Limited value of the international staging system for predicting long-term outcome of transplant-ineligible, newly diagnosed, symptomatic multiple myeloma in the era of novel agents

Real-world data on induction therapy in patients with transplant-ineligible newly diagnosed multiple myeloma: retrospective analysis of 598 cases from Kansai Myeloma Forum

To investigate the real-world clinical outcomes and management of novel drug-containing therapies for newly diagnosed multiple myeloma (MM) patients, we retrospectively analyzed data on the first-line treatment for newly diagnosed transplant-ineligible MM patients from Kansai Myeloma Forum, a registry network in Japan. A total of 598 patients treated with novel drugs between March 2007 and February 2018 were analyzed. Regimens used were VD (n = 305), Rd (n = 103), VMP (n = 97), VCD (n = 71), and VRd (n = 22). Younger patients tended to receive VRd or VCD, whereas the regimen with the highest median patient age was Rd. More than three-quarters of patients in the Rd group received a reduced dose of lenalidomide. The Rd and VRd groups had a relatively high incidence of infection and skin complications, and the VMP group had the highest incidence of peripheral neuropathy. Overall response rate did not differ significantly between regimens. Multivariate analysis in all patients revealed several poor prognostic factors, such as poor performance status. Novel drug-containing regimens for newly diagnosed MM showed a durable response with manageable AEs in the real-world setting.

SOHO State of the Art Updates and Next Questions: Treatment of Older, Vulnerable Adults with Multiple Myeloma

Multiple myeloma is primarily a disease of the elderly, and optimal treatments must weigh the risks of toxicity with the benefits of therapy.  Frailty scales have been developed to aid treatment-decision making for older adults with MM.   This review provides a framework for incorporating frailty scales into clinical care and highlights how patient-aligned priorities for care can influence the management of older or more vulnerable adults with newly diagnosed multiple myeloma newly diagnosed multiple myeloma. We review the currently available systemic therapies for managing older or more vulnerable adults with newly diagnosed multiple myeloma otherwise considered ineligible for autologous stem cell transplantation.

Treatment of older adult or frail patients with multiple myeloma

Older adults with multiple myeloma (MM) are a growing population, and personalizing treatment based on disease and health status is imperative. Similar to MM staging systems that provide disease-related prognostic information, myeloma-specific frailty tools can better identify subgroups at greatest risk for treatment-related toxicity and early treatment discontinuation, as well as predict overall survival. Several myeloma-specific validated tools are well studied. Although these fitness/frailty scores have shaped our understanding of the heterogeneity among older adults with myeloma, the application of such scores in treatment decision making (ie, transplant considerations, relapse) is an unmet need. Here we outline how to incorporate frailty assessments in the evaluation of older adults with MM in the clinical setting with consideration of other factors such as patient preferences, treatment risks/benefits, life expectancy, and disease biology.

Defining the vulnerable patient with myeloma-a frailty position paper of the European Myeloma Network

As the treatment landscape continues to evolve towards the application of precision medicine in multiple myeloma (MM), there is a clear need to identify those patients who are at risk of not achieving the maximum benefit whilst exposed to the highest level of toxicity. This group of patients, defined as frail, is an unmet clinical need. However, how we define such a vulnerable group of patients with MM remains to be clarified. An integral aspect of this is to define the physiological age and capacity of patients with MM to deal with the burden of their disease and it's treatment. Such assessments may include not only functional and clinical assessments but also laboratory-based biomarkers of frailty, aging and senescent cellular burden. A need to develop, test and validate clinical screening scores before their adoption into clinical practice is mandated. This position paper from the European Myeloma Network aims to review what is known about defining frailty in MM, and how we can advance this knowledge for the design of clinical trials and ultimately how we deliver treatment in the clinic.

[Expression of CD45 in newly diagnosed multiple myeloma and the relationship with prognosis]

目的

观察CD45在初诊多发性骨髓瘤（MM）患者中的表达，探讨其与MM疗效和预后的关系。

方法

回顾性分析2010年1月至2017年1月河南省人民医院收治的130例初诊MM患者骨髓异常浆细胞中CD45的表达情况，对CD45⁺与CD45⁻患者的疗效和预后进行比较。

结果

①130例初诊MM患者中CD45⁺组33例（25.38%），CD45⁻组97例（74.62%）。②CD45⁺组和CD45⁻组的客观缓解率（ORR）分别为33.33%和64.95%，差异有统计学意义（P=0.002）；以硼替佐米为基础方案治疗的患者，CD45⁺组和CD45⁻组的ORR分别为35.71%和66.25%，差异有统计学意义（P=0.005）。③130例MM患者的中位无进展生存（PFS）时间为33.3（95%CI 6.0~69.0）个月，中位总生存（OS）时间为36.3（95%CI 6.0~78.0）个月，CD45⁺组与CD45⁻组的中位PFS时间分别为29.8（95%CI 10.0~59.0）个月和34.5（95%CI 6.0~69.0）个月，差异有统计学意义（χ²=14.59，P<0.001），中位OS时间分别为32.5（95%CI 10.0~68.0）个月和37.6（95%CI 6.0~78.0）个月，差异有统计学意义（χ²=11.42，P=0.001）；接受硼替佐米的患者中，CD45⁺组与CD45⁻组的中位PFS分别为30.3（95%CI 10.0~59.0）个月和36.3（95%CI 6.0~69.0）个月，差异有统计学意义（χ²=14.75，P=0.001）。中位OS时间分别为34.0（95%CI 10.0~68.0）个月和39.5（95%CI 6.0~78.0）个月，差异有统计学意义（χ²=10.62，P=0.001）。④Cox风险回归模型分析显示血肌酐≥176.8 µmol/L[HR=2.723（95%CI 1.744~6.723），P=0.001]、CD45阳性[HR=1.330（95%CI 1.067~1.804），P=0.008]，LDH ≥ 220 IU/L[HR=1.308（95%CI 1.160~2.417），P=0.015]是独立于其他临床指标的预后危险因素。

