251
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Mateos MV, Ocio EM, Paiva B, Rosiñol L, Martínez-López J, Bladé J, Lahuerta JJ, García-Sanz R, San Miguel JF. Treatment for patients with newly diagnosed multiple myeloma in 2015. Blood Rev 2015; 29:387-403. [PMID: 26094881 DOI: 10.1016/j.blre.2015.06.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 06/05/2015] [Accepted: 06/08/2015] [Indexed: 10/23/2022]
Abstract
Multiple myeloma is the second most frequent haematological disease. The introduction of high-dose melphalan followed by autologous haematopoietic cell transplant (HDT/ASCT) for young patients and the availability of novel agents for young and elderly patients with multiple myeloma have dramatically changed the perspective of treatment. However, further research is necessary if we want to definitively cure the disease. Treatment goals for transplant-eligible and non-transplant-eligible patients should be to prolong survival by achieving the best possible response, while ensuring quality of life. The treatment should be individualized on the basis of host and disease features and better monitoring of the response upon use of high-sensitivity techniques for evaluating residual disease. For young patients, HDT/ASCT is a standard of care for treatment and its efficacy has been enhanced and challenged by the new drugs. For elderly patients, treatment options were limited to alkylators, but new upfront treatment combinations based on novel agents (proteasome inhibitors and immunomodulatory drugs) combined or not with alkylators have significantly improved outcomes.Extended treatment for young and elderly patients improves the quality and duration of clinical responses; however,the optimal scheme, appropriate doses and duration of long-term therapy have not yet been fully determined.This review summarises the progress in the treatment of patients with newly diagnosed multiple myeloma, addressing critical questions such as the optimal induction, early versus late ASCT, consolidation and/or maintenance for young patients, and how we can choose the best option for non-transplant-eligible patients.
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Affiliation(s)
| | - Enrique M Ocio
- Hospital Universitario de Salamanca-IBSAL, IBMCC-CSIC, Salamanca, Spain
| | - Bruno Paiva
- Clínica Universidad de Navarra/Centro de Investigación Médica Aplicada (CIMA), Spain
| | - Laura Rosiñol
- Hospital Clínic i Provincial de Barcelona, Institut d'Investigacions Biomédiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Joan Bladé
- Hospital Clínic i Provincial de Barcelona, Institut d'Investigacions Biomédiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Ramón García-Sanz
- Hospital Universitario de Salamanca-IBSAL, IBMCC-CSIC, Salamanca, Spain
| | - Jesús F San Miguel
- Clínica Universidad de Navarra/Centro de Investigación Médica Aplicada (CIMA), Spain
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252
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Arroz M, Came N, Lin P, Chen W, Yuan C, Lagoo A, Monreal M, de Tute R, Vergilio JA, Rawstron AC, Paiva B. Consensus guidelines on plasma cell myeloma minimal residual disease analysis and reporting. CYTOMETRY PART B-CLINICAL CYTOMETRY 2015; 90:31-9. [PMID: 25619868 DOI: 10.1002/cyto.b.21228] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 01/15/2015] [Accepted: 01/16/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Major heterogeneity between laboratories in flow cytometry (FC) minimal residual disease (MRD) testing in multiple myeloma (MM) must be overcome. Cytometry societies such as the International Clinical Cytometry Society and the European Society for Clinical Cell Analysis recognize a strong need to establish minimally acceptable requirements and recommendations to perform such complex testing. METHODS A group of 11 flow cytometrists currently performing FC testing in MM using different instrumentation, panel designs (≥ 6-color) and analysis software compared the procedures between their respective laboratories and reviewed the literature to propose a consensus guideline on flow-MRD analysis and reporting in MM. RESULTS/CONCLUSION Consensus guidelines support i) the use of minimum of five initial gating parameters (CD38, CD138, CD45, forward, and sideward light scatter) within the same aliquot for accurate identification of the total plasma cell compartment; ii) the analysis of potentially aberrant phenotypic markers and to report the antigen expression pattern on neoplastic plasma cells as being reduced, normal or increased, when compared to a normal reference plasma cell immunophenotype (obtained using the same instrument and parameters); and iii) the percentage of total bone marrow plasma cells plus the percentages of both normal and neoplastic plasma cells within the total bone marrow plasma cell compartment, and over total bone marrow cells. Consensus guidelines on minimal current and future MRD analyses should target a lower limit of detection of 0.001%, and ideally a limit of quantification of 0.001%, which requires at least 3 × 10(6) and 5 × 10(6) bone marrow cells to be measured, respectively.
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Affiliation(s)
- Maria Arroz
- Department of Clinical Pathology, Cytometry Laboratory, CHLO, Hospital S. Francisco Xavier, Lisbon, Portugal
| | - Neil Came
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Pei Lin
- Department of Hematopathology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Weina Chen
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Constance Yuan
- Laboratory of Pathology, NCI, NIH, Bethesda, Maryland, USA
| | - Anand Lagoo
- Department of Pathology, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Ruth de Tute
- HMDS, Department of Haematology, St. James's Institute of Oncology, Leeds, United Kingdom
| | - Jo-Anne Vergilio
- University Of Michigan Medical Center Hematology Oncology Laboratory, Ann Arbor, Michigan, USA
| | - Andy C Rawstron
- HMDS, Department of Haematology, St. James's Institute of Oncology, Leeds, United Kingdom
| | - Bruno Paiva
- Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada, University of Navarra, Pamplona, Spain
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253
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Wood BL. Principles of minimal residual disease detection for hematopoietic neoplasms by flow cytometry. CYTOMETRY PART B-CLINICAL CYTOMETRY 2015; 90:47-53. [PMID: 25906832 DOI: 10.1002/cyto.b.21239] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 03/09/2015] [Accepted: 03/18/2015] [Indexed: 01/22/2023]
Abstract
Flow cytometry has become an indispensible tool for the diagnosis and classification of hematopoietic neoplasms. The ability to rapidly distinguish cellular subpopulations via multiparametric assessment of quantitative differences in antigen expression on single cells and enumerate the relative sizes of the resulting subpopulations is a key feature of the technology. More recently, these capabilities have been expanded to include the identification and enumeration of rare subpopulations within complex cellular mixtures, for example, blood or bone marrow, leading to the application for post-therapeutic monitoring or minimal residual disease detection. This review will briefly present the principles to be considered in the construction and use of flow cytometric assays for minimal residual disease detection including the use of informative antibody combinations, the impact of immunophenotypic instability, enumeration, assay sensitivity, and reproducibility.
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Affiliation(s)
- Brent L Wood
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington.,Seattle Cancer Care Alliance, Seattle, Washington
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254
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Consolidation and maintenance therapy for multiple myeloma after autologous transplantation: where do we stand? Bone Marrow Transplant 2015; 50:1024-9. [DOI: 10.1038/bmt.2015.83] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 12/26/2014] [Accepted: 01/02/2015] [Indexed: 11/08/2022]
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255
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New criteria for response assessment: role of minimal residual disease in multiple myeloma. Blood 2015; 125:3059-68. [PMID: 25838346 DOI: 10.1182/blood-2014-11-568907] [Citation(s) in RCA: 215] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 01/17/2015] [Indexed: 12/26/2022] Open
Abstract
Assessment of minimal residual disease (MRD) is becoming standard diagnostic care for potentially curable neoplasms such as acute lymphoblastic leukemia. In multiple myeloma (MM), the majority of patients will inevitably relapse despite achievement of progressively higher complete remission (CR) rates. Novel treatment protocols with inclusion of antibodies and small molecules might well be able to further increase remission rates and potentially also cure rates. Therefore, MRD diagnostics becomes essential to assess treatment effectiveness. This review summarizes reports from the past 2 decades, which demonstrate that persistent MRD by multiparameter flow cytometry, polymerase chain reaction, next-generation sequencing, and positron emission tomography/computed tomography, predicts significantly inferior survival among CR patients. We describe the specific features of currently available techniques for MRD monitoring and outline the arguments favoring new criteria for response assessment that incorporate MRD levels. Extensive data indicate that MRD information can potentially be used as biomarker to evaluate the efficacy of different treatment strategies, help on treatment decisions, and act as surrogate for overall survival. The time has come to address within clinical trials the exact role of baseline risk factors and MRD monitoring for tailored therapy in MM, which implies systematic usage of highly sensitive, cost-effective, readily available, and standardized MRD techniques.
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256
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Gay F, Cavallo F, Palumbo A. The role of pre-transplant induction regimens and autologous stem cell transplantation in the era of novel targeted agents. Drugs 2015; 75:367-75. [PMID: 25764394 DOI: 10.1007/s40265-015-0367-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Outcome of patients with multiple myeloma (MM) has greatly improved with the use of autologous stem cell transplantation (ASCT) and new agents, such as immunomodulatory drugs (thalidomide and lenalidomide) and proteasome inhibitors (bortezomib). When compared to conventional chemotherapy, high-dose melphalan with ASCT significantly improved response rates and progression-free survival, while overall survival benefit was not consistent across all trials. ASCT is considered the standard treatment for patients who are younger than 65 years and who do not have limiting comorbidities. New, effective agents have been introduced as part of induction, consolidation and maintenance treatments within ASCT and in combinations with chemotherapy for patients not eligible for ASCT. The remarkable results obtained with these regimens are questioning the role of ASCT for newly diagnosed MM patients. This article aims to delineate the role of ASCT in the era of novel agents based on the results of recent clinical trials.
