet-Loiseau
- Laboratoire d'Hématologie, Pôle Biologie, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Ann T Farrell
- Office of Hematology and Oncology Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Nicole J Gormley
- Office of Hematology and Oncology Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Shaji K Kumar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Ola Landgren
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nikhil C Munshi
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Michele Cavo
- Seragnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
| | - Faith E Davies
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Alessandra Di Bacco
- Translational Medicine, Oncology, Takeda Pharmaceuticals, Cambridge, Massachusetts
| | - Jennifer S Dickey
- Division of Molecular Genetics and Pathology, Office of In Vitro Diagnostics and Radiological Health, Center for Devices and Radiologic Health, U.S. Food and Drug Administration, Silver Spring, Maryland
| | | | | | - Mohamad A Hussein
- Department of Hematology, Morsini College of Medicine, University of South Florida, Tampa, Florida
- Scientific Collaborations, Celgene Corporation, Summit, New Jersey
| | - J Milburn Jessup
- Precision Cancer Care Program, Inova Schar Cancer Institute, Falls Church, Virginia
| | - Ilan R Kirsch
- Translational Medicine, Adaptive Biotechnologies, Seattle, Washington
| | - Richard F Little
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | | | - Jens G Lohr
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | | | - James L Omel
- Central Nebraska Myeloma Support Group, Grand Island, Nebraska
| | - Trevor J Pugh
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Gregory H Reaman
- Office of Hematology and Oncology Products, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | | | - A Kate Sasser
- Translational Research, Oncology, Janssen Research & Development, Spring House, Pennsylvania
| | - Nancy Valente
- BioOncology, Genentech Inc., South San Francisco, California
| | - Elena Zamagni
- Seragnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
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Hoering A, Durie B, Wang H, Crowley J. End points and statistical considerations in immuno-oncology trials: impact on multiple myeloma. Future Oncol 2017; 13:1181-1193. [PMID: 28395525 PMCID: PMC5705823 DOI: 10.2217/fon-2016-0504] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Unlike conventional cancer treatment, immuno-oncology therapies are commonly associated with delayed clinical benefit and durable responses, as seen with immuno-oncology therapies for multiple myeloma (MM). Therefore, a longer-term approach to immuno-oncology data assessment is required. Appropriate study designs, end points and statistical methods are essential for evaluating immuno-oncology therapies to assess treatment outcomes, and may better accommodate immuno-oncology clinical trial data. In addition to conventional end points including median progression-free survival (PFS) and overall survival (OS), end points such as hazard ratios for PFS and OS over time, PFS and OS landmark analyses beyond the median, and immune-response end points might provide better indications of the efficacy of immuno-oncology therapies. Long-term data with these agents will allow better prediction of outcomes in MM.
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Affiliation(s)
- Antje Hoering
- Cancer Research And Biostatistics (CRAB), Seattle, WA, USA
| | - Brian Durie
- Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Hongwei Wang
- Cancer Research And Biostatistics (CRAB), Seattle, WA, USA
| | - John Crowley
- Cancer Research And Biostatistics (CRAB), Seattle, WA, USA
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Dingli D, Ailawadhi S, Bergsagel PL, Buadi FK, Dispenzieri A, Fonseca R, Gertz MA, Gonsalves WI, Hayman SR, Kapoor P, Kourelis T, Kumar SK, Kyle RA, Lacy MQ, Leung N, Lin Y, Lust JA, Mikhael JR, Reeder CB, Roy V, Russell SJ, Sher T, Stewart AK, Warsame R, Zeldenrust SR, Rajkumar SV, Chanan Khan AA. Therapy for Relapsed Multiple Myeloma: Guidelines From the Mayo Stratification for Myeloma and Risk-Adapted Therapy. Mayo Clin Proc 2017; 92:578-598. [PMID: 28291589 PMCID: PMC5554888 DOI: 10.1016/j.mayocp.2017.01.003] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 12/12/2016] [Accepted: 01/04/2017] [Indexed: 12/13/2022]
Abstract
Life expectancy in patients with multiple myeloma is increasing because of the availability of an increasing number of novel agents with various mechanisms of action against the disease. However, the disease remains incurable in most patients because of the emergence of resistant clones, leading to repeated relapses of the disease. In 2015, 5 novel agents were approved for therapy for relapsed multiple myeloma. This surfeit of novel agents renders management of relapsed multiple myeloma more complex because of the occurrence of multiple relapses, the risk of cumulative and emergent toxicity from previous therapies, as well as evolution of the disease during therapy. A group of physicians at Mayo Clinic with expertise in the care of patients with multiple myeloma regularly evaluates the evolving literature on the biology and therapy for multiple myeloma and issues guidelines on the optimal care of patients with this disease. In this article, the latest recommendations on the diagnostic evaluation of relapsed multiple myeloma and decision trees on how to treat patients at various stages of their relapse (off study) are provided together with the evidence to support them.
