101
|
Merz M, Kellermann L, Poenisch W, Tischler HJ, Kohnke J, Knauf W, Goldschmidt H. Diagnosis and treatment of multiple myeloma in Germany: analysis of a nationwide multi-institutional survey. Ann Hematol 2017; 96:987-993. [DOI: 10.1007/s00277-017-2991-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 04/04/2017] [Indexed: 11/29/2022]
|
102
|
Chakraborty R, Muchtar E, Kumar SK, Jevremovic D, Buadi FK, Dingli D, Dispenzieri A, Hayman SR, Hogan WJ, Kapoor P, Lacy MQ, Leung N, Gertz MA. Impact of Post-Transplant Response and Minimal Residual Disease on Survival in Myeloma with High-Risk Cytogenetics. Biol Blood Marrow Transplant 2017; 23:598-605. [DOI: 10.1016/j.bbmt.2017.01.076] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 01/16/2017] [Indexed: 01/10/2023]
|
103
|
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.
Collapse
|
104
|
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.
Collapse
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
| |
Collapse
|
105
|
Gassiot S, Motlló C, Llombart I, Morgades M, González Y, Garcia-Caro M, Ribera JM, Oriol A. Impact of induction treatment before autologous stem cell transplantation on long-term outcome in patients with newly diagnosed multiple myeloma. Eur J Haematol 2017; 98:569-576. [PMID: 28208219 DOI: 10.1111/ejh.12869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Clinical trials for patients with multiple myeloma (MM) using novel agent (NA)-based regimens before autologous stem cell transplantation (SCT) have shown improvement in response rates and progression-free survival (PFS); however they have failed to identify a significant overall survival (OS) benefit. The aim of this study was to analyze the potential impact of initial induction on the feasibility and outcome of subsequent treatment lines in a real clinical practice setting. METHODS Patients with consecutive MM <70 years of age diagnosed between 1999 and 2009 were prospectively registered and classified as having received conventional chemotherapy induction regimens with new agents available at relapse (CC cohort, 89 patients) or as treated with NAs upfront (NA cohort, 65 patients). RESULTS Patients in the NA cohort demonstrated a superior median PFS (2.8 years vs 1.6 years, P=.03) and also a median PFS from diagnosis to second progression (5.2 years vs 2.7 years, P=.003). After a median follow-up of 7 years, clear differences in OS were observed (7.97 years in NA cohort compared to 3.35 years in CC cohort, P<.001). CONCLUSIONS New agent-based first-line induction treatments provide benefits in both PFS and beyond that point, contributing to a significant improvement in OS.
Collapse
Affiliation(s)
- Susanna Gassiot
- ICO-Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Badalona, Spain.,Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Cristina Motlló
- ICO-Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Badalona, Spain.,Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | | | - Mireia Morgades
- ICO-Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Badalona, Spain
| | | | - Montse Garcia-Caro
- ICO-Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Badalona, Spain
| | - Josep-Maria Ribera
- ICO-Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Badalona, Spain.,Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Albert Oriol
- ICO-Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Badalona, Spain.,Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| |
Collapse
|
106
|
Xia J, Xu H, Zhang X, Allamargot C, Coleman KL, Nessler R, Frech I, Tricot G, Zhan F. Multiple Myeloma Tumor Cells are Selectively Killed by Pharmacologically-dosed Ascorbic Acid. EBioMedicine 2017; 18:41-49. [PMID: 28229908 PMCID: PMC5405162 DOI: 10.1016/j.ebiom.2017.02.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 02/13/2017] [Accepted: 02/13/2017] [Indexed: 12/15/2022] Open
Abstract
High-dose chemotherapies to treat multiple myeloma (MM) can be life-threatening due to toxicities to normal cells and there is a need to target only tumor cells and/or lower standard drug dosage without losing efficacy. We show that pharmacologically-dosed ascorbic acid (PAA), in the presence of iron, leads to the formation of highly reactive oxygen species (ROS) resulting in cell death. PAA selectively kills CD138+ MM tumor cells derived from MM and smoldering MM (SMM) but not from monoclonal gammopathy undetermined significance (MGUS) patients. PAA alone or in combination with melphalan inhibits tumor formation in MM xenograft mice. This study shows PAA efficacy on primary cancer cells and cell lines in vitro and in vivo. Pharmacologically-dosed ascorbic acid kills Multiple Myeloma cells. Pharmacologically-dosed ascorbic leads to apoptosis-inducing factor 1 cleavage. Pharmacologically-dosed ascorbic lowers melphalan dosage.
Multiple myeloma (MM) remains a difficult to cure disease in the majority of cases. Several preclinical and clinical studies have shown that ascorbic acid in pharmacologic doses (PAA) selectively kills cancer cells, while sparing normal cells. This article reveals the biological mechanism by which PAA exerts its anti-cancer effects and should lead to the development of an innovative therapy in MM.
Collapse
Affiliation(s)
- Jiliang Xia
- Department of Medicine, Division of Hematology, Oncology and Blood and Marrow Transplantation, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, United States; Institute of Cancer Research, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Hongwei Xu
- Department of Medicine, Division of Hematology, Oncology and Blood and Marrow Transplantation, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, United States
| | - Xiaoyan Zhang
- Department of Medicine, Division of Hematology, Oncology and Blood and Marrow Transplantation, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, United States; East China University of Science and Technology, Shanghai, China
| | - Chantal Allamargot
- Central Microscopy Research Facility, University of Iowa, Iowa City, IA, United States
| | - Kristen L Coleman
- Department of Medicine, Division of Hematology, Oncology and Blood and Marrow Transplantation, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, United States
| | - Randy Nessler
- Central Microscopy Research Facility, University of Iowa, Iowa City, IA, United States
| | - Ivana Frech
- Department of Medicine, Division of Hematology, Oncology and Blood and Marrow Transplantation, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, United States
| | - Guido Tricot
- Department of Medicine, Division of Hematology, Oncology and Blood and Marrow Transplantation, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, United States.
| | - Fenghuang Zhan
- Department of Medicine, Division of Hematology, Oncology and Blood and Marrow Transplantation, Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, United States.
| |
Collapse
|
107
|
de Mel S, Chen Y, Gopalakrishnan SK, Ooi M, Teo C, Tan D, Teo MLC, Tso ACY, Lee LK, Nagarajan C, Goh YT, Chng WJ. The Singapore Myeloma Study Group Consensus Guidelines for the management of patients with multiple myeloma. Singapore Med J 2017; 58:55-71. [PMID: 27609508 PMCID: PMC5311886 DOI: 10.11622/smedj.2016150] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Multiple myeloma (MM) is an incurable plasma cell neoplasm with an incidence of 100 patients per year in Singapore. Major advances have been made in the diagnosis, risk stratification and treatment of MM in the recent past. The reclassification of a subset of patients with smouldering MM, based on high-risk biomarkers, and the development of the revised international staging system are among the key new developments in diagnosis and staging. The use of novel agent-based treatment has resulted in significant improvements in the survival and quality of life of many patients with MM. Determining the optimal use of proteasome inhibitors, immunomodulators and, more recently, monoclonal antibodies is an area of ongoing investigation. In this guideline, we aim to provide an overview of the management of MM, incorporating the latest developments in diagnosis and treatment.
Collapse
Affiliation(s)
- Sanjay de Mel
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore
| | - Yunxin Chen
- Department of Haematology, Singapore General Hospital, Singapore
| | | | - Melissa Ooi
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore
| | - Constance Teo
- Division of Oncology Pharmacy, National University Cancer Institute, National University Health System, Singapore
| | - Daryl Tan
- Raffles Cancer Centre, Raffles Hospital, Singapore
| | | | - Allison CY Tso
- Department of Haematology, Tan Tock Seng Hospital, Singapore
| | - Lian King Lee
- Department of Haematology, Tan Tock Seng Hospital, Singapore
| | | | - Yeow Tee Goh
- Department of Haematology, Singapore General Hospital, Singapore
| | - Wee Joo Chng
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore
| |
Collapse
|
108
|
Cornell RF, D'Souza A, Kassim AA, Costa LJ, Innis-Shelton RD, Zhang MJ, Huang J, Abidi M, Aiello J, Akpek G, Bashey A, Bashir Q, Cerny J, Comenzo R, Diaz MA, Freytes C, Gale RP, Ganguly S, Hamadani M, Hashmi S, Holmberg L, Hossain N, Kamble RT, Kharfan-Dabaja M, Kindwall-Keller T, Kyle R, Kumar S, Lazarus H, Lee C, Maiolino A, Marks DI, Meehan K, Mikhael J, Nath R, Nishihori T, Olsson RF, Ramanathan M, Saad A, Seo S, Usmani S, Vesole D, Vij R, Vogl D, Wirk BM, Yared J, Krishnan A, Mark T, Nieto Y, Hari P. Maintenance versus Induction Therapy Choice on Outcomes after Autologous Transplantation for Multiple Myeloma. Biol Blood Marrow Transplant 2017; 23:269-277. [PMID: 27864161 PMCID: PMC5346183 DOI: 10.1016/j.bbmt.2016.11.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 11/11/2016] [Indexed: 02/07/2023]
Abstract
Bortezomib (V), lenalidomide (R), cyclophosphamide (C), and dexamethasone (D) are components of the most commonly used modern doublet (RD, VD) or triplet (VRD, CVD) initial induction regimens before autologous hematopoietic cell transplantation (AHCT) for multiple myeloma (MM) in the United States. In this study we evaluated 693 patients receiving "upfront" AHCT after initial induction therapy with modern doublet or triplet regimens using data reported to the Center for International Blood and Marrow Transplant Research from 2008 to 2013. Analysis was limited to those receiving a single AHCT after 1 line of induction therapy within 12 months from treatment initiation for MM. In multivariate analysis, progression-free survival (PFS) and overall survival were similar irrespective of induction regimen. However, high-risk cytogenetics and nonreceipt of post-transplant maintenance/consolidation therapy were associated with higher risk of relapse. Patients receiving post-transplant therapy had significantly improved 3-year PFS versus no post-transplant therapy (55% versus 39%, P = .0001). This benefit was most evident in patients not achieving at least a complete response post-AHCT (P = .005). In patients receiving upfront AHCT, the choice of induction regimen (doublet or triplet therapies) appears to be of lower impact than use of post-transplant therapy.