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Affiliation(s)
- Francesca Gay
- Myeloma Unit, Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Via Genova 3, 10126, Torino, Italy
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257
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Shah N, Callander N, Ganguly S, Gul Z, Hamadani M, Costa L, Sengsayadeth S, Abidi M, Hari P, Mohty M, Chen YB, Koreth J, Landau H, Lazarus H, Leather H, Majhail N, Nath R, Osman K, Perales MA, Schriber J, Shaughnessy P, Vesole D, Vij R, Wingard J, Giralt S, Savani BN. Hematopoietic Stem Cell Transplantation for Multiple Myeloma: Guidelines from the American Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2015; 21:1155-66. [PMID: 25769794 DOI: 10.1016/j.bbmt.2015.03.002] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 03/04/2015] [Indexed: 01/28/2023]
Abstract
Therapeutic strategies for multiple myeloma (MM) have changed dramatically over the past decade. Thus, the role of hematopoietic stem cell transplantation (HCT) must be considered in the context of this evolution. In this evidence-based review, we have critically analyzed the data from the most recent clinical trials to better understand how to incorporate HCT and when HCT is indicated. We have provided our recommendations based on strength of evidence with the knowledge that ongoing clinical trials make this a dynamic field. Within this document, we discuss the decision to proceed with autologous HCT, factors to consider before proceeding to HCT, the role of tandem autologous HCT, post-HCT maintenance therapy, and the role of allogeneic HCT for patients with MM.
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Affiliation(s)
- Nina Shah
- MD Anderson Cancer Center, Houston, Texas.
| | - Natalie Callander
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | | | - Mehdi Hamadani
- Center for International Blood and Marrow Transplant Research and Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Luciano Costa
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Parameswaran Hari
- Center for International Blood and Marrow Transplant Research and Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mohamad Mohty
- Hopital Saint-Antoine, APHP, Paris, France; Université Pierre & Marie Curie, Paris, France, INSERM, UMRs 938, Paris, France
| | - Yi-Bin Chen
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - John Koreth
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Heather Landau
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | - Rajneesh Nath
- University of Massachusetts, Worcester, Massachusetts
| | - Keren Osman
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Jeffrey Schriber
- Cancer Transplant Institute at Scottsdale Healthcare, Scottsdale, Arizona
| | | | - David Vesole
- John Theurer Cancer Center at Hackensack University Medical Center, Hackensack, New Jersey
| | - Ravi Vij
- Washington University School of Medicine, St. Louis, Missouri
| | - John Wingard
- University of Florida College of Medicine, Gainesville, Florida
| | - Sergio Giralt
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bipin N Savani
- Vanderbilt University Medical Center, Nashville, Tennesee
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258
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Paiva B, Puig N, García-Sanz R, San Miguel JF. Is This the Time to Introduce Minimal Residual Disease in Multiple Myeloma Clinical Practice? Clin Cancer Res 2015; 21:2001-8. [DOI: 10.1158/1078-0432.ccr-14-2841] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 02/06/2015] [Indexed: 11/16/2022]
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259
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Immunomodulatory molecule PD-L1 is expressed on malignant plasma cells and myeloma-propagating pre-plasma cells in the bone marrow of multiple myeloma patients. Blood Cancer J 2015; 5:e285. [PMID: 25747678 PMCID: PMC4382668 DOI: 10.1038/bcj.2015.7] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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260
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Stoppa AM, Coso D, Fouquet G, Leleu X. Consolidation and maintenance in de novo first-line multiple myeloma with modern agents. Int J Hematol Oncol 2015. [DOI: 10.2217/ijh.15.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Inclusion of new active drugs, such as IMiDs, proteasome inhibitors and soon the monoclonal antibodies, in first-line therapy has and will significantly enhance the response rate and depth of response, with the consequence of prolongation of the progression free and overall survivals. One of the greatest challenges faced in myeloma in recent years was to demonstrate the impact of prolonged therapy in the form of consolidation and/or maintenance. To date, this concept has almost always improved duration of response and progression free survival, but infrequently overall survival. Furthermore, this concept is associated to a certain cost, with not always predictable mid- and long-term adverse events along with the economic cost accompanying these events. As patients with myeloma live significantly longer, physicians need to discuss the risk/benefit of this approach at the individual level, and remain aware of the potential consequences as more knowledge becomes available.
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Affiliation(s)
- Anne Marie Stoppa
- Institut Paoli Calmettes, Departement d'Hématologie, Marseille, France
| | - Diane Coso
- Institut Paoli Calmettes, Departement d'Hématologie, Marseille, France
| | | | - Xavier Leleu
- Hopital Huriez, Service des maladies du sang, CHRU, Lille, France
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261
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Nyvold CG. Critical methodological factors in diagnosing minimal residual disease in hematological malignancies using quantitative PCR. Expert Rev Mol Diagn 2015; 15:581-4. [DOI: 10.1586/14737159.2015.1014341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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262
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Clinical impact of immunophenotypic remission after allogeneic hematopoietic cell transplantation in multiple myeloma. Bone Marrow Transplant 2015; 50:511-6. [PMID: 25665043 DOI: 10.1038/bmt.2014.319] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 11/12/2014] [Accepted: 12/20/2014] [Indexed: 12/26/2022]
Abstract
Immunophenotypic remission (IR) is a strong prognostic factor in myeloma patients. The combination of IR and conventional CR was retrospectively evaluated in 66 patients after allografting. IR was defined as the absence of monoclonal plasma cells in BM aspirates by multiparameter flow cytometry. Conditioning was non-myeloablative in 55 patients; reduced-intensity in 10 and myeloablative in 1 patient. The allograft was given upfront in 35/66 (53%) patients. After a median follow-up of 7.1 years, 24 patients achieved both CR and IR (CR/IR group), 21 achieved IR but not CR with persistence of a urine/serum M-component (no CR/IR group) and 21 did not achieve either CR or IR (no CR/no IR group). Median OS and EFS were 'not reached' and 59 months in the CR/IR group; 64 and 16 months in the no CR/IR; and 36 and 6 months in the no CR/no IR, respectively (P<0.001). Cumulative incidence of extramedullary disease was 4.4% in the CR/IR, 38.1% in the no CR/IR and 14.3% in the no CR/no IR groups, respectively, at 4 years (P<0.001). IR was a valid tool to monitor residual disease after allografting, and allowed definition of a cohort of patients at higher incidence of extramedullary relapse.
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263
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Minimal residual disease in myeloma by flow cytometry: independent prediction of survival benefit per log reduction. Blood 2015; 125:1932-5. [PMID: 25645353 DOI: 10.1182/blood-2014-07-590166] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The detection of minimal residual disease (MRD) in myeloma using a 0.01% threshold (10(-4)) after treatment is an independent predictor of progression-free survival (PFS), but not always of overall survival (OS). However, MRD level is a continuous variable, and the predictive value of the depth of tumor depletion was evaluated in 397 patients treated intensively in the Medical Research Council Myeloma IX study. There was a significant improvement in OS for each log depletion in MRD level (median OS was 1 year for ≥10%, 4 years for 1% to <10%, 5.9 years for 0.1% to <1%, 6.8 years for 0.01% to <0.1%, and more than 7.5 years for <0.01% MRD). MRD level as a continuous variable determined by flow cytometry independently predicts both PFS and OS, with approximately 1 year median OS benefit per log depletion. The trial was registered at www.isrctn.com as #68454111.
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264
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Mailankody S, Korde N, Lesokhin AM, Lendvai N, Hassoun H, Stetler-Stevenson M, Landgren O. Minimal residual disease in multiple myeloma: bringing the bench to the bedside. Nat Rev Clin Oncol 2015; 12:286-95. [PMID: 25622976 DOI: 10.1038/nrclinonc.2014.239] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Outcomes for patients with multiple myeloma (MM) have improved substantially in the past decade, with improvements in both progression-free survival and overall survival. Many patients are now achieving a complete response to treatment, and consequently highly sensitive assays are needed for detection of minimal residual disease (MRD) in patients with MM. Results of multicolour flow cytometry and deep-sequencing studies suggest that among patients achieving a complete response, MRD-negative status is associated with significant improvements in progression-free survival and overall survival. Despite the increasing need for MRD testing in patients with MM, considerable heterogeneity in techniques for MRD detection hinders the clinical interpretation of their results. The criteria used to define MRD, strengths and weaknesses of the major types of tests (flow cytometry versus molecular testing), and the optimal sample type (bone marrow aspirate versus peripheral blood) are all unresolved dilemmas in MRD testing. This Review presents an overview of the various techniques for MRD detection in patients with MM. In addition, this article discusses challenges and opportunities for the routine use of MRD testing, possible future directions for clinical trials and implications for drug approval processes.