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Affiliation(s)
- David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
| | | | - P Leif Bergsagel
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ
| | - Francis K Buadi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Angela Dispenzieri
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Rafael Fonseca
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ
| | - Morie A Gertz
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Wilson I Gonsalves
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Susan R Hayman
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Prashant Kapoor
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Taxiarchis Kourelis
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Shaji K Kumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Robert A Kyle
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Martha Q Lacy
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Nelson Leung
- Division of Nephrology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Yi Lin
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - John A Lust
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Joseph R Mikhael
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ
| | - Craig B Reeder
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ
| | - Vivek Roy
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL
| | - Stephen J Russell
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Taimur Sher
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL
| | - A Keith Stewart
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ
| | - Rahma Warsame
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Stephen R Zeldenrust
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - S Vincent Rajkumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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132
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Landgren O, Iskander K. Modern multiple myeloma therapy: deep, sustained treatment response and good clinical outcomes. J Intern Med 2017; 281:365-382. [PMID: 28205262 DOI: 10.1111/joim.12590] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In the USA at the beginning of this century, the average overall survival in patients with multiple myeloma was about 3 years. Around that time, three drugs (bortezomib, lenalidomide and thalidomide) were introduced for the treatment of multiple myeloma and, in 2012, carfilzomib received accelerated approval by the US Food and Drug Administration (FDA). Driven by access to better drugs, median overall survival in younger patients (aged <50 years) was >10 years by 2014. The FDA approved 14 new drugs for the treatment of cancer in 2015; four of these were approved for the treatment of myeloma (panobinostat, daratumumab, elotuzumab and ixazomib). In 2015 and 2016, expanded label indications were approved by the FDA for lenalidomide and carfilzomib, respectively. The recent increase in approved, highly effective combination therapies for patients with multiple myeloma has led the way to redefining the goals of therapy. Here, we review and provide a clinical perspective on the treatment goals and management of multiple myeloma in the era of modern therapy. Recent meta-analyses show that minimal residual disease (MRD) negativity is associated with longer progression-free and overall survival in patients with multiple myeloma. With the use of modern combination therapy, large proportions (>60-70%) of newly diagnosed multiple myeloma patients achieve complete responses and MRD negativity. Modern combination therapies induce rapid, deep and sustainable responses (including MRD negativity), supporting a treatment paradigm shift away from palliative two-drug combinations towards the use of modern, potent, three- or four-drug combination regimens in early lines of therapy. Data support the use of modern therapy upfront rather than reserving it for later stages of the disease. As survival time increases with modern combination therapies, development of early reliable surrogate end-points for survival, such as MRD negativity, are needed for expedited read-out of future randomized clinical trials.
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Affiliation(s)
- O Landgren
- Myeloma Service, Division of Hematology Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - K Iskander
- Department of Clinical Development, Amgen, Thousand Oaks, CA, USA
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Overexpression of EZH2 in multiple myeloma is associated with poor prognosis and dysregulation of cell cycle control. Blood Cancer J 2017; 7:e549. [PMID: 28362441 PMCID: PMC5380911 DOI: 10.1038/bcj.2017.27] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 02/23/2017] [Indexed: 12/31/2022] Open
Abstract
Myeloma is heterogeneous at the molecular level with subgroups of patients characterised by features of epigenetic dysregulation. Outcomes for myeloma patients have improved over the past few decades except for molecularly defined high-risk patients who continue to do badly. Novel therapeutic approaches are, therefore, required. A growing number of epigenetic inhibitors are now available including EZH2 inhibitors that are in early-stage clinical trials for treatment of haematological and other cancers with EZH2 mutations or in which overexpression has been correlated with poor outcomes. For the first time, we have identified and validated a robust and independent deleterious effect of high EZH2 expression on outcomes in myeloma patients. Using two chemically distinct small-molecule inhibitors, we demonstrate a reduction in myeloma cell proliferation with EZH2 inhibition, which leads to cell cycle arrest followed by apoptosis. This is mediated via upregulation of cyclin-dependent kinase inhibitors associated with removal of the inhibitory H3K27me3 mark at their gene loci. Our results suggest that EZH2 inhibition may be a potential therapeutic strategy for the treatment of myeloma and should be investigated in clinical studies.
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134
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How I manage the toxicities of myeloma drugs. Blood 2017; 129:2359-2367. [PMID: 28275090 DOI: 10.1182/blood-2017-01-725705] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 03/06/2017] [Indexed: 01/05/2023] Open
Abstract
The treatment of multiple myeloma is considered a continuously evolving paradigm as a result of the growing availability of new and highly effective drugs, including first- and second-generation proteasome inhibitors, immunomodulatory agents, and monoclonal antibodies. Clinical trials advocate long-term rather than short-term treatment schedules with combinations of these new anti-myeloma drug classes. Although the overall toxicity profile of the recommended regimens can be considered favorable, their increasing complexity and prolonged use warrant a heightened vigilance for early and late side effects, a priori because real-life patients can be more frail or present with 1 or more comorbidities. The treatment decision process, at diagnosis and at relapse, therefore requires myeloma physicians to carefully balance efficacy and toxicity profiles for each individual patient. Early and/or unnecessary tapering or treatment discontinuation for drug-related adverse events may not only reduce patients' quality of life, but also negatively impact their outcome. Accurate knowledge in recognizing and managing the potential side effects of present-day treatment regimens is therefore a cornerstone in myeloma care. Using 5 case vignettes, we discuss how to prevent and manage the most common nonhematological adverse events of anti-myeloma treatment regimens containing proteasome inhibitors, immunomodulatory drugs, and monoclonal antibodies.
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135
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Mohan M, Matin A, Davies FE. Update on the optimal use of bortezomib in the treatment of multiple myeloma. Cancer Manag Res 2017; 9:51-63. [PMID: 28280389 PMCID: PMC5338851 DOI: 10.2147/cmar.s105163] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The proteasome inhibitor (PI) "bortezomib" has now been in routine clinical practice for over a decade. It is now considered an important backbone therapy for all stages of the disease, and data continue to grow to support its use in newly diagnosed patients, relapsed and relapsed/refractory disease, maintenance therapy, high risk, and renal failure. Much has been learnt about the most clinically effective way of delivering therapy, with patients often benefiting more from a triplet bortezomib combination compared to a doublet combination. It is well tolerated and can be administered in the outpatient setting with manageable toxicity. The key to good results is managing side effects so that patients remain on therapy with minimal interruptions. Therefore, proactive management of peripheral neuropathy and thrombocytopenia is advised using dose delay and reduction strategies. The recent introduction of second- and third-generation PIs with different chemical and biological properties has resulted in a plethora of new clinical studies and has confirmed the ongoing role of this class of drugs in future myeloma therapy.