Collapse
Affiliation(s)
- Robert F Cornell
- Division of Hematology/Oncology Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anita D'Souza
- Center for International Blood and Marrow Transplant Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Adetola A Kassim
- Division of Hematology/Oncology Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Luciano J Costa
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Racquel D Innis-Shelton
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mei-Jie Zhang
- Center for International Blood and Marrow Transplant Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jiaxing Huang
- Center for International Blood and Marrow Transplant Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Muneer Abidi
- Division of BMT, Department of Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | | | - Gorgun Akpek
- Stem Cell Transplantation and Cell Therapy, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Asad Bashey
- Blood and Marrow Transplant Program at Northside Hospital, Atlanta, Georgia
| | - Qaiser Bashir
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jan Cerny
- Division of Hematology and Oncology, Department of Medicine, UMass Memorial Medical Center, Worchester, Massachusetts
| | | | - Miguel Angel Diaz
- Department of Hematology/Oncology, Hospital Infantil Universitario Nino Jesus, Madrid, Spain
| | - César Freytes
- South Texas Veterans Health Care System and University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Siddhartha Ganguly
- Blood and Marrow Transplantation, Division of Hematology and Oncology, University of Kansas Medical Center, Kansas City, Kansas
| | - Mehdi Hamadani
- Center for International Blood and Marrow Transplant Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Leona Holmberg
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Rammurti T Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Mohamed Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Tamila Kindwall-Keller
- Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, Virginia
| | | | | | - Hillard Lazarus
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Cindy Lee
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Angelo Maiolino
- Hospital Universitbrio Clementinio Fraga Filho, Universidade Federal do Rio de Janerio, Rio de Janerio, Brazil
| | - David I Marks
- Adult Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Kenneth Meehan
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Joe Mikhael
- Mayo Clinic Arizona and Phoenix Children's Hospital, Phoenix, Arizona
| | - Rajneesh Nath
- Division of Hematology and Oncology, Department of Medicine, UMass Memorial Medical Center, Worchester, Massachusetts
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Richard F Olsson
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinksa Institutet, Stockholm, Sweden; Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Muthalagu Ramanathan
- Division of Hematology and Oncology, Department of Medicine, UMass Memorial Medical Center, Worchester, Massachusetts
| | - Ayman Saad
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sachiko Seo
- National Cancer Research Center, East Hospital, Chiba, Japan
| | - Saad Usmani
- Department of Hematology v Medical Oncology, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - David Vesole
- John Theurer Cancer Center at Hackensack UMC, Hackensack, New Jersey
| | - Ravi Vij
- Divison of Hematology and Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Dan Vogl
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Baldeep M Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, Washington
| | - Jean Yared
- Blood & Marrow Transplantation Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Cancer Center, University of Maryland, Baltimore, Maryland
| | | | - Tomer Mark
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Yago Nieto
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Parameswaran Hari
- Center for International Blood and Marrow Transplant Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| |
Collapse
|
109
|
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.
Collapse
Affiliation(s)
- J Flores-Montero
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| | - L Sanoja-Flores
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| | - B Paiva
- Clinica Universidad de Navarra; Applied Medical Research Center (CIMA), IDISNA, Pamplona, Spain (UNAV)
| | - N Puig
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - O García-Sánchez
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - S Böttcher
- Second Department of Medicine, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (UNIKIEL)
| | - V H J van der Velden
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (EMC)
| | - J-J Pérez-Morán
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - M-B Vidriales
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - R García-Sanz
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - C Jimenez
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - M González
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | | | - A Corral-Mateos
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| | | | - R Fluxá
- Cytognos SL, Salamanca, Spain
| | - R Pontes
- Faculty of Medicine, Federal University of Rio de Janeiro and Institute of Pediatrics and Childhood Care, Rio de Janeiro, Brazil
| | - J Caetano
- Department of Hematology, Portuguese Institute of Oncology, Lisbon, Portugal (IPOLFG)
| | - L Sedek
- Department of Pediatric Hematology and Oncology, Medical University of Silesia in Katowice, Zabrze, Poland (SUM)
| | - M-C Del Cañizo
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - J Bladé
- Department of Hematology, Hospital Clinic I Provincial, Barcelona, Spain
| | - J-J Lahuerta
- Department of Hematology, Hospital 12 de Octubre, Madrid, Spain
| | - C Aguilar
- Department of Hematology, Hospital General de Santa Bárbara, Soria, Spain
| | - A Bárez
- Department of Hematology, Complejo Asistencial de Ávila, Ávila, Spain
| | - A García-Mateo
- Department of Hematology, Complejo Asistencial de Segovia, Segovia, Spain
| | - J Labrador
- Hematology Department, Hospital Universitario de Burgos, Burgos, Spain
| | - P Leoz
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| | - C Aguilera-Sanz
- Department of Hematology, Hospital El Bierzo, Ponferrada, Spain
| | - J San-Miguel
- Clinica Universidad de Navarra; Applied Medical Research Center (CIMA), IDISNA, Pamplona, Spain (UNAV)
| | - M-V Mateos
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - B Durie
- Cedars-Sinai Samuel Oschin Cancer Center, Los Angeles, CA, USA
| | - J J M van Dongen
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (EMC).,Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
| | - A Orfao
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| |
Collapse
|
110
|
Zauderer MG. Standard Chemotherapy Options and Clinical Trials of Novel Agents for Mesothelioma. ASBESTOS AND MESOTHELIOMA 2017. [DOI: 10.1007/978-3-319-53560-9_15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
|
111
|
Terragna C, Remondini D, Martello M, Zamagni E, Pantani L, Patriarca F, Pezzi A, Levi G, Offidani M, Proserpio I, De Sabbata G, Tacchetti P, Cangialosi C, Ciambelli F, Viganò CV, Dico FA, Santacroce B, Borsi E, Brioli A, Marzocchi G, Castellani G, Martinelli G, Palumbo A, Cavo M. The genetic and genomic background of multiple myeloma patients achieving complete response after induction therapy with bortezomib, thalidomide and dexamethasone (VTD). Oncotarget 2016; 7:9666-79. [PMID: 26575327 PMCID: PMC4891075 DOI: 10.18632/oncotarget.5718] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/27/2015] [Indexed: 11/25/2022] Open
Abstract
The prime focus of the current therapeutic strategy for Multiple Myeloma (MM) is to obtain an early and deep tumour burden reduction, up to the level of complete response (CR). To date, no description of the characteristics of the plasma cells (PC) prone to achieve CR has been reported. This study aimed at the molecular characterization of PC obtained at baseline from MM patients in CR after bortezomib-thalidomide-dexamethasone (VTD) first line therapy. One hundred and eighteen MM primary tumours obtained from homogeneously treated patients were profiled both for gene expression and for single nucleotide polymorphism genotype. Genomic results were used to obtain a predictor of sensitivity to VTD induction therapy, as well as to describe both the transcription and the genomic profile of PC derived from MM with subsequent optimal response to primary induction therapy. By analysing the gene profiles of CR patients, we identified a 5-gene signature predicting CR with an overall median accuracy of 75% (range: 72%–85%). In addition, we highlighted the differential expression of a series of genes, whose deregulation might explain patients' sensitivity to VTD therapy. We also showed that a small copy number loss, covering 606Kb on chromosome 1p22.1 was the most significantly associated with CR patients.
Collapse
Affiliation(s)
- Carolina Terragna
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Daniel Remondini
- Department of Physics and Astronomy (DIFA), Bologna University, Bologna, Italy
| | - Marina Martello
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Elena Zamagni
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Lucia Pantani
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | | | - Annalisa Pezzi
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Giuseppe Levi
- Department of Physics and Astronomy (DIFA), Bologna University, Bologna, Italy
| | - Massimo Offidani
- Clinica di Ematologia, A.O.U. Ospedali Riuniti di Ancona, Ancona, Italy
| | - Ilaria Proserpio
- U.O Oncologia Medica, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | | | - Paola Tacchetti
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Clotilde Cangialosi
- Hematology Division UTMO, Azienda "Ospedali Riuniti Villa Sofia-Cervello" Presidio Ospedaliero V.Cervello, Palermo, Italy
| | | | | | - Flores Angela Dico
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Barbara Santacroce
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Enrica Borsi
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Annamaria Brioli
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Giulia Marzocchi
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Gastone Castellani
- Department of Physics and Astronomy (DIFA), Bologna University, Bologna, Italy
| | - Giovanni Martinelli
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Antonio Palumbo
- Myeloma Unit, Division of Hematology, University of Torino, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Michele Cavo
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| |
Collapse
|
112
|
Dispenzieri A. Myeloma: management of the newly diagnosed high-risk patient. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:485-494. [PMID: 27913520 PMCID: PMC6142458 DOI: 10.1182/asheducation-2016.1.485] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Although there have been many definitions for high-risk (HR) myeloma, most recent consensus for classifying risk in patients with newly diagnosed multiple myeloma (NMM) comes from the International Myeloma Working Group. This recently published revised International Staging System includes del(17p) or t(4;14) by fluorescence in situ hybridization, β-2 microglobulin, albumin, and lactate dehydrogenase. These elements should be captured in all NMM patients. The optimal treatments for HR myeloma have not been fully worked out; therefore, these patients should be considered for clinical trials. Outside of the trial setting for those patients who are not eligible for autologous stem cell transplantation (ASCT), a regimen with bortezomib, but not thalidomide, should be considered, with a duration of therapy of at least 1 year. The regimen with the best results to date is bortezomib, melphalan, and predisone. A nonthalidomide maintenance could also be considered. In patients who are eligible for ASCT, an induction regimen with bortezomib and an immunomodulatory drug should be administered for 3 to 6 months followed by 2 ASCTs. Finally, a consolidation/maintenance regimen containing at least 1 year of bortezomib should be administered followed by maintenance thereafter. For patient convenience, an oral agent that is not thalidomide could be prescribed as maintenance. Finally, in patients with HR myeloma, allogeneic SCT may be associated with reasonable outcomes, but this too will require further research.