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Affiliation(s)
- Sham Mailankody
- Multiple Myeloma Section, Lymphoid Malignancies Branch, Centre for Cancer Research, National Institutes of Health, National Cancer Institute, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - Neha Korde
- Myeloma Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Alexander M Lesokhin
- Myeloma Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Nikoletta Lendvai
- Myeloma Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Hani Hassoun
- Myeloma Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Maryalice Stetler-Stevenson
- Flow Cytometry Laboratory, Laboratory of Pathology, National Institutes of Health, National Cancer Institute, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - Ola Landgren
- Myeloma Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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265
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Vesole DH, Siegel DS. Pretransplant induction regimens for multiple myeloma. Biol Blood Marrow Transplant 2014; 21:200-1. [PMID: 25534538 DOI: 10.1016/j.bbmt.2014.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 12/12/2014] [Indexed: 10/24/2022]
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266
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Abstract
For the last 20 years, high-dose therapy with autologous stem cell transplantation (ASCT) for multiple myeloma has been considered a standard frontline treatment for younger patients with adequate organ function. With the introduction of novel agents, specifically thalidomide, bortezomib, and lenalidomide, the role of ASCT has changed in several ways. First, novel agents have been incorporated successfully as induction regimens, increasing the response rate before ASCT, and are now being used as part of both consolidation and maintenance with the goal of extending progression-free and overall survival. These approaches have shown considerable promise with significant improvements in outcome. Furthermore, the efficacy of novel therapeutics has also led to the investigation of these agents upfront without the immediate application of ASCT, and compelling preliminary results have been reported. Next-generation novel agents and the use of monoclonal antibodies have raised the possibility of not only successful salvage strategies to facilitate delayed transplantation for younger patients, but also the prospect of an nontransplantation approach achieving the same outcome. Moreover, this could be achieved without incurring acute toxicity or long-term complications that are inherent to high-dose alkylation, and melphalan exposure in particular. At present, the role of ASCT has therefore become an area of debate: should it be used upfront in all eligible patients, or should it be used as a salvage treatment at the time of progression for patients achieving a high quality of response with initial therapy? There is a clear need to derive a consensus that is useful for clinicians considering both protocol-directed and non-protocol-directed options for their patients. Participation in ongoing prospective randomized trials is considered vital. While preliminary randomized data from studies in Europe favor early ASCT with novel agents, differences in both agents and the combinations used, as well as limited information on overall survival and benefit for specific patient subsets, suggest that one size does not fit all. Specifically, the optimal approach to treatment of younger patients eligible for ASCT remains a key area for further research. A rigid approach to its use outside of a clinical study is difficult to justify and participation in prospective studies should be a priority.
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267
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All transplantation-eligible patients with myeloma should receive ASCT in first response. Hematology 2014; 2014:250-4. [DOI: 10.1182/asheducation-2014.1.250] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
AbstractIn this last decade, one of the major advances in the management of multiple myeloma has been the introduction of the novel agents thalidomide, bortezomib, and lenalidomide as part of frontline treatment in young patients eligible for high-dose therapy (HDT) and autologous stem cell transplantation (ASCT). These drugs have markedly improved the rate of complete remission both before and after ASCT without substantially increasing toxicity. The implementation of an “optimal strategy” consisting of novel-agent-based induction, HDT, and the use of novel agents in consolidation and maintenance may result in a 5-year survival rate of 80% and cure might be considered in a subset of patients who present with good prognostic features at the time of diagnosis. Nevertheless, the high efficacy of the novel agents has led some groups to test these agents upfront without ASCT. At the end of 2014, preliminary randomized data favor early ASCT plus novel agents over novel agents alone. Therefore, the optimal approach to the treatment of multiple myeloma is still to propose the most effective treatment that should involve the use of frontline ASCT in young patients eligible for HDT.
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268
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Early or delayed transplantation for multiple myeloma in the era of novel therapy: does one size fit all? Hematology 2014; 2014:255-61. [DOI: 10.1182/asheducation-2014.1.255] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Abstract
For the last 20 years, high-dose therapy with autologous stem cell transplantation (ASCT) for multiple myeloma has been considered a standard frontline treatment for younger patients with adequate organ function. With the introduction of novel agents, specifically thalidomide, bortezomib, and lenalidomide, the role of ASCT has changed in several ways. First, novel agents have been incorporated successfully as induction regimens, increasing the response rate before ASCT, and are now being used as part of both consolidation and maintenance with the goal of extending progression-free and overall survival. These approaches have shown considerable promise with significant improvements in outcome. Furthermore, the efficacy of novel therapeutics has also led to the investigation of these agents upfront without the immediate application of ASCT, and compelling preliminary results have been reported. Next-generation novel agents and the use of monoclonal antibodies have raised the possibility of not only successful salvage strategies to facilitate delayed transplantation for younger patients, but also the prospect of an nontransplantation approach achieving the same outcome. Moreover, this could be achieved without incurring acute toxicity or long-term complications that are inherent to high-dose alkylation, and melphalan exposure in particular. At present, the role of ASCT has therefore become an area of debate: should it be used upfront in all eligible patients, or should it be used as a salvage treatment at the time of progression for patients achieving a high quality of response with initial therapy? There is a clear need to derive a consensus that is useful for clinicians considering both protocol-directed and non-protocol-directed options for their patients. Participation in ongoing prospective randomized trials is considered vital. While preliminary randomized data from studies in Europe favor early ASCT with novel agents, differences in both agents and the combinations used, as well as limited information on overall survival and benefit for specific patient subsets, suggest that one size does not fit all. Specifically, the optimal approach to treatment of younger patients eligible for ASCT remains a key area for further research. A rigid approach to its use outside of a clinical study is difficult to justify and participation in prospective studies should be a priority.
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269
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Abstract
Abstract
Multiple myeloma (MM) is a unique cancer paradigm for investigating the mechanisms involved in the transition from a premalignant condition (monoclonal gammopathy of undetermined significance) into a malignant disease (MM). In the pathogenesis of myeloma, the dialogue between plasma cells and their microenvironment is as important as the genotypic characteristics of the tumor clone. MM is genetically highly complex, with almost all patients displaying cytogenetic abnormalities and frequent intraclonal heterogeneity that play a critical role in the outcome of the disease. In fact, it is likely that myeloma will soon no longer be considered as a single entity. This, along with the availability of an unexpected number of new treatment possibilities, has reinforced the need for better tools for prognosis and for monitoring treatment efficacy through minimal residual disease techniques. The outcome of MM patients has significantly improved in the last 2 decades, first through the introduction of high-dose therapy followed by autologous stem cell transplantation and, more recently, due to the use of proteasome inhibitors (bortezomib and carfilzomib) and immunomodulatory agents (thalidomide, lenalidomide, and pomalidomide). Moreover, the need to reexamine the diagnostic criteria of early MM and the possibility of early intervention opens up new therapeutic avenues. New drugs are also emerging, including second- and third-generation proteasome inhibitors and immunomodulators, monoclonal antibodies, histone deacetylase inhibitors, and kinesin spindle protein inhibitors, among others. Our goal is to find a balance among efficacy, toxicity, and cost, with the ultimate aim of achieving a cure for this disease.
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Landgren O, Gormley N, Turley D, Owen RG, Rawstron A, Paiva B, Barnett D, Arroz M, Wallace P, Durie B, Yuan C, Dogan A, Stetler-Stevenson M, Marti GE. Flow cytometry detection of minimal residual disease in multiple myeloma: Lessons learned at FDA-NCI roundtable symposium. Am J Hematol 2014; 89:1159-60. [PMID: 25132630 DOI: 10.1002/ajh.23831] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 08/12/2014] [Indexed: 11/05/2022]
Affiliation(s)
- Ola Landgren
- National Cancer Institute (NCI); Bethesda Maryland
| | - Nicole Gormley
- U.S. Food and Drug Administration (FDA); Silver Spring Maryland
| | - Danielle Turley
- U.S. Food and Drug Administration (FDA); Silver Spring Maryland
| | - Roger G. Owen
- HMDS Laboratory; St James's Institute of Oncology; Leeds United Kingdom
| | - Andy Rawstron
- HMDS Laboratory; St James's Institute of Oncology; Leeds United Kingdom
| | - Bruno Paiva
- Clínica Universidad de Navarra; Centro de Investigación Médica Aplicada (CIMA); Pamplona Spain; on behalf of the Spanish Myeloma Group (PETHEMA/GEM)
| | - David Barnett
- UK NEQAS for Leucocyte Immunophenotyping; Royal Hallamshire Hospital; Shefield England
| | - Maria Arroz
- Centro Hospitalar de Lisboa Ocidental (CHLO), HSFX; Clinical Pathology Department; Lisbon Portugal
| | - Paul Wallace
- Roswell Park Cancer Institute; Department of Flow and Image Cytometry; Buffalo New York
| | - Brian Durie
- Cedars-Sinai Comprehensive Cancer Center; Los Angeles California
| | | | - Ahmet Dogan
- Hematopathology Service; Memorial Sloan-Kettering Cancer Center; New York New York
| | | | - Gerald E. Marti
- U.S. Food and Drug Administration (FDA); Silver Spring Maryland
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271
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Post-Autologous (ASCT) Stem Cell Transplant Therapy in Multiple Myeloma. Adv Hematol 2014; 2014:652395. [PMID: 25525435 PMCID: PMC4265378 DOI: 10.1155/2014/652395] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 10/13/2014] [Accepted: 10/14/2014] [Indexed: 12/22/2022] Open
Abstract
Autologous stem cell transplant (ASCT) is the standard of care in transplant-eligible multiple myeloma patients and is associated with significant improvement in progression-free survival (PFS), complete remission rates (CR), and overall survival (OS). However, majority of patients eventually relapse, with a median PFS of around 36 months. Relapses are harder to treat and prognosis declines with each relapse. Achieving and maintaining "best response" to initial therapy is the ultimate goal of first-line treatment and sustained CR is a powerful surrogate for extended survival especially in high-risk multiple myeloma. ASCT is often followed by consolidation/maintenance phase to deepen and/or maintain the response achieved by induction and ASCT. Novel agents like thalidomide, lenalidomide, and bortezomib have been used as single agents or in combination. Thalidomide use has been associated with a meaningful improvement in PFS and EFS, however, with substantial side effects. Data with lenalidomide maintenance after-ASCT is favorable, but the optimal duration of lenalidomide maintenance is still unclear. Bortezomib use has been associated with superior outcomes, predominantly in high-risk myeloma patients. Combination regimens utilizing a proteasome inhibitor (i.e., bortezomib) with an immunomodulatory drug (thalidomide or lenalidomide) have provided the best outcomes. This review article serves as a review of the best available evidence in post-ASCT approaches in multiple myeloma.