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Affiliation(s)
- Meera Mohan
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Aasiya Matin
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Faith E Davies
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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136
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Bolomsky A, Hübl W, Spada S, Müldür E, Schlangen K, Heintel D, Rocci A, Weißmann A, Fritz V, Willheim M, Zojer N, Palumbo A, Ludwig H. IKAROS expression in distinct bone marrow cell populations as a candidate biomarker for outcome with lenalidomide-dexamethasone therapy in multiple myeloma. Am J Hematol 2017; 92:269-278. [PMID: 28052520 DOI: 10.1002/ajh.24634] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 11/29/2016] [Accepted: 12/19/2016] [Indexed: 12/25/2022]
Abstract
Immunomodulatory drugs (IMiDs) are a cornerstone in the treatment of multiple myeloma (MM), but specific markers to predict outcome are still missing. Recent work pointed to a prognostic role for IMiD target genes (e.g. CRBN). Moreover, indirect activity of IMiDs on immune cells correlated with outcome, raising the possibility that cell populations in the bone marrow (BM) microenvironment could serve as biomarkers. We therefore analysed gene expression levels of six IMiD target genes in whole BM samples of 44 myeloma patients treated with lenalidomide-dexamethasone. Expression of CRBN (R = 0.30, P = .05), IKZF1 (R = 0.31, P = .04), IRF4 (R = 0.38, P = .01), MCT-1 (R = 0.30, P = .05), and CD147 (R = 0.38, P = .01), but not IKZF3 (R = -0.15, P = .34), was significantly associated with response. Interestingly, IKZF1 expression was elevated in BM environmental cells and thus selected for further investigation by multicolor flow cytometry. High IKAROS protein levels in total BM mononuclear cells (median OS 83.4 vs. 32.2 months, P = .02), CD19+ B cells (median OS 71.1 vs. 32.2 months, P = .05), CD3+ CD8+ T cells (median OS 83.4 vs 19.0 months, P = .008) as well as monocytes (median OS 53.9 vs 18.0 months, P = .009) were associated with superior overall survival (OS). In contrast, IKAROS protein expression in MM cells was not predictive for OS. Our data therefore corroborate the central role of immune cells for the clinical activity of IMiDs and built the groundwork for prospective analysis of IKAROS protein levels in distinct cell populations as a potential biomarker for IMiD based therapies.
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Affiliation(s)
- Arnold Bolomsky
- Department of Medicine I, Center for Oncology and HematologyWilhelminen Cancer Research Institute, WilhelminenspitalVienna Austria
| | - Wolfgang Hübl
- Department of Laboratory MedicineWilhelminenspitalVienna Austria
| | - Stefano Spada
- Division of Haematology and HaemostaseologyUniversity of Torino Italy
| | - Ercan Müldür
- Department of Medicine I, Center for Oncology and HematologyWilhelminen Cancer Research Institute, WilhelminenspitalVienna Austria
| | - Karin Schlangen
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna Austria
| | - Daniel Heintel
- Department of Medicine I, Center for Oncology and HematologyWilhelminen Cancer Research Institute, WilhelminenspitalVienna Austria
| | - Alberto Rocci
- Department of HaematologyManchester Royal Infirmary, Central Manchester University Hospital NHS Foundation TrustManchester UK
- School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchester UK
| | - Adalbert Weißmann
- Department of Medicine I, Center for Oncology and HematologyWilhelminen Cancer Research Institute, WilhelminenspitalVienna Austria
| | - Veronique Fritz
- Department of Medicine I, Center for Oncology and HematologyWilhelminen Cancer Research Institute, WilhelminenspitalVienna Austria
| | - Martin Willheim
- Department of Laboratory MedicineWilhelminenspitalVienna Austria
| | - Niklas Zojer
- Department of Medicine I, Center for Oncology and HematologyWilhelminen Cancer Research Institute, WilhelminenspitalVienna Austria
| | - Antonio Palumbo
- Division of Haematology and HaemostaseologyUniversity of Torino Italy
| | - Heinz Ludwig
- Department of Medicine I, Center for Oncology and HematologyWilhelminen Cancer Research Institute, WilhelminenspitalVienna Austria
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137
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Raza S, Safyan RA, Rosenbaum E, Bowman AS, Lentzsch S. Optimizing current and emerging therapies in multiple myeloma: a guide for the hematologist. Ther Adv Hematol 2017; 8:55-70. [PMID: 28203342 PMCID: PMC5298389 DOI: 10.1177/2040620716680548] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Multiple myeloma (MM) is the second most common hematologic malignancy. The diagnosis of MM requires ⩾10% clonal plasma cells in the bone marrow or biopsy-proven plasmacytoma, plus evidence of end-organ damage (hypercalcemia, renal failure, anemia, and lytic bone lesions). The definition of MM has recently been expanded to include a ⩾60% clonal plasma cell burden in the bone marrow, serum involved/uninvolved light chain ratio of ⩾100, or more than one focal lesion on magnetic resonance imaging ⩾5 mm in the absence of end-organ damage. MM is an incurable malignancy previously associated with poor survival rates. However, over the past two decades, the introduction of novel treatment options has resulted in a dramatic improvement in response rates and overall survival (OS). The combination of a proteasome inhibitor and an immunomodulator (IMiD) is the preferred induction treatment for newly diagnosed transplant-eligible MM patients. After induction, high-dose therapy with autologous stem cell transplant (ASCT) is still the standard of care for these patients. In patients who are transplant ineligible, dose adjusted IMiDs or proteasome inhibitor-based combinations are the preferred treatment option. With the recent approval of novel drugs like carfilzomib, ixazomib, pomalidomide, panobinostat, and monoclonal antibodies (elotuzumab and daratumumab), as well as improved understanding of risk stratification, management of comorbidities and treatment side effects, clinicians can optimize anti-MM therapy, particularly in relapse/refractory MM patients. In this review, we outline the current therapeutic approach to the management of MM.
