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Sonneveld P, Dimopoulos MA, Beksac M, van der Holt B, Aquino S, Ludwig H, Zweegman S, Zander T, Zamagni E, Wester R, Hajek R, Pantani L, Dozza L, Gay F, Cafro A, De Rosa L, Morelli A, Gregersen H, Gulbrandsen N, Cornelisse P, Troia R, Oliva S, van de Velden V, Wu K, Ypma PF, Bos G, Levin MD, Pour L, Driessen C, Broijl A, Croockewit A, Minnema MC, Waage A, Hveding C, van de Donk NWCJ, Offidani M, Palumbo GA, Spencer A, Boccadoro M, Cavo M. Consolidation and Maintenance in Newly Diagnosed Multiple Myeloma. J Clin Oncol 2021; 39:3613-3622. [PMID: 34520219 DOI: 10.1200/jco.21.01045] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To address the role of consolidation treatment for newly diagnosed, transplant eligible patients with multiple myeloma in a controlled clinical trial. PATIENTS AND METHODS The EMN02/HOVON95 trial compared consolidation treatment with two cycles of bortezomib, lenalidomide, and dexamethasone (VRD) or no consolidation after induction and intensification therapy, followed by continuous lenalidomide maintenance. Primary study end point was progression-free survival (PFS). RESULTS Eight hundred seventy-eight eligible patients were randomly assigned to receive VRD consolidation (451 patients) or no consolidation (427 patients). At a median follow-up of 74.8 months, median PFS with adjustment for pretreatment was prolonged in patients randomly assigned to VRD consolidation (59.3 v 42.9 months, hazard ratio [HR] = 0.81; 95% CI, 0.68 to 0.96; P = .016). The PFS benefit was observed across most predefined subgroups, including revised International Staging System (ISS) stage, cytogenetics, and prior treatment. Revised ISS3 stage (HR, 2.00; 95% CI, 1.41 to 2.86) and ampl1q (HR, 1.67; 95% CI, 1.37 to 2.04) were significant adverse prognostic factors. The median duration of maintenance was 33 months (interquartile range 13-86 months). Response ≥ complete response (CR) after consolidation versus no consolidation before start of maintenance was 34% versus 18%, respectively (P < .001). Response ≥ CR on protocol including maintenance was 59% with consolidation and 46% without (P < .001). Minimal residual disease analysis by flow cytometry in a subgroup of 226 patients with CR or stringent complete response or very good partial response before start of maintenance demonstrated a 74% minimal residual disease-negativity rate in VRD-treated patients. Toxicity from VRD was acceptable and manageable. CONCLUSION Consolidation treatment with VRD followed by lenalidomide maintenance improves PFS and depth of response in newly diagnosed patients with multiple myeloma as compared to maintenance alone.
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Affiliation(s)
- Pieter Sonneveld
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Meral Beksac
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Bronno van der Holt
- Department of Hematology, HOVON Data Center, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Sara Aquino
- IRCCS Azienda Ospedaliera Universitaria San Martino, IST Instituto Nazionale per la Ricerca sul Cancro, Genova, Italy
| | - Heinz Ludwig
- Wilhelminen Cancer Research Institute, c/o Wilhelminenspital, Vienna, Austria
| | - Sonja Zweegman
- Department of Hematology, Amsterdam UMC, Cancer Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Thilo Zander
- Medical Oncology, Luzerner Kantonshospital, Luzern, Switzerland
| | - Elena Zamagni
- IRCCS Azienda Ospedaliero-Universitaria di Bologna Istituto di Ematologia "Seràgnoli" and Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università di Bologna, Bologna, Italy
| | - Ruth Wester
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Roman Hajek
- University Hospital Ostrava, Ostrava, Czech Republic
| | - Lucia Pantani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli," Bologna, Italy
| | - Luca Dozza
- Department of Experimental, Diagnostic and Experimental Medicine, Seràgnoli Institute of Hematology, Bologna University School of Medicine, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Francesca Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | | | | | - Annamaria Morelli
- Department of Hematology, Transfusion Medicine and Biotechnology Santo Spirito, Civic Hospital, Pescara, Italy
| | - Henrik Gregersen
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | - Nina Gulbrandsen
- Department of Hematology, Oslo University Hospital, Oslo, Norway
| | - Petra Cornelisse
- HOVON Data Center, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Rosella Troia
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Stefania Oliva
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | | | - KaLung Wu
- Department of Hematology, ZNA Stuivenberg, Antwerp, Belgium
| | - Paula F Ypma
- Department of Hematology, Haga Ziekenhuis, The Hague, the Netherlands
| | - Gerard Bos
- Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Luca Pour
- University Hospital Brno, Brno, Czech Republic
| | - Christoph Driessen
- Department of Oncology/Hematology, Kantonsspital, St Gallen, Switzerland
| | - Annemiek Broijl
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Alexandra Croockewit
- Department of Hematology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Monique C Minnema
- Department of Hematology, University Medical Centre Utrecht, the Netherlands
| | - Anders Waage
- Department of Hematology, St Olav Hospital, Trondheim, Norway
| | | | - Niels W C J van de Donk
- Department of Hematology, Amsterdam UMC, Cancer Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Massimo Offidani
- Clinica di Ematologia, AOU Ospedali Riuniti di Ancona, Ancona, Italy
| | - Giuseppe A Palumbo
- Department of Scienze Mediche Chirurgiche e Tecnologie Avanzate "G.F. Ingrassia," University of Catania, Catania, Italy
| | - Andrew Spencer
- Department of Haematology, Alfred Hospital-Monash University, Melbourne, Australia
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Michele Cavo
- IRCCS S.Orsola-Malpighi, Istituto di Ematologia "Seràgnoli," Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi di Bologna, Bologna, Italy
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Krishna SG, Barlogie B, Lamps LW, Krishna K, Aduli F, Anaissie E. Recurrent spontaneous gastrointestinal graft-versus-host disease in autologous hematopoietic stem cell transplantation. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2010; 10:E17-21. [PMID: 20223723 DOI: 10.3816/clml.2010.n.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Acute graft-versus-host disease (GVHD) is a major complication after allogeneic stem cell transplantation (SCT). A similar manifestation involving skin, gastrointestinal (GI) mucosa, and liver can occur after autologous hematopoietic SCT (autoHSCT), either spontaneously or after treatment with cyclosporine or interferon. Severity of spontaneous GI GVHD among patients treated with autoHSCT is variable. Recurrent spontaneous GI GVHD induced by succeeding cycles of chemotherapy has rarely been reported and is poorly understood. Enteric-coated budesonide has been studied extensively in Crohn's disease, and beclomethasone has been studied in GI GVHD. There are no comparative studies between these drugs for GI GVHD. Furthermore, GI GVHD has to be considered when microbiologic workup remains negative during the workup of persistent diarrhea in autoHSCT. Endoscopic appearances can be normal, and pathologic diagnosis is essential. Further research into risk factors involving type of chemotherapy, interval between chemotherapies, and gene polymorphisms have to be considered for better understanding of autologous GVHD. We report for the first time a patient with spontaneous recurrent GI GVHD after autoHSCT for multiple myeloma with predominant lower GI symptoms and excellent response to enteric-coated budesonide therapy.
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Affiliation(s)
- Somashekar G Krishna
- Department of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock 72211, USA.
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Dispenzieri A, Jacobus S, Vesole DH, Callandar N, Fonseca R, Greipp PR. Primary therapy with single agent bortezomib as induction, maintenance and re-induction in patients with high-risk myeloma: results of the ECOG E2A02 trial. Leukemia 2010; 24:1406-11. [PMID: 20535147 PMCID: PMC2921007 DOI: 10.1038/leu.2010.129] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Single agent bortezomib results in response rates of 51% in patients with newly diagnosed multiple myeloma (MM) and is touted to be especially effective in high-risk disease. We are the first to prospectively explore single agent bortezomib as primary therapy (response rate, maintenance and reinduction) without consolidative autologous stem cell transplant in a cohort selected to have high-risk MM. Patients received 8-cycles of induction followed by maintenance bortezomib every other week indefinitely. Patients relapsing on maintenance had full induction schedule resumed. On an intention to treat basis the response rate (>=PR) was 48%. Among 7 patients, who progressed on maintenance bortezomib and received reinduction, two responded. With a median follow-up of 48.2 months, 1- and 2-year OS probabilities were 88% (95%CI, 74–95%) and 76% (95%CI, 60–86%), respectively. Median PFS was 7.9 months (95%CI, 5.8–12.0). Twenty-three and 34 patients had >=grade 3 hematologic and non-hematologic toxicity, respectively with treatment emergent neuropathy in: 7%, motor grade 1–2; 56%, sensory grade 1–2 and 2%, grade 3; and 14%, neuropathic pain grade 1–2 in and 2%, grade 3. In high-risk patients, upfront bortezomib results in response rates comparable to those reported for unselected cohorts, but single agent bortezomib is not sufficient as primary therapy.