Collapse
Affiliation(s)
- Angela Dispenzieri
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
113
|
Cost Implications of Comorbidity for Autologous Stem Cell Transplantation in Elderly Patients with Multiple Myeloma Using SEER-Medicare. BONE MARROW RESEARCH 2016; 2016:3645623. [PMID: 27830092 PMCID: PMC5088316 DOI: 10.1155/2016/3645623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 09/28/2016] [Indexed: 11/23/2022]
Abstract
Comorbidity is more common in older patients and can increase the cost of care by increasing toxicity. Using the SEER-Medicare database from 2000 to 2007, we examined the costs and life-year benefit of Auto-HSCT for MM patients over the age of 65 by evaluating the difference over time relative to comorbidity burden. One hundred ten patients had an Auto-HSCT in the early time period (2000–2003) and 160 in the late time period (2004–2007). Patients were divided by a Charlson Comorbidity Index (CCI) of 0 or greater than 1 (CCI1+). Median overall survival was 53.5 months for the late time period patients compared to 40.3 months for the early time period patients (p = 0.031). Median costs for CCI0 versus CCI1+ in the early period were, respectively, $70,900 versus $72,000 (100 d); $86,100 versus $98,300 (1 yr); and $139,200 versus $195,300 (3 yrs). Median costs for late period were, respectively, $58,400 versus $60,400 (100 d); $86,300 versus $77,700 (1 yr); and $124,400 versus $110,900 (3 yrs). Comorbidity had a significant impact on survival and cost among early time period patients but not among late time period patients. Therefore, older patients with some comorbidities can be considered for Auto-HSCT depending on clinical circumstances.
Collapse
|
114
|
Lipe B, Vukas R, Mikhael J. The role of maintenance therapy in multiple myeloma. Blood Cancer J 2016; 6:e485. [PMID: 27768093 PMCID: PMC5098261 DOI: 10.1038/bcj.2016.89] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 08/11/2016] [Accepted: 09/08/2016] [Indexed: 12/22/2022] Open
Abstract
Multiple myeloma is the second most common type of blood cancer and remains incurable despite advances in therapy. Current therapy for multiple myeloma includes a phased-approach, often consisting of initial induction therapy, consolidation and maintenance therapy. With an ever-growing landscape of treatment options, the approach to optimal therapy has become increasingly complex. Specifically, controversy surrounds the optimal use and duration of maintenance therapy. We conducted a comprehensive literature search to analyze the most current literature and to provide recommendations for maintenance therapy in multiple myeloma.
Collapse
Affiliation(s)
- B Lipe
- Department of Hematology, University of Rochester, Rochester, NY, USA
| | - R Vukas
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, KS, USA
| | - J Mikhael
- Department of Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| |
Collapse
|
115
|
Stettler J, Novak U, Baerlocher GM, Seipel K, Mansouri Taleghani B, Pabst T. Autologous stem cell transplantation in elderly patients with multiple myeloma: evaluation of its safety and efficacy. Leuk Lymphoma 2016; 58:1076-1083. [DOI: 10.1080/10428194.2016.1233542] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Jasmin Stettler
- Department of Medical Oncology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Urban Novak
- Department of Medical Oncology, Inselspital, University Hospital Bern, Bern, Switzerland
| | | | - Katja Seipel
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | | | - Thomas Pabst
- Department of Medical Oncology, Inselspital, University Hospital Bern, Bern, Switzerland
| |
Collapse
|
116
|
Muchtar E, Magen H, Gertz MA. High-risk multiple myeloma: a multifaceted entity, multiple therapeutic challenges. Leuk Lymphoma 2016; 58:1283-1296. [PMID: 27734720 DOI: 10.1080/10428194.2016.1233540] [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: 12/22/2022]
Abstract
The term high-risk multiple myeloma is aimed to identify a heterogeneous group of patients who are more likely to progress and die early of their disease. Therefore, recognition of these patients is crucial. With the increase in the number of treatment options, the outcome for high-risk patients has probably improved, although the true extent of this improvement remains unknown, due to both the heterogeneous components of high-risk disease and its under-representation in clinical trials. In this article, we review the definitions of high-risk disease, emphasizing the fact that no single definition can represent the entire high-risk population. In the second part, we review the treatment options available for the management of high-risk myeloma as well as our general approach for high-risk disease. In light of the poor prognosis associated with high-risk myeloma, even in the current era, new approaches for the management of this subset of patients are needed.
Collapse
Affiliation(s)
- Eli Muchtar
- a Division of Hematology , Mayo Clinic , Rochester , MN , USA
| | - Hila Magen
- b Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center , Petah-Tikva , Israel
| | - Morie A Gertz
- a Division of Hematology , Mayo Clinic , Rochester , MN , USA
| |
Collapse
|
117
|
Randomized phase 2 trial of ixazomib and dexamethasone in relapsed multiple myeloma not refractory to bortezomib. Blood 2016; 128:2415-2422. [PMID: 27702799 DOI: 10.1182/blood-2016-05-717769] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 09/20/2016] [Indexed: 02/02/2023] Open
Abstract
Proteasome inhibitors have become an integral part of myeloma therapy. Considerable efforts have gone into optimizing this therapeutic approach to obtain maximal proteasome inhibition with least toxicity. Ixazomib is the first oral proteasome inhibitor to enter the clinic and has been studied as a single agent as well as in various combinations. The current trial was designed to examine the efficacy and toxicity of combining 2 different doses of ixazomib (4 mg and 5.5 mg given weekly for 3 of 4 weeks) with 40 mg weekly of dexamethasone, in relapsed myeloma. Seventy patients were enrolled, 35 patients randomly assigned to each ixazomib dose. Overall, 30 (43%; 95% confidence interval, 31-55) of the patients achieved a confirmed partial response or better, with 31% achieving a response with 4 mg and 54% with 5.5 mg of ixazomib. The median event-free survival (EFS) for the entire study population was 8.4 months; 1-year overall survival was 96%. The EFS was 5.7 months for patients with prior bortezomib exposure and 11.0 months for bortezomib-naïve patients. A grade 3 or 4 adverse event considered at least possibly related to treatment was seen in 11 (32%) patients at 4 mg and in 21 (60%) at 5.5 mg. Dose reductions were more frequent with 5.5 mg dose. Overall, the ixazomib with dexamethasone has good efficacy in relapsed myeloma, is well-tolerated and with higher response rate at 5.5 mg, albeit with more toxicity. This study was registered at www.clinicaltrials.gov as #NCT01415882.
Collapse
|
118
|
Wang L, Wang H, Chen H, Wang WD, Chen XQ, Geng QR, Xia ZJ, Lu Y. Serum levels of soluble programmed death ligand 1 predict treatment response and progression free survival in multiple myeloma. Oncotarget 2016; 6:41228-36. [PMID: 26515600 PMCID: PMC4747402 DOI: 10.18632/oncotarget.5682] [Citation(s) in RCA: 142] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 09/13/2015] [Indexed: 01/22/2023] Open
Abstract
Immune checkpoint signaling plays an important role in immunosuppression in multiple myeloma (MM). Blood levels of soluble programmed death-ligand 1 (sPD-L1), a checkpoint-relevant protein, might predict treatment response and survival outcomes in MM patients. We used an enzyme-linked immunosorbent assay to measure serum sPD-L1 levels in 81 newly diagnosed MM patients. We found that myeloma patients had higher sPD-L1 concentrations than healthy controls. The best sPD-L1 cutoff value for predicting disease progression risk was 2.783 ng/mL. The overall response rate to treatment was higher in low sPD-L1 patients than in high sPD-L1 patients. The 3-year progression free survival (PFS) and overall survival (OS) rates for all patients were 16% and 64%, respectively. Multivariate survival analysis including Eastern Cooperative Oncology Group performance status score, treatment response, and sPD-L1 level showed that a less than partial treatment response (PR) and higher sPD-L1 levels (>2.783 ng/ml) were independent prognostic factors for shorter PFS; neither factor was predictive of OS. The serum sPD-L1 level is a valuable biomarker for predicting treatment response and an independent prognostic factor for PFS. PD-1/PD-L1 blockade may be a promising novel immune-based therapeutic strategy in MM.
Collapse
Affiliation(s)
- Liang Wang
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Hematologic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Hua Wang
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Hematologic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Hao Chen
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Clinical Laboratory, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Wei-da Wang
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Hematologic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Xiao-Qin Chen
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Hematologic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Qi-Rong Geng
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Hematologic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Zhong-Jun Xia
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Hematologic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Yue Lu
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Hematologic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China
| |
Collapse
|
119
|
Hong J, Lee JH. Recent advances in multiple myeloma: a Korean perspective. Korean J Intern Med 2016; 31:820-34. [PMID: 27604794 PMCID: PMC5016289 DOI: 10.3904/kjim.2015.408] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 08/22/2016] [Indexed: 12/22/2022] Open
Abstract
Epidemiologically, multiple myeloma (MM) is a malignant disorder of plasma cells with a higher incidence among Western populations than among Asians. However, there is growing evidence of a recent increase in the age-standardized incidence rate (ASR) of MM in Asian countries, particularly Korea. Application of novel agents has resulted in significant improvement of treatment outcomes, and the advances are ongoing with the recent introduction and U.S. Food and Drug Administration's approval of newer agents, including carfilzomib, ixazomib, elotuzumab, and daratumumab. In concert with the technical advances in the cytogenetic and molecular diagnostics of MM, modifications of its diagnosis and staging system have been attempted for better risk stratification. The modified diagnostic criteria from the International Myeloma Working Group in 2014 enabled a strategy of more active treatment for some patients with smoldering MM, with an ultra-high risk of progression, and fine-tuned the definition of end-organ damage, known as CRAB (hypercalcemia, renal insufficiency, anemia, and bone lesions). Considering Korea's trend of aging at an unprecedented rate, we can expect that the ASR of MM will maintain a gradual increase for many years to come; therefore, MM will be a cancer of critical importance from both medical and socioeconomic perspectives in Korea.