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272
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Ahn IE, Mailankody S, Korde N, Landgren O. Dilemmas in treating smoldering multiple myeloma. J Clin Oncol 2014; 33:115-23. [PMID: 25422486 DOI: 10.1200/jco.2014.56.4351] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Novel therapies hold promise for high-risk smoldering multiple myeloma (SMM). Recent studies suggest that modern combination approaches can be options for high-risk SMM to obtain deep molecular responses with favorable toxicity profiles. Although pioneering treatment trials based on small numbers of patients suggest progression-free and overall survival benefits, application of the data to real-life practice remains to be validated. Therapeutic modulation of disease tempo, disease burden, clonal evolution, and tumor microenvironment in SMM remains to be understood and calls for reliable biomarkers reflective of disease biology. Here, we review studies that open a new management platform for SMM, address ongoing dilemmas in practice and under investigation, and highlight emerging scientific questions in the era of SMM treatment.
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Affiliation(s)
- Inhye E Ahn
- Inhye Ahn and Sham Mailankody, the National Cancer Institute, National Institutes of Health, Bethesda, MD; Neha Korde and Ola Landgren, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sham Mailankody
- Inhye Ahn and Sham Mailankody, the National Cancer Institute, National Institutes of Health, Bethesda, MD; Neha Korde and Ola Landgren, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Neha Korde
- Inhye Ahn and Sham Mailankody, the National Cancer Institute, National Institutes of Health, Bethesda, MD; Neha Korde and Ola Landgren, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ola Landgren
- Inhye Ahn and Sham Mailankody, the National Cancer Institute, National Institutes of Health, Bethesda, MD; Neha Korde and Ola Landgren, Memorial Sloan Kettering Cancer Center, New York, NY.
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273
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Mathis S, Chapuis N, Borgeot J, Maynadié M, Fontenay M, Béné MC, Guy J, Bardet V. Comparison of cross-platform flow cytometry minimal residual disease evaluation in multiple myeloma using a common antibody combination and analysis strategy. CYTOMETRY PART B-CLINICAL CYTOMETRY 2014; 88:101-9. [DOI: 10.1002/cyto.b.21200] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 09/23/2014] [Accepted: 10/21/2014] [Indexed: 12/29/2022]
Affiliation(s)
- Stéphanie Mathis
- Service d'Hématologie Biologique; Hôpitaux Universitaires Paris Centre Cochin; Paris France
- Inserm U1016; Université Paris Descartes, Hôpitaux Universitaires Paris Centre Cochin; Paris France
| | - Nicolas Chapuis
- Service d'Hématologie Biologique; Hôpitaux Universitaires Paris Centre Cochin; Paris France
- Inserm U1016; Université Paris Descartes, Hôpitaux Universitaires Paris Centre Cochin; Paris France
| | | | | | - Michaela Fontenay
- Service d'Hématologie Biologique; Hôpitaux Universitaires Paris Centre Cochin; Paris France
- Inserm U1016; Université Paris Descartes, Hôpitaux Universitaires Paris Centre Cochin; Paris France
| | | | - Julien Guy
- Service d'Hématologie Biologique; CHU; Dijon France
| | - Valérie Bardet
- Service d'Hématologie Biologique; Hôpitaux Universitaires Paris Centre Cochin; Paris France
- Inserm U1016; Université Paris Descartes, Hôpitaux Universitaires Paris Centre Cochin; Paris France
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274
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Hourigan CS, McCarthy P, de Lima M. Reprint of: Back to the future! The evolving role of maintenance therapy after hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2014; 20:S8-S17. [PMID: 24485019 DOI: 10.1016/j.bbmt.2014.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 11/21/2013] [Indexed: 11/26/2022]
Abstract
Relapse is a devastating event for patients with hematologic cancers treated with hematopoietic stem cell transplantation. In most situations, relapse treatment options are limited. Maintenance therapy offers the possibility of delaying or avoiding disease recurrence, but its role remains unclear in most conditions that we treat with transplantation. Here, Dr. Hourigan presents an overview of minimal residual disease (MRD) measurement in hematologic malignancies and the applicability of MRD-based post-transplantation interventions. Dr. McCarthy reviews current knowledge of maintenance therapy in the autologous transplantation context, with emphasis on immunologic interventions and immune modulation strategies designed to prevent relapse. Dr. de Lima discusses current lines of investigation in disease recurrence prevention after allogeneic transplantation, focusing on acute myeloid leukemia and myelodysplastic syndrome.
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Affiliation(s)
- Christopher S Hourigan
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Philip McCarthy
- Blood and Marrow Transplant Program, Roswell Park Cancer Institute, Buffalo, New York
| | - Marcos de Lima
- University Hospitals Case Medical Center, Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio.
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275
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Paiva B, Chandia M, Puig N, Vidriales MB, Perez JJ, Lopez-Corral L, Ocio EM, Garcia-Sanz R, Gutierrez NC, Jimenez-Ubieto A, Lahuerta JJ, Mateos MV, San Miguel JF. The prognostic value of multiparameter flow cytometry minimal residual disease assessment in relapsed multiple myeloma. Haematologica 2014; 100:e53-5. [PMID: 25381128 DOI: 10.3324/haematol.2014.115162] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Bruno Paiva
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), Pamplona
| | - Mauricio Chandia
- Hospital Universitario de Salamanca, Instituto de Investigaion Biomedica de Salamanca, IBMCC (USAL-CSIC), Spain
| | - Noemi Puig
- Hospital Universitario de Salamanca, Instituto de Investigaion Biomedica de Salamanca, IBMCC (USAL-CSIC), Spain
| | - Maria-Belen Vidriales
- Hospital Universitario de Salamanca, Instituto de Investigaion Biomedica de Salamanca, IBMCC (USAL-CSIC), Spain
| | - Jose J Perez
- Hospital Universitario de Salamanca, Instituto de Investigaion Biomedica de Salamanca, IBMCC (USAL-CSIC), Spain
| | - Lucia Lopez-Corral
- Hospital Universitario de Salamanca, Instituto de Investigaion Biomedica de Salamanca, IBMCC (USAL-CSIC), Spain
| | - Enrique M Ocio
- Hospital Universitario de Salamanca, Instituto de Investigaion Biomedica de Salamanca, IBMCC (USAL-CSIC), Spain
| | - Ramon Garcia-Sanz
- Hospital Universitario de Salamanca, Instituto de Investigaion Biomedica de Salamanca, IBMCC (USAL-CSIC), Spain
| | - Norma C Gutierrez
- Hospital Universitario de Salamanca, Instituto de Investigaion Biomedica de Salamanca, IBMCC (USAL-CSIC), Spain
| | | | | | - Maria-Victoria Mateos
- Hospital Universitario de Salamanca, Instituto de Investigaion Biomedica de Salamanca, IBMCC (USAL-CSIC), Spain
| | - Jesús F San Miguel
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), Pamplona
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276
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Bianchi G, Anderson KC. Understanding biology to tackle the disease: Multiple myeloma from bench to bedside, and back. CA Cancer J Clin 2014; 64:422-44. [PMID: 25266555 DOI: 10.3322/caac.21252] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 08/21/2014] [Accepted: 08/21/2014] [Indexed: 02/01/2023] Open
Abstract
Multiple myeloma (MM) is a cancer of antibody-producing plasma cells. The pathognomonic laboratory finding is a monoclonal immunoglobulin or free light chain in the serum and/or urine in association with bone marrow infiltration by malignant plasma cells. MM develops from a premalignant condition, monoclonal gammopathy of undetermined significance (MGUS), often via an intermediate stage termed smoldering multiple myeloma (SMM), which differs from active myeloma by the absence of disease-related end-organ damage. Unlike MGUS and SMM, active MM requires therapy. Over the past 6 decades, major advancements in the care of MM patients have occurred, in particular, the introduction of novel agents (ie, proteasome inhibitors, immunomodulatory agents) and the implementation of hematopoietic stem cell transplantation in suitable candidates. The effectiveness and good tolerability of novel agents allowed for their combined use in induction, consolidation, and maintenance therapy, resulting in deeper and more sustained clinical response and extended progression-free and overall survival. Previously a rapidly lethal cancer with few therapeutic options, MM is the hematologic cancer with the most novel US Food and Drug Administration-approved drugs in the past 15 years. These advances have resulted in more frequent long-term remissions, transforming MM into a chronic illness for many patients.