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Affiliation(s)
- Shahzad Raza
- Division of Hematology & Oncology, Columbia University Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Rachael A. Safyan
- Division of Hematology & Oncology, Columbia University Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Evan Rosenbaum
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Alex S. Bowman
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Suzanne Lentzsch
- Professor of Medicine, Director, Multiple Myeloma and Amyloidosis Service, Columbia University Medical Center, Herbert Irving Pavilion, R 953, 161 Ft. Washington Ave, New York, NY 10032, USA
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138
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Nadiminti K, Singh Abbi KK, Mott SL, Dozeman L, Tricot A, Schultz A, Behrends S, Zhan F, Tricot G. VTD-melphalan is well tolerated and results in very high rates of stringent CR and MRD-negative status in multiple myeloma. Onco Targets Ther 2017; 10:217-226. [PMID: 28123303 PMCID: PMC5229169 DOI: 10.2147/ott.s112423] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The addition of cytotoxic drugs to high-dose melphalan as a preparative regimen for autologous stem cell transplantation in multiple myeloma has not resulted in superior activity. Although novel agents have significantly improved outcome in multiple myeloma, their role in preparative regimens remains largely unknown. We have evaluated the toxicity and efficacy of combining bortezomib, thalidomide, and dexamethasone with high-dose melphalan. An institutional review board-approved retrospective analysis was performed on 100 consecutive patients receiving 153 transplants; 53 had tandem transplants; 64 patients received early transplants; and 36 had salvage transplantation. Endpoints were treatment-related toxicity and mortality, and quality of response post-transplantation with assessment of stringent complete remission (sCR) and minimal residual disease (MRD) status. Median age was 61 years, and median follow-up was 16.2 months. At 6 months, sCR was attained in 56% of patients and CR in 20%. An MRD status, assessed by sensitive (10−4) multiparameter flow cytometry, was achieved in 85%. The 100-day mortality rate was 2.6% (4/153); 1.8% for early transplants and 4.5% for salvage transplants. Grade 3–5 non-hematologic toxicities were mainly related to metabolism/nutrition; gastrointestinal and infectious problems. Median time to absolute neutrophil count of >500/µL was 12 days for both early and salvage transplantations. No significant differences in quality of response were observed between early and salvage transplantation or between single and tandem autologous stem cell transplantation. Since both sCR and MRD are excellent early surrogate markers for progression-free and overall survival, this regimen will likely be superior to melphalan alone, but it needs to be formally assessed in a randomized study.
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Affiliation(s)
- Kalyan Nadiminti
- Division of Hematology/Oncology; Holden Comprehensive Cancer Center
| | - Kamal Kant Singh Abbi
- Holden Comprehensive Cancer Center; Department of Internal Medicine, Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | | | | | | | - Sonya Behrends
- Holden Comprehensive Cancer Center; Department of Internal Medicine, Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Fenghuang Zhan
- Holden Comprehensive Cancer Center; Department of Internal Medicine, Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Guido Tricot
- Holden Comprehensive Cancer Center; Department of Internal Medicine, Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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139
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Flores-Montero J, Sanoja-Flores L, Paiva B, Puig N, García-Sánchez O, Böttcher S, van der Velden VHJ, Pérez-Morán JJ, Vidriales MB, García-Sanz R, Jimenez C, González M, Martínez-López J, Corral-Mateos A, Grigore GE, Fluxá R, Pontes R, Caetano J, Sedek L, Del Cañizo MC, Bladé J, Lahuerta JJ, Aguilar C, Bárez A, García-Mateo A, Labrador J, Leoz P, Aguilera-Sanz C, San-Miguel J, Mateos MV, Durie B, van Dongen JJM, Orfao A. Next Generation Flow for highly sensitive and standardized detection of minimal residual disease in multiple myeloma. Leukemia 2017; 31:2094-2103. [PMID: 28104919 PMCID: PMC5629369 DOI: 10.1038/leu.2017.29] [Citation(s) in RCA: 417] [Impact Index Per Article: 59.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 12/24/2016] [Accepted: 01/03/2017] [Indexed: 12/20/2022]
Abstract
Flow cytometry has become a highly valuable method to monitor minimal residual disease (MRD) and evaluate the depth of complete response (CR) in bone marrow (BM) of multiple myeloma (MM) after therapy. However, current flow-MRD has lower sensitivity than molecular methods and lacks standardization. Here we report on a novel next generation flow (NGF) approach for highly sensitive and standardized MRD detection in MM. An optimized 2-tube 8-color antibody panel was constructed in five cycles of design-evaluation-redesign. In addition, a bulk-lysis procedure was established for acquisition of ⩾107 cells/sample, and novel software tools were constructed for automatic plasma cell gating. Multicenter evaluation of 110 follow-up BM from MM patients in very good partial response (VGPR) or CR showed a higher sensitivity for NGF-MRD vs conventional 8-color flow-MRD -MRD-positive rate of 47 vs 34% (P=0.003)-. Thus, 25% of patients classified as MRD-negative by conventional 8-color flow were MRD-positive by NGF, translating into a significantly longer progression-free survival for MRD-negative vs MRD-positive CR patients by NGF (75% progression-free survival not reached vs 7 months; P=0.02). This study establishes EuroFlow-based NGF as a highly sensitive, fully standardized approach for MRD detection in MM which overcomes the major limitations of conventional flow-MRD methods and is ready for implementation in routine diagnostics.