Collapse
Affiliation(s)
| | - Jae Hoon Lee
- Correspondence to Jae Hoon Lee, M.D. Department of Internal Medicine, Gachon University Gil Medical Center, 21 Namdong-daero 774beon-gil, Namdong-gu, Incheon 21565, Korea Tel: +82-32-460-2186 Fax: +82-32-460-3233 E-mail:
| |
Collapse
|
120
|
Chakraborty R, Muchtar E, Kumar S, Buadi FK, Dingli D, Dispenzieri A, Hayman SR, Hogan WJ, Kapoor P, Lacy MQ, Leung N, Gertz MA. The impact of induction regimen on transplant outcome in newly diagnosed multiple myeloma in the era of novel agents. Bone Marrow Transplant 2016; 52:34-40. [PMID: 27548464 DOI: 10.1038/bmt.2016.214] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 06/14/2016] [Accepted: 07/08/2016] [Indexed: 12/22/2022]
Abstract
We compared overall survival (OS) of 1017 patients with newly diagnosed multiple myeloma (MM) who were treated with different novel agent-based induction regimens and who underwent early autologous stem cell transplant (ASCT). Subgroups were defined by type of induction therapy: cyclophosphamide-bortezomib-dexamethasone (CyBorD; n=193), bortezomib-dexamethasone (Vd; n=64), lenalidomide-dexamethasone (Rd; n=251), bortezomib-lenalidomide-dexamethasone (VRd; n=126), thalidomide-dexamethasone (Td; n=155) and vincristine-doxorubicin-dexamethasone or dexamethasone alone (VAD/Dex; n=228). The median follow-up of the surviving patients was 66.7 months. The 5-year OS rates with CyBorD, Vd, Rd, VRd, Td and VAD/Dex were 79.2%, 72.3%, 79.2%, 79.0%, 57.4% and 63.4%, respectively (log-rank, P<0.001). In a multivariate analysis, after controlling for important patient and disease variables, VRd had a superior OS compared with CyBorD (hazard ratio (HR), 0.32; 95% confidence interval (CI), 0.10-0.88; P=0.03) and Vd (HR, 0.16; 95% CI, 0.04-0.52; P=0.002). In conclusion, our study demonstrates that among patients completing induction therapy and continuing to early transplant, VRd induction leads to improved OS compared with CyBorD and Vd regimens.
Collapse
Affiliation(s)
- R Chakraborty
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.,Hospitalist Services, Essentia Health-St. Joseph's Medical Center, Brainerd, MN, USA
| | - E Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - S Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - F K Buadi
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - D Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - A Dispenzieri
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - S R Hayman
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - W J Hogan
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - P Kapoor
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - M Q Lacy
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - N Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - M A Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
121
|
Citrin R, Foster JB, Teachey DT. The role of proteasome inhibition in the treatment of malignant and non-malignant hematologic disorders. Expert Rev Hematol 2016; 9:873-89. [DOI: 10.1080/17474086.2016.1216311] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
|
122
|
Parrish C, Morris CT, Williams CD, Cairns DA, Cavenagh J, Snowden JA, Ashcroft J, Cavet J, Hunter H, Bird JM, Chalmers A, Brown JM, Yong K, Schey S, Chown S, Cook G. Stem Cell Harvesting after Bortezomib-Based Reinduction for Myeloma Relapsing after Autologous Transplantation: Results from the British Society of Blood and Marrow Transplantation/United Kingdom Myeloma Forum Myeloma X (Intensive) Trial. Biol Blood Marrow Transplant 2016; 22:1009-1016. [DOI: 10.1016/j.bbmt.2016.01.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 01/11/2016] [Indexed: 12/20/2022]
|
123
|
El-Ghammaz AMS, Abdelwahed E. Bortezomib-based induction improves progression-free survival of myeloma patients harboring 17p deletion and/or t(4;14) and overcomes their adverse prognosis. Ann Hematol 2016; 95:1315-21. [PMID: 27184486 DOI: 10.1007/s00277-016-2692-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 05/09/2016] [Indexed: 11/26/2022]
Abstract
Providing a risk-adapted treatment strategy has been a key goal in the ongoing research efforts aimed at providing treatment tailored to the individual genetic make-up. Eighty myeloma patients have been tested for presence of 17p deletion and/or t(4;14) by fluorescent in situ hybridization (FISH). Based on FISH results, they have been categorized into patients lacking them (standard risk) and those harboring them (high risk). Patients in each category were randomly assigned 1:1 to induction treatment by either vincristine, adriamycin and dexamethasone (VAD), or bortezomib and dexamethasone (VD) followed by autologous stem cell transplantation and thalidomide maintenance and were followed up for 32 months. 32.5 % of patients were high risk. Following induction, there were significantly higher rates of at least very good partial response achievement in VD arms in standard- and high-risk patients. Regarding complete response achievement, there were insignificant differences between VAD and VD arms in standard and high-risk patients. After a median follow-up of 17.5 months, there was insignificant difference in overall survival (OS) between VAD and VD arms in standard and high-risk patients. There was superior progression-free survival (PFS) in VD arms in standard- and high-risk patients. Among patients who received VD, those belonging to standard and high-risk groups had similar PFS. In conclusion, bortezomib-based induction is superior to non-bortezomib-based one in patients harboring 17p deletion and/or t(4;14) in terms of improving PFS but not OS. Also, it reduces progression risk in patients harboring these high risk cytogenetics.
Collapse
Affiliation(s)
- Amro M S El-Ghammaz
- Hematology and Bone Marrow Transplantation Unit, Internal Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Essam Abdelwahed
- Hematology and Bone Marrow Transplantation Unit, Internal Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| |
Collapse
|
124
|
Rondeau V, Cornet E, Moreau P, Troussard X. Prediction of patients with multiple myeloma eligible for second- or third-line treatment in France. Ann Hematol 2016; 95:1307-13. [DOI: 10.1007/s00277-016-2688-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 04/28/2016] [Indexed: 10/21/2022]
|
125
|
Rodriguez TE, Hari P, Stiff PJ, Smith SE, Sterrenberg D, Vesole DH. Busulfan, Melphalan, and Bortezomib versus High-Dose Melphalan as a Conditioning Regimen for Autologous Hematopoietic Stem Cell Transplantation in Multiple Myeloma. Biol Blood Marrow Transplant 2016; 22:1391-1396. [PMID: 27164062 PMCID: PMC5075527 DOI: 10.1016/j.bbmt.2016.03.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 03/18/2016] [Indexed: 11/16/2022]
Abstract
High-dose melphalan 200 mg/m2 (MEL 200) is the standard of care as a conditioning regimen for autologous hematopoietic stem cell transplantation (AHSCT) for multiple myeloma (MM). We compared a novel conditioning combination incorporating busulfan, melphalan, and bortezomib (BUMELVEL) versus standard MEL 200 in newly diagnosed patients undergoing AHSCT for MM. Between July 2009 and May 2012, 43 eligible patients received BUMELVEL conditioning followed by AHSCT. BU was administered i.v. daily for 4 days to achieve a target area under the concentration-time curve total of 20,000 mM·min based on pharmacokinetic analysis after the first dose. MEL 140 mg/m2 (MEL 140) and VEL 1.6 mg/m2 were administered i.v. on days −2 and −1, respectively. Outcomes were compared with a contemporaneous North American cohort (n = 162) receiving MEL 200 matched for age, sex, performance status, stage, interval from diagnosis to AHSCT, and disease status before AHSCT. Multivariate analysis of relapse, progression-free survival (PFS), and overall survival (OS) was performed. The median follow-up was 25 months. No transplant-related mortality was observed in the study cohort at 1 year. PFS at 1 year was superior in the BUMELVEL cohort (90%) in comparison with 77% in MEL 200 historical control subjects (P = .02). Cumulative incidence of relapse was lower in the BUMELVEL group versus the MEL 200 group (10% at 1 year versus 21%; P = .047). OS at 1 year was similar between cohorts (93% versus 93%; P =.89). BU can be safely combined with MEL 140 and VEL without an increase in toxicities or transplant-related mortality. We observed a superior PFS in the BUMELVEL cohort without maintenance therapy, warranting further trials.
Collapse
Affiliation(s)
- Tulio E Rodriguez
- Division of Hematology and Oncology, Department of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois.
| | - Parameswaran Hari
- Department of Medicine and Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Patrick J Stiff
- Division of Hematology and Oncology, Department of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Scott E Smith
- Division of Hematology and Oncology, Department of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Danielle Sterrenberg
- Division of Hematology and Oncology, Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - David H Vesole
- Multiple Myeloma Division, John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey; Multiple Myeloma Program, MedStar Georgetown University Hospital, Washington, DC
| |
Collapse
|
126
|
Abstract
BACKGROUND Multiple myeloma is a malignancy of plasma cells accounting for approximately 1% of cancers and 12% of haematological malignancies. The first-in-class proteasome inhibitor, bortezomib, is commonly used to treat newly diagnosed as well as relapsed/refractory myeloma, either as single agent or combined with other therapies. OBJECTIVES We conducted a systematic review and meta-analysis to assess the effects of bortezomib on overall survival (OS), progression-free survival (PFS), response rate (RR), health-related quality of life (HRQoL), adverse events (AEs) and treatment-related death (TRD). SEARCH METHODS We searched MEDLINE, the Cochrane Central Register of Controlled Trials and EMBASE (till 27 January 2016) as well as conference proceedings and clinical trial registries for randomised controlled trials (RCTs). SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared i) bortezomib versus no bortezomib with the same background therapy in each arm; ii) bortezomib versus no bortezomib with different background therapy in each arm or compared to other agent(s) and iii) bortezomib dose comparisons and comparisons of different treatment administrations and schedules. DATA COLLECTION AND ANALYSIS Two review authors independently extracted outcomes data and assessed risk of bias. We extracted hazard ratios (HR) and their confidence intervals for OS and PFS and odds ratios (OR) for response rates, AEs and TRD. We contacted trial authors to provide summary statistics if missing. We estimated Logrank statistics which were not available. We extracted HRQoL data, where available. MAIN RESULTS We screened a total of 3667 records, identifying 16 relevant RCTs involving 5626 patients and included 12 trials in the meta-analyses. All trials were randomised and open-label studies. Two trials were published in abstract form and therefore we were unable to assess potential risk of bias in full.There is moderate-quality evidence that bortezomib prolongs OS (four studies, 1586 patients; Peto OR 0.77, 95% CI 0.65 to 0.92) and PFS (five studies, 1855 patients; Peto OR 0.65, 95% CI 0.57 to 0.74) from analysing trials of bortezomib versus no bortezomib with the same background therapy in each arm.There is high-quality evidence that bortezomib prolongs OS (five studies, 2532 patients; Peto OR 0.76, 95% CI 0.67 to 0.88) but low-quality evidence for PFS (four studies, 2489 patients; Peto OR 0.67, 95% CI 0.61 to 0.75) from analysing trials of bortezomib versus no bortezomib with different background therapy in each arm or compared to other agent(s).Four trials (N = 716) examined different doses, methods of administrations and treatment schedules and were reviewed qualitatively only.We identified four trials in the meta-analysis that measured time to progression (TTP) and were able to extract and analyse PFS data for three of the studies, while in the case of one study, we included TTP data as PFS data were not available. We therefore did not analyse TTP separately in this review.Patients treated with bortezomib have increased risk of thrombocytopenia, neutropenia, gastro-intestinal toxicities, peripheral neuropathy, infection and fatigue with the quality of evidence highly variable. There is high-quality evidence for increased risk of cardiac disorders from analysing trials of bortezomib versus no bortezomib with different background therapy in each arm or versus other agents. The risk of TRD in either comparison group analysed is uncertain due to the low quality of the evidence.Only four trials analysed HRQoL and the data could not be meta-analysed.Subgroup analyses by disease setting revealed improvements in all outcomes, whereas for therapy setting, an improved benefit for bortezomib was observed in all outcomes and subgroups except for OS following consolidation therapy. AUTHORS' CONCLUSIONS This meta-analysis found that myeloma patients receiving bortezomib benefited in terms of OS, PFS and response rate compared to those who did not receive bortezomib. This benefit was observed in trials of bortezomib versus no bortezomib with the same background therapy and in trials of bortezomib versus no bortezomib with different background therapy in each arm or compared to other agent(s). Further evaluation of newer proteasome inhibitors is required to ascertain whether these agents offer an improved risk-benefit profile, while more studies of HRQoL are also required.