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Affiliation(s)
- A Dispenzieri
- Department of Hematology, Mayo Clinic, Rochester, MN 55905, USA.
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Total Therapy 3 for multiple myeloma: prognostic implications of cumulative dosing and premature discontinuation of VTD maintenance components, bortezomib, thalidomide, and dexamethasone, relevant to all phases of therapy. Blood 2010; 116:1220-7. [PMID: 20501894 DOI: 10.1182/blood-2010-01-264333] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The impact of cumulative dosing and premature drug discontinuation (PMDD) of bortezomib (V), thalidomide (T), and dexamethasone (D) on overall survival (OS), event-free survival (EFS), time to next therapy, and post-relapse survival in Total Therapy 3 were examined, using time-dependent methodology, relevant to induction, peritransplantation, consolidation, and maintenance phases. Univariately, OS and EFS were longer in case higher doses were used of all agents during induction, consolidation (except T), and maintenance (except V and T). The favorable OS and EFS impact of D induction dosing provided the rationale for examining the expression of glucocorticoid receptor NR3C1, top-tertile levels of which significantly prolonged OS and EFS and rendered outcomes independent of D and T dosing, whereas T and D, but not V, dosing was critical to outcome improvement in the bottom-tertile NR3C1 setting. PMDD of V was an independent highly adverse feature for OS (hazard ratio = 6.44; P < .001), whereas PMDD of both T and D independently imparted shorter time to next therapy. The absence of adverse effects on postrelapse survival of dosing of any VTD components and indeed a benefit from V supports the use up-front of all active agents in a dose-dense and dose-intense fashion, as practiced in Total Therapy 3, toward maximizing myeloma survival.
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Pineda-Roman M, Zangari M, van Rhee F, Anaissie E, Szymonifka J, Hoering A, Petty N, Crowley J, Shaughnessy J, Epstein J, Barlogie B. VTD combination therapy with bortezomib-thalidomide-dexamethasone is highly effective in advanced and refractory multiple myeloma. Leukemia 2008; 22:1419-27. [PMID: 18432260 DOI: 10.1038/leu.2008.99] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Bortezomib (V) was combined with thalidomide (T) and dexamethasone (D) in a phase I/II trial to determine dose-limiting toxicities (DLT's) and clinical activity of the VTD regimen in 85 patients with advanced and refractory myeloma. The starting dose of V was 1.0 mg/m(2) (days 1, 4, 8, 11, every 21 day) with T added from cycle 2 at 50 mg/day, with 50 mg increments per 10 patient cohorts, to a maximum dose of 200 mg. In the absence of DLT's, the same reiteration of T dose increases was applied with a higher dose of V=1.3 mg/m(2). D was added with cycle 4 in the absence of partial response (PR). Ninety-two percent had prior autotransplants, 74% had prior T and 76% abnormal cytogenetics. MTD was reached at V=1.3 mg/m(2) and T=150 mg. Minor response (MR) was recorded in 79%, and 63% achieved PR including 22% who qualified for near-complete remission. At 4 years, 6% remain event-free and 23% alive. Both OS and EFS were significantly longer in the absence of prior T exposure and when at least MR status was attained. The MMSET/FGFR3 molecular subtype was prognostically favorable, a finding since reported for a VTD-incorporating tandem transplant trial (Total Therapy 3) for untreated patients with myeloma (BJH 2008).
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Affiliation(s)
- M Pineda-Roman
- Myeloma Institute for Research and Therapy, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
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