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Affiliation(s)
- J Flores-Montero
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| | - L Sanoja-Flores
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| | - B Paiva
- Clinica Universidad de Navarra; Applied Medical Research Center (CIMA), IDISNA, Pamplona, Spain (UNAV)
| | - N Puig
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - O García-Sánchez
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - S Böttcher
- Second Department of Medicine, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (UNIKIEL)
| | - V H J van der Velden
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (EMC)
| | - J-J Pérez-Morán
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - M-B Vidriales
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - R García-Sanz
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - C Jimenez
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - M González
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | | | - A Corral-Mateos
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| | | | - R Fluxá
- Cytognos SL, Salamanca, Spain
| | - R Pontes
- Faculty of Medicine, Federal University of Rio de Janeiro and Institute of Pediatrics and Childhood Care, Rio de Janeiro, Brazil
| | - J Caetano
- Department of Hematology, Portuguese Institute of Oncology, Lisbon, Portugal (IPOLFG)
| | - L Sedek
- Department of Pediatric Hematology and Oncology, Medical University of Silesia in Katowice, Zabrze, Poland (SUM)
| | - M-C Del Cañizo
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - J Bladé
- Department of Hematology, Hospital Clinic I Provincial, Barcelona, Spain
| | - J-J Lahuerta
- Department of Hematology, Hospital 12 de Octubre, Madrid, Spain
| | - C Aguilar
- Department of Hematology, Hospital General de Santa Bárbara, Soria, Spain
| | - A Bárez
- Department of Hematology, Complejo Asistencial de Ávila, Ávila, Spain
| | - A García-Mateo
- Department of Hematology, Complejo Asistencial de Segovia, Segovia, Spain
| | - J Labrador
- Hematology Department, Hospital Universitario de Burgos, Burgos, Spain
| | - P Leoz
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| | - C Aguilera-Sanz
- Department of Hematology, Hospital El Bierzo, Ponferrada, Spain
| | - J San-Miguel
- Clinica Universidad de Navarra; Applied Medical Research Center (CIMA), IDISNA, Pamplona, Spain (UNAV)
| | - M-V Mateos
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - B Durie
- Cedars-Sinai Samuel Oschin Cancer Center, Los Angeles, CA, USA
| | - J J M van Dongen
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (EMC).,Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
| | - A Orfao
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
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140
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Morgan GJ, Jones JR. Integration of Genomics Into Treatment: Are We There Yet? Am Soc Clin Oncol Educ Book 2017; 37:569-574. [PMID: 28561666 DOI: 10.1200/edbk_175166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Using advances in genetic analysis to segment and direct treatment of multiple myeloma (MM) represents a way of maintaining therapeutic progress. Recent genetic analyses have opened the possibility of enhancing risk stratification approaches and of using different risk and biologic strata as part of clinical trials. The Myeloma Genome Project is a collaborative project that has compiled the largest set of cases with sequencing and have outcome data that are available for stratification purposes. Mutation-targeted treatment of the Ras pathway has been shown to be active in MM, but is compromised by the presence of the subclonal genetic variation typical of myeloma. Going forward, risk and biologically stratified therapy for MM looks to be a promising way of maintaining therapeutic progress, as does precision immunotherapy directed by the cellular context of the bone marrow.
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Affiliation(s)
- Gareth J Morgan
- From the Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR; Institute of Cancer Research, The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
| | - John R Jones
- From the Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR; Institute of Cancer Research, The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
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141
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Hinduja A, Limaye K, Ravilla R, Sasapu A, Papanikolaou X, Wei L, Torbey M, Waheed S. Spectrum of Cerebrovascular Disease in Patients with Multiple Myeloma Undergoing Chemotherapy-Results of a Case Control Study. PLoS One 2016; 11:e0166627. [PMID: 27902730 PMCID: PMC5130211 DOI: 10.1371/journal.pone.0166627] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 11/01/2016] [Indexed: 12/21/2022] Open
Abstract
Objectives Patients with multiple myeloma (MM) are at increased risk of arterial thrombosis. Our aim was to determine the risk factors, mechanisms and outcome of strokes in these patients. Methods We conducted a retrospective matched case–control study from our database of MM patients enrolled in Total Therapy (TT) 2, TT3a and TT3b protocols who developed a vascular event (transient ischemic attack, ischemic stroke, or intracerebral hemorrhage) from October 1998 to January 2014. Cases were matched for age-matched selected controls. Baseline demographics, risk factors, MM characteristics, laboratory values, and mortality of cases were compared to those of controls. Multivariate logistic regression analysis identified risk factors associated with stroke. Ischemic strokes (IS) were classified with modified Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. Results Of 1,148 patients, 46 developed a vascular event (ischemic stroke, 33; transient ischemic attack, 11; hypertensive intracerebral hemorrhage, 2). Multivariate logistic regression analysis determined renal insufficiency (odds Ratio, 3.528; 95% CI, 1.36–9.14; P = 0.0094) and MM Stages I and II (odds Ratio, 2.770, 95% CI, 1.31–5.81; p = 0.0073) were independent predictors of stroke. In our study, strokes attributable to hypercoagulability, atrial fibrillation and small-vessel occlusion were common mechanisms. After a stroke, 78% of patients were discharged to home or a rehabilitation facility and 4% to a long-term nursing facility; in-hospital mortality was 15%. Despite suffering a stroke no significant differences in survival were observed. Conclusion In our cohort of multiple myeloma patients, renal failure and MM Stages I and II had increased risk of stroke.
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Affiliation(s)
- Archana Hinduja
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus, OH, United States of America
- * E-mail:
| | - Kaustubh Limaye
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Rahul Ravilla
- Department of Hematology and Oncology, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Appalnaidu Sasapu
- Department of Hematology and Oncology, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Xenofon Papanikolaou
- Multiple Myeloma for Research and Therapy, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Lai Wei
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Michel Torbey
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus, OH, United States of America
- Department of Neurosurgery, Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Sarah Waheed
- Multiple Myeloma for Research and Therapy, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
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142
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Malard F, Harousseau JL, Mohty M. Multiple myeloma treatment at relapse after autologous stem cell transplantation: A practical analysis. Cancer Treat Rev 2016; 52:41-47. [PMID: 27888768 DOI: 10.1016/j.ctrv.2016.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 10/19/2016] [Accepted: 11/05/2016] [Indexed: 11/30/2022]
Abstract
Over the past decade, significant advances have been made in the field of multiple myeloma. Introduction of the so-called novel agents, proteasome inhibitors (PI) and immunomodulatory drugs (IMiD), and improved supportive care have resulted in significantly better outcome. Standard first line treatment in fit patients include PI and IMiD based induction, high dose melphalan with autologous hematopoietic stem cell transplantation (ASCT) and consolidation/maintenance. However, despite these progresses MM remains incurable for the majority of patients and most patients will relapse. Next generation PI (carfilzomib, ixazomib) and IMiD (pomalidomide) and new therapeutic classes: monoclonal antibody (elotuzumab, daratumumab) and pan-deacetylase inhibitors (panobinostat) have been successfully evaluated in relapse multiple myeloma. Some of these new agents are now approved for multiple myeloma treatment at relapse. However choosing the most appropriate treatment at relapse may be difficult. This review sum up the most important studies and provide evidence to choose the most relevant therapeutic strategy for relapse after ASCT, based on disease, patient and previous treatment related parameters.