Collapse
Affiliation(s)
- Kathleen Scott
- School of Nursing & Midwifery, Trinity College Dublin, 24 D'Olier St, Dublin, Ireland
| | | | | | | | | |
Collapse
|
127
|
Cornell RF, Kassim AA. Evolving paradigms in the treatment of relapsed/refractory multiple myeloma: increased options and increased complexity. Bone Marrow Transplant 2016; 51:479-91. [PMID: 26726946 PMCID: PMC4827007 DOI: 10.1038/bmt.2015.307] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 10/08/2015] [Accepted: 10/22/2015] [Indexed: 12/12/2022]
Abstract
The use of modern therapies such as thalidomide, bortezomib and lenalidomide coupled with upfront high-dose therapy and autologous stem cell transplant (ASCT) has resulted in improved survival in patients with newly diagnosed multiple myeloma (MM). However, patients with relapsed/refractory multiple myeloma (RRMM) often have poorer clinical outcomes and might benefit from novel therapeutic strategies. Emerging therapies, such as deacetylase inhibitors, monoclonal antibodies and new proteasome inhibitors, appear promising and may change the therapeutic landscape in RRMM. A limited number of studies has shown a benefit with salvage ASCT in patients with RRMM, although there remains ongoing debate about its timing and effectiveness. Improvement in transplant outcomes has re-ignited a debate on the timing and possible role for salvage ASCT and allogeneic stem cell transplant in RRMM. As the treatment options for management of patients with RRMM become increasingly complex, physicians must consider both disease- and patient-related factors in choosing the appropriate therapeutic approach, with the goal of improving efficacy while minimizing toxicity.
Collapse
Affiliation(s)
- R F Cornell
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - A A Kassim
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt University School of Medicine, Nashville, TN, USA
| |
Collapse
|
128
|
Nishihori T, Song J, Shain KH. Minimal Residual Disease Assessment in the Context of Multiple Myeloma Treatment. Curr Hematol Malig Rep 2016; 11:118-26. [PMID: 26898557 PMCID: PMC4819726 DOI: 10.1007/s11899-016-0308-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
With contemporary therapeutic strategies in multiple myeloma, heretofore unseen depth and rate of responses are being achieved. These strategies have paralleled improvements in outcome of multiple myeloma patients. The integration of the next generation of proteasome inhibitors and antibody therapeutics promise continued improvements in therapy with the expectation of consistent depth of response not quantifiable by current clinical methods. As such, there is a growing need to develop adequate tools to evaluate deeper disease response after therapy and to refine the response criteria including the minimal residual disease. Several emerging techniques are being evaluated for these purposes including multi-parameter flow cytometry, allele-specific oligonucleotide polymerase chain reaction, next-generation sequencing, and imaging modalities. In this review, we highlight the recent developments and evaluate advantages and limitations of the current technologies to assess minimal residual disease. We also discuss future applications of these methodologies in potentially guiding multiple myeloma treatment decisions.
Collapse
Affiliation(s)
- Taiga Nishihori
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
- Department of Oncologic Sciences, Moffitt Cancer Center/University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Jinming Song
- Department of Oncologic Sciences, Moffitt Cancer Center/University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Department of Hematopathology, Moffitt Cancer Center, Tampa, FL, USA
| | - Kenneth H Shain
- Department of Oncologic Sciences, Moffitt Cancer Center/University of South Florida Morsani College of Medicine, Tampa, FL, USA.
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA.
- Tumor Biology Department, Moffitt Cancer Center, Tampa, FL, USA.
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
| |
Collapse
|
129
|
VTD is superior to VCD prior to intensive therapy in multiple myeloma: results of the prospective IFM2013-04 trial. Blood 2016; 127:2569-74. [PMID: 27002117 DOI: 10.1182/blood-2016-01-693580] [Citation(s) in RCA: 197] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 03/07/2016] [Indexed: 12/21/2022] Open
Abstract
The Intergroupe Francophone du Myélome conducted a randomized trial to compare bortezomib-thalidomide-dexamethasone (VTD) with bortezomib-cyclophosphamide-dexamethasone (VCD) as induction before high-dose therapy and autologous stem cell transplantation (ASCT) in patients with newly diagnosed multiple myeloma. Overall, a total of 340 patients were centrally randomly assigned to receive VTD or VCD. After 4 cycles, on an intent-to-treat basis, 66.3% of the patients in the VTD arm achieved at least a very good partial response (primary end point) vs 56.2% in the VCD arm (P = .05). In addition, the overall response rate was significantly higher in the VTD arm (92.3% vs 83.4% in the VCD arm; P = .01). Hematologic toxicity was higher in the VCD arm, with significantly increased rates of grade 3 and 4 anemia, thrombocytopenia, and neutropenia. On the other hand, the rate of peripheral neuropathy (PN) was significantly higher in the VTD arm. With the exception of hematologic adverse events and PN, other grade 3 or 4 toxicities were rare, with no significant differences between the VTD and VCD arms. Our data support the preferential use of VTD rather than VCD in preparation for ASCT. This trial was registered at www.clinicaltrials.gov as #NCT01564537 and at EudraCT as #2013-003174-27.
Collapse
|
130
|
Treatment of multiple myeloma with high-risk cytogenetics: a consensus of the International Myeloma Working Group. Blood 2016; 127:2955-62. [PMID: 27002115 DOI: 10.1182/blood-2016-01-631200] [Citation(s) in RCA: 624] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 03/08/2016] [Indexed: 02/07/2023] Open
Abstract
The International Myeloma Working Group consensus updates the definition for high-risk (HR) multiple myeloma based on cytogenetics Several cytogenetic abnormalities such as t(4;14), del(17/17p), t(14;16), t(14;20), nonhyperdiploidy, and gain(1q) were identified that confer poor prognosis. The prognosis of patients showing these abnormalities may vary with the choice of therapy. Treatment strategies have shown promise for HR cytogenetic diseases, such as proteasome inhibition in combination with lenalidomide/pomalidomide, double autologous stem cell transplant plus bortezomib, or combination of immunotherapy with lenalidomide or pomalidomide. Careful analysis of cytogenetic subgroups in trials comparing different treatments remains an important goal. Cross-trial comparisons may provide insight into the effect of new drugs in patients with cytogenetic abnormalities. However, to achieve this, consensus on definitions of analytical techniques, proportion of abnormal cells, and treatment regimens is needed. Based on data available today, bortezomib and carfilzomib treatment appear to improve complete response, progression-free survival, and overall survival in t(4;14) and del(17/17p), whereas lenalidomide may be associated with improved progression-free survival in t(4;14) and del(17/17p). Patients with multiple adverse cytogenetic abnormalities do not benefit from these agents. FISH data are implemented in the revised International Staging System for risk stratification.
Collapse
|
131
|
Mai EK, Benner A, Bertsch U, Brossart P, Hänel A, Kunzmann V, Naumann R, Neben K, Egerer G, Ho AD, Hillengass J, Raab MS, Neubauer A, Peyn A, Ko YD, Peter N, Scheid C, Goldschmidt H. Singleversustandem high-dose melphalan followed by autologous blood stem cell transplantation in multiple myeloma: long-term results from the phase III GMMG-HD2 trial. Br J Haematol 2016; 173:731-41. [DOI: 10.1111/bjh.13994] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/28/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Elias K. Mai
- Department of Internal Medicine V; University Clinic Heidelberg; Heidelberg Germany
| | - Axel Benner
- Division of Biostatistics; German Cancer Research Centre (DKFZ); Heidelberg Germany
| | - Uta Bertsch
- Department of Internal Medicine V; University Clinic Heidelberg; Heidelberg Germany
- Nationales Centrum für Tumorerkrankungen (NCT) Heidelberg; Heidelberg Germany
| | - Peter Brossart
- Medical Clinic and Polyclinic III; University Hospital Bonn; Bonn Germany
| | - Annette Hänel
- Department of Internal Medicine III; Klinikum Chemnitz; Chemnitz Germany
| | - Volker Kunzmann
- Department of Internal Medicine II; University Clinic Würzburg; Würzburg Germany
| | - Ralph Naumann
- Department of Medicine I; University Hospital Dresden Carl Gustav Carus; Dresden Germany
| | - Kai Neben
- Department of Haematology and Oncology; Klinikum Baden Baden; Baden Baden Germany
| | - Gerlinde Egerer
- Department of Internal Medicine V; University Clinic Heidelberg; Heidelberg Germany
| | - Anthony D. Ho
- Department of Internal Medicine V; University Clinic Heidelberg; Heidelberg Germany
| | - Jens Hillengass
- Department of Internal Medicine V; University Clinic Heidelberg; Heidelberg Germany
| | - Marc S. Raab
- Department of Internal Medicine V; University Clinic Heidelberg; Heidelberg Germany
| | - Andreas Neubauer
- Department of Haematology and Oncology; University Clinic Gießen/Marburg; Marburg Germany
| | - Astrid Peyn
- Department of Internal Medicine I; Klinikum Bremen Mitte; Bremen Germany
| | - Yon-Dschun Ko
- Department of Haematology and Oncology; Evangelische Kliniken Bonn; Bonn Germany
| | - Norma Peter
- Department of Internal Medicine II; Carl-Thiem Klinikum Cottbus; Cottbus Germany
| | - Christof Scheid
- Department of Internal Medicine I; University Hospital Köln; Köln Germany
| | - Hartmut Goldschmidt
- Department of Internal Medicine V; University Clinic Heidelberg; Heidelberg Germany
- Nationales Centrum für Tumorerkrankungen (NCT) Heidelberg; Heidelberg Germany
| |
Collapse
|
132
|
Early relapse post autologous transplant is a stronger predictor of survival compared with pretreatment patient factors in the novel agent era: analysis of the Singapore Multiple Myeloma Working Group. Bone Marrow Transplant 2016; 51:933-7. [DOI: 10.1038/bmt.2016.43] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 01/17/2016] [Accepted: 02/01/2016] [Indexed: 02/04/2023]
|
133
|
van de Donk NWCJ, Janmaat ML, Mutis T, Lammerts van Bueren JJ, Ahmadi T, Sasser AK, Lokhorst HM, Parren PWHI. Monoclonal antibodies targeting CD38 in hematological malignancies and beyond. Immunol Rev 2016; 270:95-112. [PMID: 26864107 PMCID: PMC4755228 DOI: 10.1111/imr.12389] [Citation(s) in RCA: 238] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
CD38 is a multifunctional cell surface protein that has receptor as well as enzyme functions. The protein is generally expressed at low levels on various hematological and solid tissues, while plasma cells express particularly high levels of CD38. The protein is also expressed in a subset of hematological tumors, and shows especially broad and high expression levels in plasma cell tumors such as multiple myeloma (MM). Together, this triggered the development of various therapeutic CD38 antibodies, including daratumumab, isatuximab, and MOR202. Daratumumab binds a unique CD38 epitope and showed strong anti-tumor activity in preclinical models. The antibody engages diverse mechanisms of action, including complement-dependent cytotoxicity, antibody-dependent cellular cytotoxicity, antibody-dependent cellular phagocytosis, programmed cell death, modulation of enzymatic activity, and immunomodulatory activity. CD38-targeting antibodies have a favorable toxicity profile in patients, and early clinical data show a marked activity in MM, while studies in other hematological malignancies are ongoing. Daratumumab has single agent activity and a limited toxicity profile, allowing favorable combination therapies with existing as well as emerging therapies, which are currently evaluated in the clinic. Finally, CD38 antibodies may have a role in the treatment of diseases beyond hematological malignancies, including solid tumors and antibody-mediated autoimmune diseases.