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Affiliation(s)
- Giada Bianchi
- Hematology Oncology Fellow, Jerome Lipper Multiple Myeloma Center and LeBow Institute for Myeloma Therapeutics, Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
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277
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Manasanch EE, Salem DA, Yuan CM, Tageja N, Bhutani M, Kwok M, Kazandjian D, Carter G, Steinberg SM, Zuchlinski D, Mulquin M, Calvo K, Maric I, Roschewski M, Korde N, Braylan R, Landgren O, Stetler-Stevenson M. Flow cytometric sensitivity and characteristics of plasma cells in patients with multiple myeloma or its precursor disease: influence of biopsy site and anticoagulation method. Leuk Lymphoma 2014; 56:1416-24. [PMID: 25263319 DOI: 10.3109/10428194.2014.955020] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Flow cytometry has increasing relevance for prognosis in myeloma and precursor disease (monoclonal gammopathy of unknown significance/smoldering myeloma), yet it has been reported that plasma cell enumeration by flow varies depending on the quality of marrow aspirate and field biopsied in patchy disease. We demonstrated increased sensitivity of flow over immunohistochemistry in abnormal-plasma cell detection in monoclonal gammopathy (n = 59)/smoldering myeloma (n = 87). We prospectively evaluated treatment-na ve smoldering myeloma (n = 9)/myeloma (n = 11) patients for the percentage of abnormal plasma cells/total plasma cell compartment, plasma cell viability/infiltration and flow immunophenotype depending on anticoagulant use, biopsy site and pull sequence in uni-and-bilateral bone marrow biopsies and aspirates. We found no statistical difference regarding the percentage of abnormal plasma cells, their immunophenotype or number/distribution in marrow samples even when obtained by different sequence in aspirates, or anticoagulants (p > 0.05). Our results show that plasma cell enumeration and immunophenotyping by flow cytometry is consistent under different conditions in these populations.
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Affiliation(s)
- Elisabet E Manasanch
- Multiple Myeloma Section, Metabolism Branch, National Cancer Institute, National Institutes of Health , Bethesda, MD , USA
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278
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What We Mean When We Talk About MRD in Myeloma. A Review of Current Methods. Part 1 of a Two-Part Series. Curr Hematol Malig Rep 2014; 9:379-88. [DOI: 10.1007/s11899-014-0238-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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279
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280
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Identifying Professional Education Gaps and Barriers in Multiple Myeloma Patient Care: Findings of the Managing Myeloma Continuing Educational Initiative Advisory Committee. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 14:356-69. [DOI: 10.1016/j.clml.2014.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 03/26/2014] [Accepted: 04/03/2014] [Indexed: 12/31/2022]
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281
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Abstract
Autologous stem cell transplant (ASCT) remains an integral part of the treatment strategy for many myeloma patients. The role of allogeneic stem cell transplant continues to be defined. There is increasing evidence that posttransplant maintenance therapy can significantly improve outcomes. It is predicted that with more routine use of cytogenetic and gene expression profiling in the future, we will be better able to identify those subgroups of patients who are expected to benefit most from early versus late versus no ASCT and those who will benefit from allogeneic stem cell transplant.
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Affiliation(s)
- Sarah A Holstein
- Department of Medicine, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA
| | - Hong Liu
- Department of Medicine, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA
| | - Philip L McCarthy
- Department of Medicine, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA.
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282
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Fernández de Larrea C, Delforge M, Davies F, Bladé J. Response evaluation and monitoring of multiple myeloma. Expert Rev Hematol 2014; 7:33-42. [PMID: 24483347 DOI: 10.1586/17474086.2014.876899] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Monitoring multiple myeloma (MM) is essential during the evaluation of response to each therapy line, after transplantation and at the time of relapse or progression in all patients. An initial complete workup, including appropriate protein studies in serum and urine is mandatory. The use of uniform criteria is particularly important in the context of clinical trials. Complete remission (CR) definition, the goal for the majority of patients, is now in constant evolution, with immunophenotypic and molecular minimal residual disease measurement in bone marrow as well as imaging techniques. Identification of relapse/progression with traditional and novel techniques for eventual prompt intervention with rescue treatment is a current issue of debate.
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Affiliation(s)
- Carlos Fernández de Larrea
- Department of Hematology, Amyloidosis and Myeloma Unit, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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283
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Biran N, Ely S, Chari A. Controversies in the Assessment of Minimal Residual Disease in Multiple Myeloma: Clinical Significance of Minimal Residual Disease Negativity Using Highly Sensitive Techniques. Curr Hematol Malig Rep 2014; 9:368-78. [DOI: 10.1007/s11899-014-0237-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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284
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Abstract
WNT-β-catenin signalling is involved in a multitude of developmental processes and the maintenance of adult tissue homeostasis by regulating cell proliferation, differentiation, migration, genetic stability and apoptosis, as well as by maintaining adult stem cells in a pluripotent state. Not surprisingly, aberrant regulation of this pathway is therefore associated with a variety of diseases, including cancer, fibrosis and neurodegeneration. Despite this knowledge, therapeutic agents specifically targeting the WNT pathway have only recently entered clinical trials and none has yet been approved. This Review examines the problems and potential solutions to this vexing situation and attempts to bring them into perspective.
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285
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Behdad A, Ross CW, Jacques J, Kota U, Keren D, Stoolman L. Utility of nine-color, 11-parameter flow cytometry for detection of plasma cell neoplasms: a comparison with bone marrow morphologic findings and concurrent M-protein studies in serum and urine. Am J Clin Pathol 2014; 142:398-410. [PMID: 25125632 DOI: 10.1309/ajcpo5gqpxf8qcec] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES Multiparameter flow cytometry (MFC) is a widely available laboratory platform for the evaluation of plasma cell (PC) neoplasms. We assess the performance of a nine-color MFC assay that uses stain-lyse-fix processing of bone marrow aspirates, minimal wash steps, and high acquisition rates with analysis of up to 1.8 × 10(6) cells. METHODS MFC results were compared with microscopic examinations, immunohistochemical studies, and serum/urine M-protein measurements from patients with documented or suspected PC neoplasms. RESULTS Sensitivity exceeded that of microscopic examinations, with or without immunohistochemistry. In patients with PC myeloma, clonal PC detection by MFC fell in concert with M-protein levels. However, in a subset of patients, MFC detected clonal PCs after serum/urine studies turned negative. CONCLUSIONS The nine-color analytic cocktail eliminates duplication of PC gating reagents required for evaluation of the same epitopes using a five- or six-color approach. Fewer analytic cocktails result in lower instrument acquisition times per case, a significant factor for the large data sets required for optimal residual disease assessment. Finally, concurrent analysis of nine epitopes and two light scatter parameters aids detection of residual disease, particularly when it is mixed with polyclonal PCs.
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Affiliation(s)
- Amir Behdad
- Department of Pathology, University of Michigan, Ann Arbor
| | | | - Joshua Jacques
- Department of Pathology, University of Michigan, Ann Arbor
| | - Usha Kota
- Department of Pathology, University of Michigan, Ann Arbor
| | - David Keren
- Department of Pathology, University of Michigan, Ann Arbor
| | - Lloyd Stoolman
- Department of Pathology, University of Michigan, Ann Arbor
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286
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Roussel M, Lauwers-Cances V, Robillard N, Hulin C, Leleu X, Benboubker L, Marit G, Moreau P, Pegourie B, Caillot D, Fruchart C, Stoppa AM, Gentil C, Wuilleme S, Huynh A, Hebraud B, Corre J, Chretien ML, Facon T, Avet-Loiseau H, Attal M. Front-Line Transplantation Program With Lenalidomide, Bortezomib, and Dexamethasone Combination As Induction and Consolidation Followed by Lenalidomide Maintenance in Patients With Multiple Myeloma: A Phase II Study by the Intergroupe Francophone du Myélome. J Clin Oncol 2014; 32:2712-7. [DOI: 10.1200/jco.2013.54.8164] [Citation(s) in RCA: 217] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The three-drug combination of lenalidomide, bortezomib, and dexamethasone (RVD) has shown significant efficacy in multiple myeloma (MM). The Intergroupe Francophone du Myélome (IFM) decided to evaluate RVD induction and consolidation therapies in a sequential intensive strategy for previously untreated transplantation-eligible patients with MM. Patients and Methods In this phase II study, 31 symptomatic patients age < 65 years were enrolled to receive three RVD induction cycles followed by cyclophosphamide harvest and transplantation. Patients subsequently received two RVD consolidation cycles and 1-year lenalidomide maintenance. Results Very good partial response rate or better at the completion of induction, transplantation, and consolidation therapy was 58%, 70%, and 87%, respectively. Maintenance upgraded responses in 27% of patients. Overall, 58% of patients achieved complete response, and 68% were minimal residual disease (MRD) negative by flow cytometry. The most common toxicities with RVD were neurologic and hematologic, including grade 1 to 2 sensory neuropathy (55%), grade 3 to 4 neutropenia (35%), and thrombocytopenia (13%). Two basal cell carcinomas in the same patient and one case of breast cancer were observed. There was no treatment-related mortality. With a median follow-up of 39 months, estimated 3-year progression-free and overall survival were 77% and 100%, respectively. None of the patients who achieved MRD negativity relapsed. Conclusion The transplantation program with RVD induction and consolidation followed by lenalidomide maintenance produced high-quality responses and showed favorable tolerability in patients with newly diagnosed MM. Overall, 68% of patients achieved MRD negativity; none of these patients relapsed. This program is being evaluated in the ongoing IFM/Dana-Farber Cancer Institute 2009 phase III study.