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Affiliation(s)
- F Malard
- Department of Haematology, Saint Antoine Hospital, Paris, France; INSERM UMRs 938, Paris, France; Université Pierre et Marie Curie, Paris, France.
| | | | - M Mohty
- Department of Haematology, Saint Antoine Hospital, Paris, France; INSERM UMRs 938, Paris, France; Université Pierre et Marie Curie, Paris, France
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143
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Remenyi P, Varga G, Mikala G, Reti M, Gopcsa L, Batai A, Csukly Z, Lengyel L, Torbagyi E, Barta A, Fabian J, Levai D, Szombath G, Andrikovics H, Masszi T. Early Versus Delayed Autologous Stem Cell Transplantation and Interferon Maintenance in Multiple Myeloma: Single-Center Experience of 18 Years. Transplant Proc 2016; 48:177-84. [PMID: 26915865 DOI: 10.1016/j.transproceed.2015.12.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 12/14/2015] [Accepted: 12/30/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND Autologous stem cell transplantation (ASCT) has become the mainstay of 1st-line treatment in younger patients with multiple myeloma (MM), but statistical confirmation of its superiority over other therapies, especially in the era of novel agents, is still lacking. METHODS We reviewed the results of all 548 myeloma ASCTs performed in our institute over the past 18 years. RESULTS More than one-half of the patients had access to novel agents before their transplantations. Although the age of the transplanted patients increased significantly over the years, treatment-related mortality (TRM) was remarkably low, especially in 1st-line transplanted patients (100-day TRM, 0.3%). The median overall survival (OS) of the entire cohort was 98.4 months. Patients transplanted within 12 months from the start of their therapy had significantly better responses than those having delayed ASCT (complete response rate, 58.1% vs 46.8%; P = .016) and significant post-ASCT progression-free survival (PFS) benefit (30.2 [26.1-34.3] mo vs 23.3 [16.8-29.8] mo; P = .036), but we found no significant overall survival difference. The results were similar in patients treated with or without novel agents before ASCT. During a period of time, interferon maintenance was our standard approach to post-ASCT maintenance. Our analysis showed not only a significant PFS advantage with interferon, but also a highly significant overall survival benefit (150.4 [105.1-195.8] mo vs 86.1 [72.5-99.7] mo; P = .003). CONCLUSIONS Our findings demonstrate that delayed ASCT can be feasible in selected patients.
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Affiliation(s)
- P Remenyi
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - G Varga
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary.
| | - G Mikala
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - M Reti
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - L Gopcsa
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - A Batai
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - Z Csukly
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - L Lengyel
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - E Torbagyi
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - A Barta
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - J Fabian
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - D Levai
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - G Szombath
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - H Andrikovics
- Laboratory of Molecular Diagnostics, Hungarian National Blood Transfusion Service, Budapest, Hungary; Institute of Pathophysiology, Semmelweis University, Budapest, Hungary
| | - T Masszi
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary; Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
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144
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Jethava YS, Mitchell A, Epstein J, Zangari M, Yaccoby S, Tian E, Waheed S, Khan R, Papanikolaou X, Grazziutti M, Cottler-Fox M, Petty N, Steward D, Panozzo S, Bailey C, Hoering A, Crowley J, Sawyer J, Morgan G, Barlogie B, van Rhee F. Adverse Metaphase Cytogenetics Can Be Overcome by Adding Bortezomib and Thalidomide to Fractionated Melphalan Transplants. Clin Cancer Res 2016; 23:2665-2672. [PMID: 27810902 DOI: 10.1158/1078-0432.ccr-15-2620] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 09/26/2016] [Accepted: 10/18/2016] [Indexed: 12/22/2022]
Abstract
Purpose: To determine whether a reduction in the intensity of Total Therapy (TT) reduces toxicity and maintains efficacy.Experimental Design: A total of 289 patients with gene expression profiling (GEP70)-defined low-risk multiple myeloma were randomized between a standard arm (TT4-S) and a light arm (TT4-L). TT4-L employed one instead of two inductions and consolidations. To compensate for potential loss of efficacy of TT4-L, bortezomib and thalidomide were added to fractionated melphalan 50 mg/m2/d for 4 days.Results: Grade ≥3 toxicities and treatment-related mortalities were not reduced in TT4-L. Complete response (CR) rates were virtually identical (P = 0.2; TT4-S, 59%; TT4-L, 61% at 2 years), although CR duration was superior with TT4-S (P = 0.05; TT4-S, 87%; TT4-L, 81% at 2 years). With a median follow-up of 4.5 years, there was no difference in overall survival (OS) and progression-free survival (PFS). Whereas metaphase cytogenetic abnormalities (CAs) tended to be an adverse feature in TT4-S, as with predecessor TT trials, the reverse applied to TT4-L. Employing historical TT3a as training and TT3b as test set, 51 gene probes (GEP51) significantly differentiated the presence and absence of CA (q < 0.0001), seven of which function in DNA replication, recombination, and repair. Applying the GEP51 model to clinical outcomes, OS and PFS were significantly inferior with GEP51/CA in TT4-S; such a difference was not observed in TT4-L.Conclusions: We identified a prognostic CA-linked GEP51 signature, the adversity of which could be overcome by potentially synergizing anti-multiple myeloma effects of melphalan and bortezomib. These exploratory findings require confirmation in a prospective randomized trial. Clin Cancer Res; 23(11); 2665-72. ©2016 AACR.