Collapse
MESH Headings
- ADP-ribosyl Cyclase 1/antagonists & inhibitors
- ADP-ribosyl Cyclase 1/genetics
- ADP-ribosyl Cyclase 1/metabolism
- Animals
- Antibodies, Monoclonal/pharmacology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized/pharmacology
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Agents/pharmacology
- Antineoplastic Agents/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Clinical Studies as Topic
- Cytotoxicity, Immunologic
- Drug Evaluation, Preclinical
- Drug Resistance, Neoplasm
- Gene Expression Regulation, Neoplastic/drug effects
- Hematologic Neoplasms/drug therapy
- Hematologic Neoplasms/genetics
- Hematologic Neoplasms/immunology
- Hematologic Neoplasms/metabolism
- Humans
- Immunomodulation/drug effects
- Protein Binding
- Recurrence
- Treatment Outcome
Collapse
Affiliation(s)
| | | | - Tuna Mutis
- Department of HematologyVU University Medical CenterAmsterdamthe Netherlands
| | | | | | | | - Henk M. Lokhorst
- Department of HematologyVU University Medical CenterAmsterdamthe Netherlands
| | - Paul W. H. I. Parren
- GenmabUtrechtthe Netherlands
- Department of Cancer and inflammation ResearchInstitute of Molecular MedicineUniversity of Southern DenmarkOdenseDenmark
- Department of Immunohematology and Blood TransfusionLeiden University Medical CenterLeidenthe Netherlands
| |
Collapse
|
134
|
Noonan KA, Huff CA, Davis J, Lemas MV, Fiorino S, Bitzan J, Ferguson A, Emerling A, Luznik L, Matsui W, Powell J, Fuchs E, Rosner GL, Epstein C, Rudraraju L, Ambinder RF, Jones RJ, Pardoll D, Borrello I. Adoptive transfer of activated marrow-infiltrating lymphocytes induces measurable antitumor immunity in the bone marrow in multiple myeloma. Sci Transl Med 2016; 7:288ra78. [PMID: 25995224 DOI: 10.1126/scitranslmed.aaa7014] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Successful adoptive T cell therapy (ACT) requires the ability to activate tumor-specific T cells with the ability to traffic to the tumor site and effectively kill their target as well as persist over time. We hypothesized that ACT using marrow-infiltrating lymphocytes (MILs) in multiple myeloma (MM) could impart greater antitumor immunity in that they were obtained from the tumor microenvironment. We describe the results from the first clinical trial using MILs in MM. Twenty-five patients with either newly diagnosed or relapsed disease had their MILs harvested, activated and expanded, and subsequently infused on the third day after myeloablative therapy. Cells were obtained and adequately expanded in all patients with anti-CD3/CD28 beads plus interleukin-2, and a median of 9.5 × 10(8) MILs were infused. Factors indicative of response to MIL ACT included (i) the presence of measurable myeloma-specific activity of the ex vivo expanded product, (ii) low endogenous bone marrow T cell interferon-γ production at baseline, (iii) a CD8(+) central memory phenotype at baseline, and (iv) the generation and persistence of myeloma-specific immunity in the bone marrow at 1 year after ACT. Achieving at least a 90% reduction in disease burden significantly increased the progression-free survival (25.1 months versus 11.8 months; P = 0.01). This study demonstrates the feasibility and efficacy of MILs as a form of ACT with applicability across many hematologic malignancies and possibly solid tumors infiltrating the bone marrow.
Collapse
Affiliation(s)
- Kimberly A Noonan
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - Carol A Huff
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - Janice Davis
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - M Victor Lemas
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - Susan Fiorino
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - Jeffrey Bitzan
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - Anna Ferguson
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - Amy Emerling
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - Leo Luznik
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - William Matsui
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - Jonathan Powell
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - Ephraim Fuchs
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - Gary L Rosner
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - Caroline Epstein
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - Lakshmi Rudraraju
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - Richard F Ambinder
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - Richard J Jones
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - Drew Pardoll
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA
| | - Ivan Borrello
- Johns Hopkins University School of Medicine, 1650 Orleans Street, CRB1 Room 453, Baltimore, MD 21231, USA.
| |
Collapse
|
135
|
Yun HD, Dossul T, Bernal-Mizrachi L, Switchenko J, Ndibe C, Ibraheem A, Dixon MD, Langston AA, Nooka AK, Flowers CR, Pentz RD, Waller EK. Referral Patterns and Clinical Outcomes for Transplant-Eligible Lymphoma and Myeloma Patients Evaluated at an Urban County Hospital. ACTA ACUST UNITED AC 2016; 6. [PMID: 28966870 DOI: 10.4172/2157-7633.1000328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Disparities in clinical care have been described for patients with limited insurance coverage or social support. We hypothesized that patients with relapsed Hodgkin lymphoma (HL), non-Hodgkin lymphoma (NHL), or multiple myeloma (MM) treated at an urban county hospital serving indigent and under-insured patients would face barriers for referral to a private academic transplant center for autologous stem cell transplantation (ASCT). Charts of patients with HL, NHL, or MM treated at Grady Memorial Hospital between 2007 and 2013 were reviewed, and 215 patients with diagnosis of HD (n=40), NHL (n=96), and MM (n=79). 55 patients were referred for ASCT consults and 160 patients were not referred. Reasons for transplant non-referral included established clinical criteria (64% of cases), poor performance status (13%), refusal (4%), moved/lost-to-follow-up (4%), medical non-compliance (3%), death (3%), or referral to another hospital (1%). Non-referral based upon socio-economic criteria included: lack of legal immigration status/insurance (2%), and lack of social support/substance abuse (2%). Among the 55 referred patients, 27 patients (49%) underwent ASCT. Median follow-up for all referred patients from the time of diagnosis was 3.9 [0.7-22.7] years. 5-year survival from the date of diagnosis for patients who received ASCT was 80.2% versus 65.7% for non-transplanted patients (log-rank test, p-value=0.11). While the referral process did not demonstrate significant barriers based upon insurance or social status, further evaluation is needed to identify modifiable factors that can improve referral and assess the impact of the Affordable Care Act on access to ASCT.
Collapse
Affiliation(s)
- Hyun D Yun
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Tehseen Dossul
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Leon Bernal-Mizrachi
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Jeffrey Switchenko
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
| | - Chukwuma Ndibe
- Division of Hematology and Oncology, Department of Medicine, University of Alabama, Birmingham, AL 35294, USA
| | - Abiola Ibraheem
- Department of Hematology and Oncology, University Chicago, Chicago, IL 60637, USA
| | - Margie D Dixon
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Amelia A Langston
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Ajay K Nooka
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Christopher R Flowers
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Rebecca D Pentz
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Edmund K Waller
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA
| |
Collapse
|
136
|
Efficacy and Safety of Novel Agent-Based Therapies for Multiple Myeloma: A Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:6848902. [PMID: 26949704 PMCID: PMC4753325 DOI: 10.1155/2016/6848902] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 12/15/2015] [Accepted: 12/22/2015] [Indexed: 12/26/2022]
Abstract
This study aimed at comparing bortezomib, thalidomide, and lenalidomide in patients with multiple myeloma (MM) for safety and efficacy using meta-analysis. This meta-analysis identified 17 randomized controlled trials (RCTs) including 6742 patients. These RCTs were separated according to the different agent-based regimens and to autologous stem-cell transplantation (ASCT). Complete response (CR), progression-free survival (PFS), overall survival (OS), and adverse events (AE) were combined. The total weighted risk ratio (RR) of CR was 3.29 [95% confidence interval (95% CI): 2.22–4.88] (P < 0.0001) for the novel agent-based regimens. These novel agent-based regimens showed greater benefit in terms of PFS of all subgroups irrespective of whether the patient received ASCT or not. The hazard ratio (HR) for PFS was 0.64 [95% CI: 0.60–0.69] (P < 0.00001). Improvements of OS could be found only in the bortezomib- and thalidomide-based regimens without ASCT. The pooled HRs were 0.74 [95% CI: 0.65–0.86] (P < 0.0001) and 0.80 [95% CI: 0.70–0.90] (P = 0.0004), respectively. Several AEs were shown more frequently in the novel agent-based regimens compared with controls such as hematologic events (neutropenia, anemia, and thrombocytopenia), gastrointestinal infection, peripheral neuropathy, thrombosis, and embolism events. In conclusion, in spite of the AEs, novel agent-based regimens are safe and effective for the treatment of MM.