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Affiliation(s)
- Murielle Roussel
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Valérie Lauwers-Cances
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Nelly Robillard
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Cyrille Hulin
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Xavier Leleu
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Lotfi Benboubker
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Gérald Marit
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Philippe Moreau
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Brigitte Pegourie
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Denis Caillot
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Christophe Fruchart
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Anne-Marie Stoppa
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Catherine Gentil
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Soraya Wuilleme
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Anne Huynh
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Benjamin Hebraud
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Jill Corre
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Marie-Lorraine Chretien
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Thierry Facon
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Hervé Avet-Loiseau
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
| | - Michel Attal
- Murielle Roussel, Valérie Lauwers-Cances, Catherine Gentil, Anne Huynh, Benjamin Hebraud, Jill Corre, and Hervé Avet-Loiseau, Hopitaux de Toulouse; Michel Attal, Institut Claudius Regaud, Toulouse; Nelly Robillard, Philippe Moreau, and Soraya Wuilleme, Hôtel Dieu, Nantes; Cyrille Hulin, Centre Hospitalier Brabois, Nancy; Xavier Leleu and Thierry Facon, Hôpital Claude Huriez, Lille; Lotfi Benboubker, Hôpital Bretonneau, Tours; Gérald Marit, Hôpital Haut-Lévêque, Bordeaux Pessac; Brigitte Pegourie, Hôpital
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Outcome prediction in plasmacytoma of bone: a risk model utilizing bone marrow flow cytometry and light-chain analysis. Blood 2014; 124:1296-9. [DOI: 10.1182/blood-2014-04-566521] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Key Points
Occult marrow disease is demonstrable in 68% of patients with solitary plasmacytoma of bone and is predictive of progression. Trials of adjuvant systemic therapy are warranted in high-risk patients.
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288
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Ludwig H, Sonneveld P, Davies F, Bladé J, Boccadoro M, Cavo M, Morgan G, de la Rubia J, Delforge M, Dimopoulos M, Einsele H, Facon T, Goldschmidt H, Moreau P, Nahi H, Plesner T, San-Miguel J, Hajek R, Sondergeld P, Palumbo A. European perspective on multiple myeloma treatment strategies in 2014. Oncologist 2014; 19:829-44. [PMID: 25063227 PMCID: PMC4122482 DOI: 10.1634/theoncologist.2014-0042] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
The treatment of multiple myeloma has undergone significant changes and has resulted in the achievement of molecular remissions, the prolongation of remission duration, and extended survival becoming realistic goals, with a cure being possible in a small but growing number of patients. In addition, nowadays it is possible to categorize patients more precisely into different risk groups, thus allowing the evaluation of therapies in different settings and enabling a better comparison of results across trials. Here, we review the evidence from clinical studies, which forms the basis for our recommendations for the management of patients with myeloma. Treatment approaches depend on "fitness," with chronological age still being an important discriminator for selecting therapy. In younger, fit patients, a short three drug-based induction treatment followed by autologous stem cell transplantation (ASCT) remains the preferred option. Consolidation and maintenance therapy are attractive strategies not yet approved by the European Medicines Agency, and a decision regarding post-ASCT therapy should only be made after detailed discussion of the pros and cons with the individual patient. Two- and three-drug combinations are recommended for patients not eligible for transplantation. Treatment should be administered for at least nine cycles, although different durations of initial therapy have only rarely been compared so far. Comorbidity and frailty should be thoroughly assessed in elderly patients, and treatment must be adapted to individual needs, carefully selecting appropriate drugs and doses. A substantial number of new drugs and novel drug classes in early clinical development have shown promising activity. Their introduction into clinical practice will most likely further improve treatment results.
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Affiliation(s)
- Heinz Ludwig
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Pieter Sonneveld
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Faith Davies
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Joan Bladé
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Mario Boccadoro
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Michele Cavo
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Gareth Morgan
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Javier de la Rubia
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Michel Delforge
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Meletios Dimopoulos
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Hermann Einsele
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Thierry Facon
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Hartmut Goldschmidt
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Philippe Moreau
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Hareth Nahi
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Torben Plesner
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Jesús San-Miguel
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Roman Hajek
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Pia Sondergeld
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
| | - Antonio Palumbo
- Department of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria; Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; Institute of Cancer Research, Royal Marsden Hospital, London, United Kingdom; Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain; Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Ospedale Molinette, Turin, Italy; Institute of Hematology and Medical Oncology, Seragnoli, Bologna, Italy; Haemato-Oncology Unit, Royal Marsden Hospital, Surrey, United Kingdom; Hematology Service, University Hospital La Fe, Valencia, Spain; Department of Hematology, University Hospital, Leuven, Belgium; Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece; Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany; Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France; Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; University Hospital, Nantes, France; Karolinska Institute, Stockholm, Sweden; Department of Hematology, Center Lillebaelt, University of Southern Denmark, Odense, Denmark; Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada, Pamplona, Spain; Department of Hemato-oncology, University of Ostrava, Ostrava, Czech Republic; University of Giessen, Giessen, Germany
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Engelhardt M, Terpos E, Kleber M, Gay F, Wäsch R, Morgan G, Cavo M, van de Donk N, Beilhack A, Bruno B, Johnsen HE, Hajek R, Driessen C, Ludwig H, Beksac M, Boccadoro M, Straka C, Brighen S, Gramatzki M, Larocca A, Lokhorst H, Magarotto V, Morabito F, Dimopoulos MA, Einsele H, Sonneveld P, Palumbo A. European Myeloma Network recommendations on the evaluation and treatment of newly diagnosed patients with multiple myeloma. Haematologica 2014; 99:232-42. [PMID: 24497560 DOI: 10.3324/haematol.2013.099358] [Citation(s) in RCA: 145] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Multiple myeloma management has undergone profound changes in the past thanks to advances in our understanding of the disease biology and improvements in treatment and supportive care approaches. This article presents recommendations of the European Myeloma Network for newly diagnosed patients based on the GRADE system for level of evidence. All patients with symptomatic disease should undergo risk stratification to classify patients for International Staging System stage (level of evidence: 1A) and for cytogenetically defined high- versus standard-risk groups (2B). Novel-agent-based induction and up-front autologous stem cell transplantation in medically fit patients remains the standard of care (1A). Induction therapy should include a triple combination of bortezomib, with either adriamycin or thalidomide and dexamethasone (1A), or with cyclophosphamide and dexamethasone (2B). Currently, allogeneic stem cell transplantation may be considered for young patients with high-risk disease and preferably in the context of a clinical trial (2B). Thalidomide (1B) or lenalidomide (1A) maintenance increases progression-free survival and possibly overall survival (2B). Bortezomib-based regimens are a valuable consolidation option, especially for patients who failed excellent response after autologous stem cell transplantation (2A). Bortezomib-melphalan-prednisone or melphalan-prednisone-thalidomide are the standards of care for transplant-ineligible patients (1A). Melphalan-prednisone-lenalidomide with lenalidomide maintenance increases progression-free survival, but overall survival data are needed. New data from the phase III study (MM-020/IFM 07-01) of lenalidomide-low-dose dexamethasone reached its primary end point of a statistically significant improvement in progression-free survival as compared to melphalan-prednisone-thalidomide and provides further evidence for the efficacy of lenalidomide-low-dose dexamethasone in transplant-ineligible patients (2B).
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290
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van de Donk NWCJ, Sonneveld P. Diagnosis and risk stratification in multiple myeloma. Hematol Oncol Clin North Am 2014; 28:791-813. [PMID: 25212883 DOI: 10.1016/j.hoc.2014.06.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Multiple myeloma (MM) is a tumor of monoclonal plasma cells, which produce a monoclonal antibody and expand predominantly in the bone marrow. Patients present with hypercalcemia, renal impairment, anemia, and/or bone disease. Only patients with symptomatic MM require therapy, whereas asymptomatic patients receive regular follow-up. Survival of patients with MM is very heterogeneous. The variety in outcome is explained by host factors as well as tumor-related characteristics reflecting biology of the MM clone and tumor burden. The identification of cytogenetic abnormalities by fluorescence in situ hybridization is currently the most important and widely available prognostic factor in MM.