结论

CD45阳性是MM患者的预后不良因素。硼替佐米不能改善CD45⁺MM患者的不良预后。

Clinical effect of immunophenotyping on the prognosis of multiple myeloma patients treated with bortezomib

In the present study, the effect of immunophenotyping on the prognoses of patients with multiple myeloma (MM) treated with bortezomib plus dexamethasone was investigated. The study involved 46 patients with MM, and analyzed the prognostic significance of the expression of cluster of differentiation (CD)45, CD56 and mature plasma cell (MPC)-1, and other factors including the International Staging System (ISS) stage, age, gender, the immunoglobulin subtype and the treatment line number prior to bortezomib treatment. Although CD56 and MPC-1 expression did not appear to affect the time to next treatment (TNT) or overall survival rate (OS), the univariate analysis determined that CD45 positivity was an adverse prognostic factor for TNT and OS, and that being male was significantly associated with inferior TNT and OS. Multivariate analyses determined that CD45 expression was prognostically significant for TNT and OS. In conclusion, CD45 positivity is an adverse prognostic factor in MM patients treated with bortezomib. The data from the present study demonstrate the clinical importance of classifying MM cells immunophenotypically to determine the prognoses of patients.

Prognostic value of the inverse platelet to lymphocyte ratio (iPLR) in patients with multiple myeloma who were treated up front with a novel agent-containing regimen

Recently, reactive thrombosis or platelet to lymphocyte ratio has been reported as a strong predictor of poor prognosis in various types of cancer. However, a study investigating the relationship between platelet counts and thrombopoietic cytokines suggested that low platelet could be important in multiple myeloma (MM), which means platelet count decreased in advanced International Staging System (ISS) stage. Therefore, we developed inverse platelet to lymphocyte ratio (iPLR) and assessed the prognostic value of iPLR in patients with MM. We retrospectively analyzed 283 patients who were treated up front with a novel agent-containing regimen. Patients were classified into three groups based on hazard ratio (HR) according to iPLR: low iPLR (group 1), middle iPLR (group 2), and high iPLR (group 3). Over a median follow-up of 34.8 months, staging by iPLR group had predictive value for progression-free survival (PFS) and overall survival (OS). In addition, staging by iPLR group was a reliable method to predict for survival in patients who presented with renal failure (eGFR<60 mL/min/1.73 m2) and in elderly patients. Multivariate analyses demonstrated that staging by iPLR group was associated with PFS and OS in patients with MM. In conclusion, this study suggested that iPLR is a simple and reliable inflammatory prognostic factor in the era of novel agents.

Neutrophil to lymphocyte ratio (NLR) improves the risk assessment of ISS staging in newly diagnosed MM patients treated upfront with novel agents

Recent reports identify the ratio between absolute neutrophil count (ANC) and absolute lymphocyte count (ALC), called neutrophil to lymphocyte ratio (NLR), as a predictor of progression-free survival (PFS) and overall survival (OS) in various malignancies. We retrospectively examined the NLR in a cohort of 309 newly diagnosed multiple myeloma (MM) patients treated upfront with novel agents. NLR was calculated using data obtained from the complete blood count (CBC) at diagnosis and subsequently correlated with PFS and OS. The median NLR was 1.9 (range 0.4-15.9). Higher NLR was independent of international staging system (ISS) stage, plasma cell infiltration or cytogenetics. The 5-year PFS and OS estimates were, respectively, 18.2 and 36.4 % for patients with NLR ≥ 2 versus 25.5 and 66.6 % in patients with NLR < 2. Among younger patients (age <65 years, N = 179), NLR ≥ 2 had a negative prognostic impact on both PFS and OS, in all ISS stages. By combining ISS stage and NLR in a model limited to young patients, we found that 19 % of the patients were classified as very low risk, 70 % standard risk and 11 % very high risk. The 5-year estimates were 39.3, 19.4 and 10.9 % for PFS and 95.8, 50.9 and 23.6 % for OS for very low, standard-risk and very high-risk groups. We found NLR to be a predictor of PFS and OS in MM patients treated upfront with novel agents. NLR can be combined with ISS staging system to identify patients with dismal outcome. However, larger cohorts and prospective studies are needed to use NLR as additional parameter to personalise MM therapy in the era of novel agents.

Impact of early use of lenalidomide and low-dose dexamethasone on clinical outcomes in patients with relapsed/refractory multiple myeloma

We retrospectively investigated the prognostic factor of lenalidomide plus low-dose dexamethasone (Rd) in Japanese patients with refractory or relapsed multiple myeloma (RRMM) registered in the Kansai Myeloma Forum from January 2006 to December 2013. A total of 140 patients were analyzed. The median age was 66 years. The overall response rate was 68.6 %, including 33.1 % with a better than very good partial response. At 13.0 months median follow-up, the median overall survival (OS) and progression-free survival (PFS) were 34.2 and 17.0 months, respectively. In univariate analyses, patients with one or two prior therapies had significantly longer OS (41.2 vs. 21.5 months; P = 0.002) and PFS (29.0 vs. 13.0 months; P = 0.006) than patients treated with three or more prior therapies. Prior use of thalidomide was associated with significantly shorter PFS (19.0 vs. 16.0 months; P = 0.045). The prior use of bortezomib or high-dose therapy with stem cell transplantation, and the International Staging System had no impact on long-term outcome. Multivariate analysis showed that only the number of prior therapies was a significant predictor of both OS and PFS. Our findings suggest that greater benefit may occur when Rd therapy is used at the first or second relapse in RRMM.