Collapse
|
137
|
Hashimoto S, Kuroha T, Yano T, Sato N, Furukawa T. The Addition of Low-dose Thalidomide to Bortezomib and Dexamethasone for Refractory Multiple Myeloma. Intern Med 2016; 55:3025-3028. [PMID: 27746443 PMCID: PMC5109573 DOI: 10.2169/internalmedicine.55.6470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Five cases were treated by adding daily low-dose thalidomide (50 mg) to bortezomib and dexamethasone therapy for refractory multiple myeloma. This therapy was effective in four cases, with an improvement of bone pain and regression of M-protein. One case was treated with cyclophosphamide, thalidomide, and dexamethasone, adding bortezomib after starting the three-drug combination therapy. This patient has remained in a stable disease state since the beginning of this therapy. Regarding the other four cases, a partial response and a prolonged survival for approximately one year were noted. Peripheral neuropathy did not increase after thalidomide addition. Adding low-dose thalidomide may safely improve the responses for multiple myeloma refractory to bortezomib and dexamethasone.
Collapse
|
138
|
Abstract
Assessment of minimal residual disease (MRD) is becoming standard diagnostic care for potentially curable neoplasms such as some acute leukemias as well as chronic myeloid and lymphocytic leukemia. Although multiple myeloma (MM) remains as an incurable disease, around half of the patients achieve complete remission (CR), and recent data suggests increasing rates of curability with "total-therapy-like" programs. This landscape is likely to be improved with the advent of new antibodies and small molecules. Therefore, conventional serological and morphological techniques have become suboptimal for sensitive evaluation of highly effective treatment strategies. Although, existing data suggests that MRD could be used as a biomarker to evaluate treatment efficacy, help on therapeutic decisions, and act as surrogate for overall survival, the role of MRD in MM is still a matter of extensive debate. Here, we review the different levels of remission used to define depth of response in MM and their clinical significance, as well as the prognostic value and unique characteristics of MRD detection using immunophenotypic, molecular, and imaging techniques. Key facts The higher efficacy of new treatment strategies for MM demand the incorporation of highly sensitive techniques to monitor treatment efficacy MRD could be used as a more potent surrogate biomarker for survival than standard CR We need to understand the pros and cons of the different MRD techniques The time has come to incorporate highly sensitive, cost-effective, readily available, and standardized MRD techniques into clinical trials to assess its role in therapeutic decisions.
Collapse
Affiliation(s)
- Bruno Paiva
- Centro de Investigacion Medica Aplicada (CIMA), Clinica Universidad de Navarra, IDISNA, Pamplona, Spain
| | - Ramón García-Sanz
- Hospital Universitario de Salamanca, Centro de Investigación Del Cancer (IBMCC-USAL, CSIC), Instituto de Investigaion Biomedica de Salamanca (IBSAL), Salamanca, Spain
| | - Jesús F San Miguel
- Centro de Investigacion Medica Aplicada (CIMA), Clinica Universidad de Navarra, IDISNA, Pamplona, Spain.
| |
Collapse
|
139
|
Wang L, Wang KF, Chang BY, Chen XQ, Xia ZJ. Once-weekly subcutaneous administration of bortezomib in patients with multiple myeloma. Asian Pac J Cancer Prev 2015; 16:2093-8. [PMID: 25773856 DOI: 10.7314/apjcp.2015.16.5.2093] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
In patients with multiple myeloma (MM), once-weekly intravenous injection or twice-weekly subcutaneous injection (SC) of bortezomib has been proven to offer non-inferior efficacy to standard twice-weekly intravenous administration, with an improved safety profile. However, whether once-weekly SC bortezomib can further reduce the incidence rate of peripheral neuropathy (PN) and not compromise the efficacy remains to be investigated. 25 patients of MM treated with once-weekly SC bortezomib were reviewed in this study. The median treatment cycles were 4 (range, 2-9 cycles). Complete response (CR) rate was 52%, ≥very good partial response (VGPR) rate was 72%, and ≥partial response (PR) rate was 84%. 1-year and 2-year PFS rate was 63.0% and 34.3%, respectively, and 2-year OS rate was 100%. Any grade of PN was reported in 9 patients (36.0%), with 7 patients (28.0%) had grade 1 PN, and 2 patients (8.0%) had grade 2 PN. No patients reported grade 3/4 PN in this cohort. In conclusion, once-weekly subcutaneous administration of bortezomib offers excellent efficacy with a further improved safety profile, especially with regard to PN. It needs to be validated in future prospective randomized trials.
Collapse
Affiliation(s)
- Liang Wang
- Department of Hematologic Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, People's Republic of China E-mail :
| | | | | | | | | |
Collapse
|
140
|
Musso M, Messina G, Marcacci G, Crescimanno A, Console G, Donnarumma D, Scalone R, Pinto A, Martino M. High-Dose Melphalan Plus Thiotepa as Conditioning Regimen before Second Autologous Stem Cell Transplantation for “De Novo” Multiple Myeloma Patients: A Phase II Study. Biol Blood Marrow Transplant 2015; 21:1932-8. [DOI: 10.1016/j.bbmt.2015.06.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 06/12/2015] [Indexed: 12/12/2022]
|
141
|
Stella F, Pedrazzini E, Agazzoni M, Ballester O, Slavutsky I. Cytogenetic Alterations in Multiple Myeloma: Prognostic Significance and the Choice of Frontline Therapy. Cancer Invest 2015; 33:496-504. [DOI: 10.3109/07357907.2015.1080833] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
142
|
Mueller BU, Keller S, Seipel K, Mansouri Taleghani B, Rauch D, Betticher D, Egger T, Pabst T. Stem cell mobilization chemotherapy with gemcitabine is effective and safe in myeloma patients with bortezomib-induced neurotoxicity. Leuk Lymphoma 2015; 57:1122-9. [DOI: 10.3109/10428194.2015.1079315] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
143
|
Trends of survival in patients with multiple myeloma in Japan: a multicenter retrospective collaborative study of the Japanese Society of Myeloma. Blood Cancer J 2015; 5:e349. [PMID: 26383822 PMCID: PMC4648525 DOI: 10.1038/bcj.2015.79] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
144
|
Cejalvo MJ, de la Rubia J. Clinical treatment of newly diagnosed multiple myeloma. Expert Rev Hematol 2015; 8:595-611. [DOI: 10.1586/17474086.2015.1078236] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
145
|
Phase I dose-escalation study of cyclophosphamide combined with bortezomib and dexamethasone in Japanese patients with relapsed and/or refractory multiple myeloma. Int J Hematol 2015; 102:434-40. [PMID: 26298823 DOI: 10.1007/s12185-015-1846-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 07/10/2015] [Accepted: 07/28/2015] [Indexed: 10/23/2022]
Abstract
The present study was conducted to determine the recommended dose (RD) of cyclophosphamide (CPM) in the CBD regimen, a triplet combination of CPM, bortezomib (BTZ), and dexamethasone (Dex), for relapsed and/or refractory multiple myeloma (RRMM). Patients received intravenous CPM on days 1 and 8 at one of three dose levels: 300, 400, or 500 mg/m(2), with dose escalation in a 3 + 3 design. BTZ at 1.3 mg/m(2) was given twice weekly in 3-week cycles, with Dex at 20 mg/m(2) on the day of and day after BTZ. Of 16 patients enrolled, 15 eligible patients were allocated to the study. Dose-limiting toxicities (DLTs) were seen in two patients: one in dose level 1 with increased γ-GTP and the other in dose level 3 with increased γ-GTP and ALT. Both patients spontaneously recovered from DLT. Neither therapy-related mortality nor severe adverse events were reported during the study. Therefore, the RD of CPM was determined as 500 mg/m(2). Overall, 2 (13.3 %), 1 (6.7 %), and 8 (53.3 %) patients achieved CR, VGPR, and PR, respectively. The regimen was well tolerated and showed promising activity in patients with RRMM.
Collapse
|
146
|
Kazmi SM, Nusrat M, Gunaydin H, Cornelison AM, Shah N, Kebriaei P, Nieto Y, Parmar S, Popat UR, Oran B, Shah JJ, Orlowski RZ, Champlin RE, Qazilbash MH, Bashir Q. Outcomes Among High-Risk and Standard-Risk Multiple Myeloma Patients Treated With High-Dose Chemotherapy and Autologous Hematopoietic Stem-Cell Transplantation. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15:687-93. [PMID: 26361647 DOI: 10.1016/j.clml.2015.07.641] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 06/29/2015] [Accepted: 07/28/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND Conventional cytogenetics and interphase fluorescence in-situ hybridization (FISH) identify a high-risk multiple myeloma population characterized by poor response and short survival. PATIENTS AND METHODS We compared outcomes between high-risk and standard-risk myeloma patients who underwent autologous hematopoietic stem-cell transplantation (auto-HCT) at our institution between January 2005 and December 2009. High-risk myeloma was defined as -13/del(13q) or hypodiploidy in at least 2 metaphases of conventional cytogenetics, or -17/del(17p), t(4;14), t(14;16), t(14;20), hypodiploidy (< 45 chromosomes excluding -Y), or chromosome 1 abnormalities (+1q, -1p, t(1;x)) on FISH or conventional cytogenetics. RESULTS Of 670 myeloma patients, 74 (11%) had high-risk myeloma. These high-risk patients had significantly lower overall response rates (74% vs. 85%; P < .01), shorter median progression-free survival (10.3 vs. 32.4 months; P < .001), and shorter overall survival (28 months vs. not reached; P < .001) than the standard-risk patients. Having only 1 high-risk cytogenetic abnormality or experiencing at least very good partial remission after auto-HCT independently predicted improved progression-free survival and overall survival (P < .05) in high-risk patients. CONCLUSION Even in an era of novel therapies, cytogenetically identified high-risk myeloma patients have worse prognoses than standard-risk myeloma patients after auto-HCT, and having more than 1 high-risk cytogenetic abnormality further reduces survival.