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Affiliation(s)
- Niels W C J van de Donk
- Department of Hematology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht 3584CX, The Netherlands
| | - Pieter Sonneveld
- Department of Hematology, Erasmus MC Cancer Institute, 's Gravendijkwal 230, Rotterdam 3015CE, The Netherlands.
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291
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Caltagirone S, Ruggeri M, Aschero S, Gilestro M, Oddolo D, Gay F, Bringhen S, Musolino C, Baldini L, Musto P, Petrucci MT, Gaidano G, Passera R, Bruno B, Palumbo A, Boccadoro M, Omedè P. Chromosome 1 abnormalities in elderly patients with newly diagnosed multiple myeloma treated with novel therapies. Haematologica 2014; 99:1611-7. [PMID: 25015938 DOI: 10.3324/haematol.2014.103853] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Multiple myeloma is a plasma cell disorder characterized by malignant plasma cell infiltration in the bone marrow, serum and/or urine monoclonal protein and organ damage. The aim of this study was to investigate the impact of chromosome 1 abnormalities in a group of elderly patients (>65 years) with newly diagnosed multiple myeloma enrolled in the GIMEMA-MM-03-05 trial and treated with bortezomib, melphalan and prednisone or bortezomib, melphalan, prednisone and thalidomide followed by bortezomib and thalidomide maintenance. We also evaluated the link between chromosome 1 abnormalities and other clinical, genetic and immunophenotypic features by a multivariate logistic regression model. Interphase fluorescence in situ hybridization on immunomagnetically purified plasma cells and bone marrow multiparameter flow cytometry were employed. A multivariate Cox model showed that chromosome 1 abnormalities, age >75 years and a CD19(+)/CD117(-) immunophenotype of bone marrow plasma cells were independent risk factors for overall survival in elderly patients with newly diagnosed multiple myeloma. Moreover, a detrimental effect of thalidomide, even when administered in association with bortezomib, was observed in patients with abnormal chromosome 1 as well as in those with 17p deletion, while the benefit of adding thalidomide to the bortezomib-melphalan-prednisone regimen was noted in patients carrying an aggressive CD19(+)/CD117(-) bone marrow plasma cell immunophenotype. This trial was registered at www.clinicaltri-als.gov as #NCT01063179.
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Affiliation(s)
- Simona Caltagirone
- Divisione di Ematologia, Università di Torino, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Italy Scuola di specializzazione in medicina clinica, Università di Torino, Italy
| | - Marina Ruggeri
- Divisione di Ematologia, Università di Torino, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Italy
| | - Simona Aschero
- Divisione di Ematologia, Università di Torino, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Italy
| | - Milena Gilestro
- Divisione di Ematologia, Università di Torino, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Italy
| | - Daniela Oddolo
- Divisione di Ematologia, Università di Torino, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Italy
| | - Francesca Gay
- Divisione di Ematologia, Università di Torino, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Italy
| | - Sara Bringhen
- Divisione di Ematologia, Università di Torino, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Italy
| | - Caterina Musolino
- Divisione di Ematologia, Dipartimento di Chirurgia Generale e Oncologia, A.O.U. Policlinico G. Martino, Messina, Italy
| | - Luca Baldini
- Divisione di Ematologia, Fondazione IRCCS Ca Granda, OM Policlinico, Università di Milano, Italy
| | - Pellegrino Musto
- Direzione Scientifica, IRCCS - CROB, Centro di riferimento ongcologico della Basilicata, Rionero in Vulture, Italy
| | - Maria T Petrucci
- Dipartimento di Biotecnologia cellulare e di Ematologia, Università"La Sapienza" di Roma, Italy
| | - Gianluca Gaidano
- Divisione di Ematologia, Dipartimento di Medicina Traslazionale, Università degli studi del Piemonte Orientale "Amedeo Avogadro", Novara, Italy
| | - Roberto Passera
- Divisione di medicina nucleare, Università di Torino, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Università di Torino, Italy
| | - Benedetto Bruno
- Divisione di Ematologia, Università di Torino, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Italy
| | - Antonio Palumbo
- Divisione di Ematologia, Università di Torino, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Italy
| | - Mario Boccadoro
- Divisione di Ematologia, Università di Torino, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Italy
| | - Paola Omedè
- Divisione di Ematologia, Università di Torino, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Italy
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292
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Implications of heterogeneity in multiple myeloma. BIOMED RESEARCH INTERNATIONAL 2014; 2014:232546. [PMID: 25101266 PMCID: PMC4102035 DOI: 10.1155/2014/232546] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 05/02/2014] [Indexed: 11/17/2022]
Abstract
Multiple myeloma is the second most common hematologic malignancy in the world. Despite improvement in outcome, the disease is still incurable for most patients. However, not all myeloma are the same. With the same treatment, some patients can have very long survival whereas others can have very short survival. This suggests that there is underlying heterogeneity in myeloma. Studies over the years have revealed multiple layers of heterogeneity. First, clinical parameters such as age and tumor burden could significantly affect outcome. At the genetic level, there are also significant heterogeneity ranging for chromosome numbers, genetic translocations, and genetic mutations. At the clonal level, there appears to be significant clonal heterogeneity with multiple clones coexisting in the same patient. At the cell differentiation level, there appears to be a hierarchy of clonally related cells that have different clonogenic potential and sensitivity to therapies. These levels of complexities present challenges in terms of treatment and prognostication as well as monitoring of treatment. However, if we can clearly delineate and dissect this heterogeneity, we may also be presented with unique opportunities for precision and personalized treatment of myeloma. Some proof of concepts of such approaches has been demonstrated.
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293
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Douds JJ, Long DJ, Kim AS, Li S. Diagnostic and prognostic significance of CD200 expression and its stability in plasma cell myeloma. J Clin Pathol 2014; 67:792-6. [DOI: 10.1136/jclinpath-2014-202421] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
AimPrevious studies showed that CD200 expression is a prognostic factor for plasma cell myeloma (PCM), but the prognostic effect is conflicting between studies. We studied CD200 protein expression and the stability of expression in PCM to clarify its potential utility in diagnosis, prognosis and monitoring of disease.MethodCD200 expression was studied in 77 cases of PCM by immunohistochemistry on paraffin sections from decalcified bone marrow biopsies.ResultThere were 16 newly diagnosed cases and 61 post-treatment cases from 54 patients: 37 men and 17 women, with a median age of 62 years (range, 41–88 years). CD200 demonstrated moderate to strong membrane expression in positive cases. Fifty-six of 77 cases (73%) showed CD200 expression. Twenty of the 22 (91%) patients with serial specimens demonstrated stable CD200 expression (n=15) or lack of CD200 expression (n=5). One patient lost CD200 expression, while another one gained CD200 expression during treatment. The clinical, pathologic and cytogenetic features between the CD200+ group and the CD200− group were similar in most instances. However, CD200 expression was associated with lower serum β2-microglobulin (p=0.03). There was no significant difference in overall survival and progression-free survival between the CD200+ and CD200− patients (p>0.05).ConclusionsCD200 is expressed in a majority of PCM cases, and the expression is stable during the treatment process. Therefore, immunohistochemical expression of CD200 is a useful marker for the diagnosis and follow-up of PCM.
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High-dose chemotherapy plus autologous stem-cell transplantation as consolidation therapy in patients with relapsed multiple myeloma after previous autologous stem-cell transplantation (NCRI Myeloma X Relapse [Intensive trial]): a randomised, open-label, phase 3 trial. Lancet Oncol 2014; 15:874-85. [PMID: 24948586 DOI: 10.1016/s1470-2045(14)70245-1] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Relapsed multiple myeloma has no standard treatment, and the role of autologous stem-cell transplantation (ASCT) has not been fully defined. We aimed to compare high-dose melphalan plus salvage ASCT with cyclophosphamide in patients with relapsed multiple myeloma who had previously undergone ASCT. METHODS This multicentre, randomised, open-label, phase 3 study recruited patients aged at least 18 years with multiple myeloma who needed treatment for first progressive or relapsed disease at least 18 months after a previous ASCT from 51 centres across the UK. Before randomisation, eligible patients received bortezomib, doxorubicin, and dexamethasone (PAD) induction therapy and then underwent peripheral blood stem-cell mobilisation and harvesting if applicable. Eligible patients (with adequate stem-cell harvest) were randomly assigned (1:1), using an automated telephone randomisation line, to either high-dose melphalan 200 mg/m(2) plus salvage ASCT or oral cyclophosphamide (400mg/m(2) per week for 12 weeks). Randomisation was stratified by length of first remission or plateau and response to PAD re-induction therapy. The primary endpoint was time to disease progression, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00747877, and EudraCT, number 2006-005890-24. FINDINGS Between April 16, 2008, and Nov 19, 2012, 297 patients were registered, of whom 293 received PAD re-induction therapy. Between Aug 26, 2008, and Nov 16, 2012, 174 patients with sufficient PBSCs were randomised to salvage ASCT (n=89) or cyclophosphamide (n=85). After a median follow-up of 31 months (IQR 19-42), median time to progression was significantly longer in the salvage ASCT than in the cyclophosphamide group (19 months [95% CI 16-25] vs 11 months [9-12]; hazard ratio 0·36 [95% CI 0·25-0·53]; p<0·0001). Frequently reported (in >10% of patients) grade 3-4 adverse events with PAD induction, salvage ASCT, and cyclophosphamide were: neutropenia (125 [43%] of 293 patients after PAD, and 63 [76%] of 83 patients in the salvage ASCT group vs 11 [13%] of 84 patients in the cyclophosphamide group), thrombocytopenia (150 [51%] after PAD, and 60 [72%] vs four [5%], respectively), and peripheral neuropathy (35 [12%] after PAD, and none vs none, respectively). INTERPRETATION This study provides evidence for the improved efficacy of high-dose melphalan plus salvage ASCT when compared with cyclophosphamide in patients with relapsed multiple myeloma eligible for intensive therapy, which might help to guide clinical decisions regarding the management of such patients. FUNDING Cancer Research UK.