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Affiliation(s)
- Yogesh S Jethava
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Alan Mitchell
- Cancer Research and Biostatistics, Seattle, Washington
| | - Joshua Epstein
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Maurizio Zangari
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Shmuel Yaccoby
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Erming Tian
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Sarah Waheed
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Rashid Khan
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Xenofon Papanikolaou
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Monica Grazziutti
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Michele Cottler-Fox
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Nathan Petty
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Douglas Steward
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Susan Panozzo
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Clyde Bailey
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Antje Hoering
- Cancer Research and Biostatistics, Seattle, Washington
| | - John Crowley
- Cancer Research and Biostatistics, Seattle, Washington
| | - Jeffrey Sawyer
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Gareth Morgan
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Bart Barlogie
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Frits van Rhee
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
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145
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Lub S, Maes A, Maes K, De Veirman K, De Bruyne E, Menu E, Fostier K, Kassambara A, Moreaux J, Hose D, Leleu X, King RW, Vanderkerken K, Van Valckenborgh E. Inhibiting the anaphase promoting complex/cyclosome induces a metaphase arrest and cell death in multiple myeloma cells. Oncotarget 2016; 7:4062-76. [PMID: 26716651 PMCID: PMC4826190 DOI: 10.18632/oncotarget.6768] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/26/2015] [Indexed: 01/11/2023] Open
Abstract
The anaphase promoting complex/cyclosome (APC/C) is an ubiquitin ligase involved in cell cycle. During the metaphase-anaphase transition the APC/C is activated by Cdc20. The aim of this study is to elucidate the importance and therapeutic potential of APC/C and its co-activator Cdc20 in multiple myeloma (MM). Gene expression analysis revealed that Cdc20 was expressed at higher levels in gene expression-based high-risk MM patients. Moreover, high Cdc20 expression correlated with poor prognosis. Treatment of human myeloma cell lines with proTAME, an APC/C inhibitor, resulted in an accumulation of APC/CCdc20 substrate cyclin B1 and an accumulation of cells in metaphase. Moreover we observed a significant dose-dependent decrease in viability and increase in apoptosis in MM cells upon proTAME treatment. The induction of apoptosis was accompanied with caspase 3, 8, 9 and PARP cleavage. A similar metaphase arrest and induction of apoptosis were obtained with specific knockdown of Cdc20. In addition, we demonstrated the accumulation of Bim was partially responsible for the observed cell death. Combining proTAME with another APC/C inhibitor apcin or the alkylating agent melphalan resulted in enhanced anti-MM activity. This study suggests that the APC/C and its co-activator Cdc20 could be a new and promising target especially in high-risk MM patients.
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Affiliation(s)
- Susanne Lub
- Laboratory of Hematology and Immunology, Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Anke Maes
- Laboratory of Hematology and Immunology, Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Ken Maes
- Laboratory of Hematology and Immunology, Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Kim De Veirman
- Laboratory of Hematology and Immunology, Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Elke De Bruyne
- Laboratory of Hematology and Immunology, Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Eline Menu
- Laboratory of Hematology and Immunology, Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Karel Fostier
- Laboratory of Hematology and Immunology, Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Alboukadel Kassambara
- Department of Biological Hematology, CHU Montpellier, Montpellier, France.,Institute of Human Genetics, CNRS-UPR1142, Montpellier, France
| | - Jérôme Moreaux
- Department of Biological Hematology, CHU Montpellier, Montpellier, France.,Institute of Human Genetics, CNRS-UPR1142, Montpellier, France.,University of Montpellier 1, UFR de Médecine, Montpellier, France
| | - Dirk Hose
- Medizinische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Xavier Leleu
- Service des maladies du sang, Hôpital Huriez, CHRU, Lille, France
| | - Randall W King
- Department of Cell Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Karin Vanderkerken
- Laboratory of Hematology and Immunology, Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Els Van Valckenborgh
- Laboratory of Hematology and Immunology, Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
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146
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Hu Q, Qian C, Sun W, Wang J, Chen Z, Bomba HN, Xin H, Shen Q, Gu Z. Engineered Nanoplatelets for Enhanced Treatment of Multiple Myeloma and Thrombus. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2016; 28:9573-9580. [PMID: 27626769 PMCID: PMC5283718 DOI: 10.1002/adma.201603463] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/07/2016] [Indexed: 05/09/2023]
Abstract
A platelet-membrane-coated biomimetic nanocarrier, which can sequentially target the bone microenvironment and myeloma cells to enhance the drug availability at the myeloma site and decrease off-target effects, is developed for inhibiting multiple myeloma growth and simultaneously eradicating thrombus complication.