Collapse
Affiliation(s)
- Syed M Kazmi
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Maliha Nusrat
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX
| | - Hilal Gunaydin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amanda M Cornelison
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nina Shah
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yago Nieto
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Simrit Parmar
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Uday R Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Betul Oran
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jatin J Shah
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Robert Z Orlowski
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Muzaffar H Qazilbash
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Qaiser Bashir
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX.
| |
Collapse
|
147
|
Mateos MV, Oriol A, Rosiñol L, de Arriba F, Puig N, Martín J, Martínez-López J, Echeveste MA, Sarrá J, Ocio E, Ramírez G, Martínez R, Palomera L, Payer A, Iglesias R, de la Rubia J, Alegre A, Chinea AI, Bladé J, Lahuerta JJ, San Miguel JF. Bendamustine, bortezomib and prednisone for the treatment of patients with newly diagnosed multiple myeloma: results of a prospective phase 2 Spanish/PETHEMA trial. Haematologica 2015; 100:1096-102. [PMID: 25911554 PMCID: PMC5004426 DOI: 10.3324/haematol.2015.124818] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/22/2015] [Indexed: 11/09/2022] Open
Abstract
Bendamustine is a bifunctional alkylating agent with proven activity in myeloma. In this study 60 newly diagnosed myeloma patients were given bendamustine plus bortezomib and prednisone in a regimen consisting of one cycle of bortezomib twice weekly for 6 weeks (1.3 mg/m(2) on days 1, 4, 8, 11, 22, 25, 29, and 32), plus bendamustine (90 mg/m(2) on days 1 and 4) and prednisone. The following cycles included bortezomib once weekly. Patients who were transplant candidates proceeded to stem cell collection after four cycles and the transplant was performed after six cycles. Patients who were not candidates for transplantation received up to nine cycles. Forty-two patients were transplant candidates and after six cycles, 50% achieved at least a very good partial response, with 24% having complete responses; 35 proceeded to a transplant, and the complete response rate was 54%. Seventeen patients continued up to nine cycles, and 57% achieved at least a very good partial response, including 26% with complete responses. The 2-year progression-free survival and overall survival rates were 62% and 86%, respectively. The safety profile was manageable, but stem cell mobilization was compromised in 35% of patients. In summary, this combination is effective in untreated patients, with an acceptable toxicity profile, but given the introduction of second-generation novel agents and monoclonal antibodies, the combination will probably be better reserved for relapsing patients, in whom stem cell collection is not needed, while cost-effective combinations with non-cross-resistant drugs continue to represent a medical need. This trial was registered with ClinicalTrials.gov, number NCT01376401.
Collapse
Affiliation(s)
| | | | - Laura Rosiñol
- Hospital Clinic i Provincial, Institut d'Investigasions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona
| | | | - Noemí Puig
- University Hospital of Salamanca/IBSAL, Salamanca
| | | | | | | | - Josep Sarrá
- Hospital Universitario Joan XXIII de Tarragona, Institut Català d'Oncologia (ICO)
| | - Enrique Ocio
- University Hospital of Salamanca/IBSAL, Salamanca
| | | | | | | | - Angel Payer
- Hospital Universitario Central de Asturias, Oviedo
| | | | - Javier de la Rubia
- Hospital Dr Peset and Universidad Católica de Valencia "San Vicente Mártir"
| | | | | | - Joan Bladé
- Hospital Clinic i Provincial, Institut d'Investigasions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona
| | | | | |
Collapse
|
148
|
Rapoport AP, Stadtmauer EA, Binder-Scholl GK, Goloubeva O, Vogl DT, Lacey SF, Badros AZ, Garfall A, Weiss B, Finklestein J, Kulikovskaya I, Sinha SK, Kronsberg S, Gupta M, Bond S, Melchiori L, Brewer JE, Bennett AD, Gerry AB, Pumphrey NJ, Williams D, Tayton-Martin HK, Ribeiro L, Holdich T, Yanovich S, Hardy N, Yared J, Kerr N, Philip S, Westphal S, Siegel DL, Levine BL, Jakobsen BK, Kalos M, June CH. NY-ESO-1-specific TCR-engineered T cells mediate sustained antigen-specific antitumor effects in myeloma. Nat Med 2015; 21:914-921. [PMID: 26193344 PMCID: PMC4529359 DOI: 10.1038/nm.3910] [Citation(s) in RCA: 639] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 06/23/2015] [Indexed: 12/22/2022]
Abstract
Despite recent therapeutic advances, multiple myeloma (MM) remains largely incurable. Here we report results of a phase I/II trial to evaluate the safety and activity of autologous T cells engineered to express an affinity-enhanced T cell receptor (TCR) recognizing a naturally processed peptide shared by the cancer-testis antigens NY-ESO-1 and LAGE-1. Twenty patients with antigen-positive MM received an average 2.4 × 10(9) engineered T cells 2 d after autologous stem cell transplant. Infusions were well tolerated without clinically apparent cytokine-release syndrome, despite high IL-6 levels. Engineered T cells expanded, persisted, trafficked to marrow and exhibited a cytotoxic phenotype. Persistence of engineered T cells in blood was inversely associated with NY-ESO-1 levels in the marrow. Disease progression was associated with loss of T cell persistence or antigen escape, in accordance with the expected mechanism of action of the transferred T cells. Encouraging clinical responses were observed in 16 of 20 patients (80%) with advanced disease, with a median progression-free survival of 19.1 months. NY-ESO-1-LAGE-1 TCR-engineered T cells were safe, trafficked to marrow and showed extended persistence that correlated with clinical activity against antigen-positive myeloma.
Collapse
Affiliation(s)
- Aaron P Rapoport
- The Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Edward A Stadtmauer
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Olga Goloubeva
- The Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD USA
| | - Dan T Vogl
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Simon F Lacey
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashraf Z Badros
- The Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Alfred Garfall
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brendan Weiss
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey Finklestein
- Department of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD USA
| | - Irina Kulikovskaya
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sanjoy K Sinha
- School of Mathematics and Statistics, Carleton University, Ottawa, Canada
| | - Shari Kronsberg
- The Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD USA
| | - Minnal Gupta
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah Bond
- Cambridge Biomedical, Cambridge, Massachusetts, USA
| | | | | | | | | | | | | | | | | | | | - Saul Yanovich
- The Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nancy Hardy
- The Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jean Yared
- The Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Naseem Kerr
- Department of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sunita Philip
- The Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sandra Westphal
- The Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Don L Siegel
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Bruce L Levine
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Michael Kalos
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Carl H June
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
149
|
Martin JR, Beegle NL, Zhu Y, Hanisch EM. Subcutaneous Administration of Bortezomib: A Pilot Survey of Oncology Nurses. J Adv Pract Oncol 2015; 6:308-18. [PMID: 26705492 PMCID: PMC4677804 DOI: 10.6004/jadpro.2015.6.4.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Subcutaneous (SC) administration of the proteasome inhibitor bortezomib was approved in the United States and European Union in 2012. There is limited guidance regarding how to administer SC bortezomib and a general lack of clear direction on optimal techniques for administering SC chemotherapy injections. Nurses may be utilizing different techniques, and inconsistent techniques may result in injection-site reactions, causing patient discomfort and treatment cessatioin. This observational survey of oncology nurses in community oncology clinics aimed to identify techniques being used and explore nurses’ opinions about SC bortezomib administration. A 44-question electronic survey was developed, based on the current literature regarding appropriate techniques for administering SC injections. A total of 43 nurses from 17 clinics in 12 states responded. The majority (74%) had been practicing oncology nursing for at more than 5 years. Respondents predominantly used and preferred the abdomen for injections (88%); 81% used a skin lift to ensure injection into adipose tissue. There was no relationship between the angle of insertion and the needle length; 51% used an air-bubble technique. Nurses took 3–5 (49%), 5–10 (35%), 10–30 (9%), or > 30 (7%) seconds to administer each mL of SC bortezomib injection. All nurses completely/somewhat agreed that practice guidelines would be important for standardizing SC bortezomib administration. Advanced practice registered nurses (APRNs) shared the responsibility for ordering SC bortezomib, according to 53% of respondents. These findings could help APRNs improve the quality of patient care, may help minimize adverse events and maximize effective therapy, and could help inform the development of practice guidelines.
Collapse
Affiliation(s)
| | - Nancy L Beegle
- Cancer Clinics of Excellence, Greenwood Village, Colorado
| | - Yanyan Zhu
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, Massachusetts
| | | |
Collapse
|
150
|
Liu X, He CK, Meng X, He L, Li K, Liang Q, Shao L, Liu S. Bortezomib-based vs non-bortezomib-based post-transplantation treatment in multiple myeloma patients: a systematic review and meta-analysis of Phase III randomized controlled trials. Onco Targets Ther 2015; 8:1459-69. [PMID: 26109870 PMCID: PMC4474400 DOI: 10.2147/ott.s84828] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objective To evaluate the efficacy and safety of bortezomib-based vs non-bortezomib-based post-transplantation therapy in patients with multiple myeloma. Methods Data of relevant randomized controlled trials assessing the effect of bortezomib as post-transplantation consolidation or maintenance therapy was obtained through a comprehensive search. The outcome measures included response rate, progression-free survival, overall survival, and adverse events (AEs). The hazard ratio (HR), Cochran-Mantel-Haenszel odds ratio (OR), and 95% confidence interval (95% CI) were applied to evaluate the effect of bortezomib in relation to the end points such as progression-free survival, overall survival, response rate, and AEs. Results Three randomized controlled trials comprising 1,518 participants were included in this study. Pooled ORs for the rates of overall response, and complete response and near complete response, were 1.85 and 1.75, respectively. Pooled HR for progression-free survival favored bortezomib-based therapy over non-bortezomib-based therapy (0.73, 95% CI: 0.67–0.81), while no statistically significant difference could be found between the two groups regarding the pooled HR for 3-year overall survival. Moreover, incidence rates of overall adverse events and grade 3 and 4 peripheral neuropathy were similar in the bortezomib-based groups and the non-bortezomib-based groups (P=0.12 and P=0.41, respectively). The corresponding cumulative meta-analyses of the rates of overall response rate, complete response and near complete response, and grades 3 and 4 peripheral neuropathy supported the superiority of bortezomib-based maintenance therapy over consolidation therapy. Conclusion Bortezomib-based therapy after autologous stem cell transplantation, with tolerable AEs, could obviously improve the response as well as the outcome of multiple myeloma patients, particularly when bortezomib was administered as maintenance therapy.
Collapse
Affiliation(s)
- Xiaoping Liu
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China
| | | | - Xiangyu Meng
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China
| | - Li He
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China
| | - Kaili Li
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China
| | - Qing Liang
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China
| | - Liang Shao
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China
| | - Shangqin Liu
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China
| |
Collapse
|