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Abstract
Autologous stem cell transplantation (ASCT) has long been considered frontline therapy for newly diagnosed myeloma patients. This Spotlight examines the role of ASCT in the era of novel drugs and argues that ASCT should continue to be considered for eligible patients. A combination of novel drugs with ASCT in a sequential treatment approach can attain long-term survival and perhaps cure a subset of patients. ASCT will likely remain an important platform to develop curative strategies in the foreseeable future.
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Bianchi G, Richardson PG, Anderson KC. Best treatment strategies in high-risk multiple myeloma: navigating a gray area. J Clin Oncol 2014; 32:2125-32. [PMID: 24888801 DOI: 10.1200/jco.2014.55.7900] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
A previously healthy 62-year-old man presented to his primary care physician with a 3-month history of fatigue and unremitting back pain. Physical examination revealed mucosal pallor, point tenderness at T10-T12, and a normal neurologic examination with preserved lower extremity strength and sphincter tone. Laboratory work-up disclosed hemoglobin 10.1 g/dL with mean corpuscular volume of 101 fL and otherwise normal blood cell counts; reticulocytes, 0.98%; stable creatinine, 1.1 mg/dL; calcium, 9.1 mg/dL; albumin, 3.4 g/dL; β2-microglobulin, 5.7 mg/L; lactate dehydrogenase (LDH), 397 IU/L; and normal liver function tests. Bone survey showed lytic lesions at T10, T12, and throughout the axial skeleton and osteopenia. Serum protein electrophoresis (SPEP) demonstrated a 3.5 g/dL monoclonal peak in the gamma region, with monoclonal immunoglobulin G and lambda light chain detected on immunofixation. Serum free light chain (sFLC) ratio was 0.0001. Twenty-four-hour urine protein electrophoresis (UPEP) was normal. Bone marrow biopsy showed 60% infiltration with lambda light chain-restricted plasma cells staining positive for CD138 and CD56 and negative for CD45 by flow cytometry (Fig 1). Congo red stain on bone marrow biopsy and fat pad aspirate was negative for amyloid light-chain deposition. Cytogenetics of the malignant cells identified a t(4;14) translocation, confirming the diagnosis of high-risk, International Staging System stage III immunoglobulin G lambda multiple myeloma (MM). The patient began treatment with lenalidomide, bortezomib, and dexamethasone (RVD) plus monthly intravenous zoledronic acid therapy. He has tolerated therapy well, and the monoclonal protein peak is rapidly declining. He is now referred to discuss indications for autologous stem-cell transplantation (ASCT) and overall prognosis.
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Kumar L, Iqbal N, Mookerjee A, Verma RK, Sharma OD, Batra A, Pramanik R, Gupta R. Complete response after autologous stem cell transplant in multiple myeloma. Cancer Med 2014; 3:939-46. [PMID: 24777883 PMCID: PMC4303161 DOI: 10.1002/cam4.257] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Revised: 03/17/2014] [Accepted: 03/21/2014] [Indexed: 12/15/2022] Open
Abstract
We evaluated long-term outcome of patients achieving complete response (CR) after autologous stem cell transplantation (ASCT) for multiple myeloma. Between April 1990 and June 2012 191 patients underwent ASCT. The median age was 53 years (range, 26-68 years), 135 were men. Pretransplant, patients received induction therapy with VAD (vincristine, doxorubicin, dexamethasone; n = 77), novel agents (n = 92), or alkylating agent-based, n = 22); 43% received more than one line of induction regimen. Response to transplant was defined as per EBMT criteria. The median follow-up for the entire group was 85 months (range, 6-232.5 months). Following transplant 109 (57.1%) patients achieved CR. Median progression-free survival (PFS) for patients with CR was higher compared to those with VGPR and PR, (107 vs. 18 vs. 18 months, P < 0.001). Number of lines of therapy pretransplant (one or two vs. more than two lines of therapy (P < 0.001), and absolute lymphocyte count of ≤ 3000/cmm were predictors of superior PFS. Median overall survival (OS) for patients with CR was higher, (204 months), compared to those with VGPR (71.5 months, P < 0.001) and PR (51.5 months, P < 0.001), respectively. On Cox regression analysis, patients who received one line of induction therapy pretransplant (hazard ratio, HR 2.154, P < 0.001) and those with absolute lymphocyte count of ≤ 3000/mm(3) (HR 0.132, P < 0.001) had superior PFS. For overall survival, induction treatment up to one line (HR 2.403, P < 0.004) and Hb > 7.1 G/dL at diagnosis (HR 4.756, P < 0.01) were associated with superior outcome. On landmark analysis at 12 months, PFS and OS continued to remain superior for patients attaining CR. Achievement of CR post transplant is associated with longer OS and PFS. Among complete responders, those who receive one line of induction therapy pretransplant have superior outcome.
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Affiliation(s)
- Lalit Kumar
- Department of Medical Oncology and Laboratory Oncology Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, 11 00 29, India
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Rabin N, Lai M, Pratt G, Morgan G, Snowden J, Bird J, Cook G, Bowcock S, Owen R, Yong K, Wechalaker A, Low E, Davies F. United Kingdom Myeloma Forum position statement on the use of consolidation and maintenance treatment in myeloma. Int J Lab Hematol 2014; 36:665-75. [DOI: 10.1111/ijlh.12205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 02/06/2014] [Indexed: 11/28/2022]
Affiliation(s)
- N. Rabin
- Department of Haematology; University College London Hospitals; London UK
| | | | - G. Pratt
- Department of Haematology; Birmingham Hertlands Hospital; Birmingham UK
| | - G. Morgan
- Haemato-oncology; Royal Marsden Hospital; London UK
| | - J. Snowden
- Department of Haematology; Sheffield Teaching Hospitals; Sheffield UK
| | - J. Bird
- Department of Haematology; University Hospitals Bristol; Bristol UK
| | - G. Cook
- St James's Institute of Oncology; Leeds Teaching Hospitals Trust; Leeds UK
| | - S. Bowcock
- Department of Haematology; Princess Royal Hospital; Orpington Kent UK
| | - R. Owen
- St James's Institute of Oncology; Leeds Teaching Hospitals Trust; Leeds UK
| | - K. Yong
- Department of Haematology; University College London Hospitals; London UK
| | - A. Wechalaker
- Centre for Amyloidosis and Acute Phase Proteins; Royal Free Hospital; London UK
| | | | - F. Davies
- Haemato-oncology; Royal Marsden Hospital; London UK
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Prognostic value of deep sequencing method for minimal residual disease detection in multiple myeloma. Blood 2014; 123:3073-9. [PMID: 24646471 DOI: 10.1182/blood-2014-01-550020] [Citation(s) in RCA: 318] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
We assessed the prognostic value of minimal residual disease (MRD) detection in multiple myeloma (MM) patients using a sequencing-based platform in bone marrow samples from 133 MM patients in at least very good partial response (VGPR) after front-line therapy. Deep sequencing was carried out in patients in whom a high-frequency myeloma clone was identified and MRD was assessed using the IGH-VDJH, IGH-DJH, and IGK assays. The results were contrasted with those of multiparametric flow cytometry (MFC) and allele-specific oligonucleotide polymerase chain reaction (ASO-PCR). The applicability of deep sequencing was 91%. Concordance between sequencing and MFC and ASO-PCR was 83% and 85%, respectively. Patients who were MRD(-) by sequencing had a significantly longer time to tumor progression (TTP) (median 80 vs 31 months; P < .0001) and overall survival (median not reached vs 81 months; P = .02), compared with patients who were MRD(+). When stratifying patients by different levels of MRD, the respective TTP medians were: MRD ≥10(-3) 27 months, MRD 10(-3) to 10(-5) 48 months, and MRD <10(-5) 80 months (P = .003 to .0001). Ninety-two percent of VGPR patients were MRD(+). In complete response patients, the TTP remained significantly longer for MRD(-) compared with MRD(+) patients (131 vs 35 months; P = .0009).
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