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Affiliation(s)
- Quanyin Hu
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC 27695, USA and Division of Molecular Pharmaceutics and Center for Nanotechnology in Drug Delivery, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Chenggen Qian
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC 27695, USA and Division of Molecular Pharmaceutics and Center for Nanotechnology in Drug Delivery, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; Department of Polymer Science and Engineering and Key Laboratory of High Performance Polymer Materials and Technology of MOE, School of Chemistry and Chemical Engineering, Nanjing University Nanjing 210023, China
| | - Wujin Sun
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC 27695, USA and Division of Molecular Pharmaceutics and Center for Nanotechnology in Drug Delivery, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Jinqiang Wang
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC 27695, USA and Division of Molecular Pharmaceutics and Center for Nanotechnology in Drug Delivery, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Zhaowei Chen
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC 27695, USA and Division of Molecular Pharmaceutics and Center for Nanotechnology in Drug Delivery, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Hunter N. Bomba
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC 27695, USA and Division of Molecular Pharmaceutics and Center for Nanotechnology in Drug Delivery, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Hongliang Xin
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC 27695, USA and Division of Molecular Pharmaceutics and Center for Nanotechnology in Drug Delivery, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Qundong Shen
- Department of Polymer Science and Engineering and Key Laboratory of High Performance Polymer Materials and Technology of MOE, School of Chemistry and Chemical Engineering, Nanjing University Nanjing 210023, China
| | - Zhen Gu
- Corresponding author. ; Phone: 1-919-515-7944
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147
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Hyperhaploidy is a novel high-risk cytogenetic subgroup in multiple myeloma. Leukemia 2016; 31:637-644. [PMID: 27694925 DOI: 10.1038/leu.2016.253] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 07/20/2016] [Accepted: 08/19/2016] [Indexed: 12/13/2022]
Abstract
Hyperhaploid clones (24-34 chromosomes) were identified in 33 patients with multiple myeloma (MM), demonstrating a novel numerical cytogenetic subgroup. Strikingly, all hyperhaploid karyotypes were found to harbor monosomy 17p, the single most important risk stratification lesion in MM. A catastrophic loss of nearly a haploid set of chromosomes results in disomies of chromosomes 3, 5, 7, 9, 11, 15, 18, 19 and 21, the same basic set of odd-numbered chromosomes found in trisomy in hyperdiploid myeloma. All other autosomes are found in monosomy, resulting in additional clinically relevant monosomies of 1p, 6q, 13q and 16q. Hypotriploid subclones (58-68 chromosomes) were also identified in 11 of the 33 patients and represent a duplication of the hyperhaploid clone. Analysis of clones utilizing interphase fluorescence in situ hybridization (iFISH), metaphase FISH and spectral karyotyping identified either monosomy 17 or del17p in all patients. Amplification of 1q21 was identified in eight patients, demonstrating an additional high-risk marker. Importantly, our findings indicate that current iFISH strategies may be uninformative or ambiguous in the detection of these clones, suggesting this patient subgroup maybe underreported. Overall survival for patients with hyperhaploid clones was poor, with a 5-year survival rate of 23.1%. These findings identify a distinct numerical subgroup with cytogenetically defined high-risk disease.
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148
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Offidani M, Corvatta L, Gentili S, Maracci L, Leoni P. Oral ixazomib maintenance therapy in multiple myeloma. Expert Rev Anticancer Ther 2016; 16:21-32. [PMID: 26588946 DOI: 10.1586/14737140.2016.1123627] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Continuous therapy has proven to be an effective therapeutic strategy to improve the outcome of both young and elderly multiple myeloma patients. Remarkably, lenalidomide and bortezomib showed to play a crucial role in this setting due to their safety profile allowing long-term exposure. Ixazomib, the first oral proteasome inhibitor to be evaluated in multiple myeloma, exerts substantial anti-myeloma activity as a single agent and particularly in combination with immunomodulatory drugs and it may be an attractive option for maintenance therapy. Here we address the issue of maintenance therapy as part of a therapeutic approach of multiple myeloma patients focusing on the potential role of ixazomib.
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Affiliation(s)
- Massimo Offidani
- a Azienda Ospedaliero-Universitaria , Ospedali Riuniti di Ancona , Ancona , Italy
| | - Laura Corvatta
- b Dipartimento di Medicina, UOC Medicina , Fabriano , Italy
| | - Silvia Gentili
- a Azienda Ospedaliero-Universitaria , Ospedali Riuniti di Ancona , Ancona , Italy
| | - Laura Maracci
- a Azienda Ospedaliero-Universitaria , Ospedali Riuniti di Ancona , Ancona , Italy
| | - Pietro Leoni
- a Azienda Ospedaliero-Universitaria , Ospedali Riuniti di Ancona , Ancona , Italy
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149
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Abstract
There have been major recent advancements in the understanding and management of multiple myeloma. Diagnostic criteria have been revised and former ultra-high-risk smoldering multiple myeloma is now considered multiple myeloma in need of treatment. Understanding clonal progression, evolution, and tides not only has helped elucidate the disease behavior but might help expand therapeutic choices in order to select appropriate treatment for patients. Unprecedented response rates with modern triplet induction therapies containing proteasome inhibitor and immunomodulators have made this approach standard for initial treatment. The US Food and Drug Administration approved four new drugs (two targeted antibodies and two oral agents) in 2015 in relapsed/refractory multiple myeloma and these drugs along with the other already-available drugs have now increased the choices of regimens. Even drugs without single-agent activity, such as panobinostat and elotuzumab, have an important role, especially in the proteasome inhibitor refractory setting. Recent studies done in the context of novel agent induction suggest that high-dose therapy followed by autologous transplant continues to improve response rates and progression-free survival, thus underscoring their role in transplant-eligible patients. Evolving paradigms in the treatment of multiple myeloma include newer promising immune approaches, such as adoptive cellular therapies, vaccines, or antibody-based immune manipulations. Though multiple myeloma is still considered incurable, it is clear that with the improved understanding of disease biology and clonal architecture of relapse combined with the availability of multi-targeted approaches, we are ever closer to a lasting cure or transformation into indolent and long-lasting disease courses or both.
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Affiliation(s)
- Binod Dhakal
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Saulius Girnius
- Division of Hematology/Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Parameswaran Hari
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
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150
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Clonal selection and double-hit events involving tumor suppressor genes underlie relapse in myeloma. Blood 2016; 128:1735-44. [PMID: 27516441 DOI: 10.1182/blood-2016-06-723007] [Citation(s) in RCA: 155] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 08/02/2016] [Indexed: 02/06/2023] Open
Abstract
To elucidate the mechanisms underlying relapse from chemotherapy in multiple myeloma, we performed a longitudinal study of 33 patients entered into Total Therapy protocols investigating them using gene expression profiling, high-resolution copy number arrays, and whole-exome sequencing. The study illustrates the mechanistic importance of acquired mutations in known myeloma driver genes and the critical nature of biallelic inactivation events affecting tumor suppressor genes, especially TP53, the end result being resistance to apoptosis and increased proliferation rates, which drive relapse by Darwinian-type clonal evolution. The number of copy number aberration changes and biallelic inactivation of tumor suppressor genes was increased in GEP70 high risk, consistent with genomic instability being a key feature of high risk. In conclusion, the study highlights the impact of acquired genetic events, which enhance the evolutionary fitness level of myeloma-propagating cells to survive multiagent chemotherapy and to result in relapse.
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