The role of pre-transplant induction regimens and autologous stem cell transplantation in the era of novel targeted agents

Anakinra: efficacy in the management of fever during neutropenia and mucositis in autologous stem cell transplantation (AFFECT-2)-study protocol for a multicenter randomized double-blind placebo-controlled trial

Background

Since decades, fever and infections have been the most important complications of intensive chemotherapy and hematopoietic stem cell transplantation (HSCT) in the treatment of hematologic malignancies. Neutropenia has long been considered to be the most important risk factor for these complications. However, recent studies have shown that not neutropenia, but the development of mucositis is the most important cause of these complications. Currently, limited options for the prevention and treatment of mucositis are available, of which most are only supportive. The pro-inflammatory cytokine interleukin-1 (IL-1) plays a crucial role in the pathogenesis of mucositis. Pre-clinical studies of chemotherapy-induced mucositis have shown that recombinant human IL-1 receptor antagonist anakinra significantly ameliorated intestinal mucositis. In our pilot study AFFECT-1, we examined the safety and maximal tolerated dose of anakinra in patients with multiple myeloma, treated with high-dose melphalan (HDM) and autologous HSCT, selecting a dose of 300 mg daily for the phase IIb trial. The aim of the AFFECT-2 study is to determine the efficacy of anakinra in preventing fever during neutropenia (FN) and mucositis in this study population.

Methods/design

A multicenter, randomized, placebo-controlled, double-blind phase IIb trial will be conducted. Ninety patients with multiple myeloma scheduled for treatment with HDM and autologous HSCT will be included. Patients will be randomized between intravenous treatment with anakinra (300 mg) or placebo. Each group will be treated from day − 2 (day of HDM; day 0 is HSCT) up until day + 12. Outcome measures will be assessed at baseline, during admission, at discharge or day + 30, at day + 90, and + 1 year. The primary outcome will be reduction of FN. Secondary outcome measures include mucositis scores, bloodstream infections, citrulline levels, quality of life, and fatigue severity.

Discussion

The AFFECT-2 trial will examine the efficacy of anakinra in the management of fever during neutropenia and mucositis in patients with multiple myeloma treated with HDM and autologous HSCT. The results of this study may provide a new treatment option for these important complications. Also, this study will give us more insight in the pathophysiology of mucositis, including the role of IL-1 and the role of the microbiota in mucositis.

Trial registration

Clinicaltrials.gov NCT04099901. Registered on September 23, 2019. EudraCT: 2018-005046-10.

Predictors of inferior clinical outcome in patients with standard-risk multiple myeloma

INTRODUCTION

Outcome of patients with standard-risk (SR) multiple myeloma (MM) has improved; however, subsets of patients do worse than expected. We sought to identify the factors associated with inferior outcome.

METHODS

We evaluated 51 patients with SR MM that received upfront autologous hematopoietic stem cell transplantation (auto-HCT) after induction and had a progression-free survival (PFS) of ≤18 months.

RESULTS

The median age of patients was 61 yr. Forty-one (80%) patients received induction with immunomodulatory drugs, proteosome inhibitors, or combination of both. The overall response rate (ORR) after auto-HCT was 96% (stringent complete response 23%, complete response 10%, very good partial response 22%, and partial response 39%). The median PFS was 7.8, and median overall survival (OS) was 56.3 months. On univariate analysis, concurrent light-chain amyloidosis (AL) was associated with inferior PFS [hematological response (HR); 2.51, 95% CI; 0.64-10.58, P = 0.03] and occurrence of soft tissue plasmacytoma was associated with a significantly shorter OS (HR: 3.05, 95% CI: 0.57-16.29, P = 0.02).

CONCLUSION

Our analysis suggests that concurrent AL and soft tissue plasmacytoma were associated with shorter PFS and OS, respectively. Heterogeneity in clinical outcome of SR MM merits better tools for prognostication, such as gene expression profiling and minimal residual disease assessment to identify high-risk patients.

[Efficacy and prognostic factors of induction therapy combined with autologous stem cell transplantation in 201 patients with multiple myeloma]

目的

探讨诱导治疗序贯自体外周血造血干细胞移植（APBSCT）后多发性骨髓瘤（MM）患者预后的影响因素。

方法

回顾性分析1998年1月至2015年5月接受诱导治疗序贯APBSCT的201例MM患者临床资料。对预后影响因素进行分析。

结果

①201例患者中位疾病无进展生存（PFS）期为22.87（17.48~28.26）个月，中位总生存（OS）期为69.63（63.57~75.69）个月，5年PFS率、OS率分别为17%、49%。②APBSCT后达完全缓解（CR）组（112例）与未达CR组（89例）的中位PFS期分别为32.93（21.03~44.83）、18.13（14.46~21.80）个月（P<0.001），中位OS期分别为96.77（71.79~121.75）、54.70（49.53~59.87）个月（P=0.004）。③诱导治疗方案含硼替佐米或沙利度胺组（123例）与不含硼替佐米或沙利度胺组（21例）的中位PFS期分别为31.67(24.36~38.98)、15.20(10.11~20.29)个月（P=0.013），中位OS期分别为76.30（55.44~97.15）、52.03（33.76~70.30）个月（P=0.014）。④国际分期系统（ISS）Ⅰ、Ⅱ、Ⅲ期组中位OS期分别为99.47 (59.58~139.36)、66.77（52.17~81.37）、53.97（28.71~79.23）个月（P<0.001），Ⅱ、Ⅲ期患者发生死亡的风险分别为Ⅰ期患者的2.16、3.40倍。⑤IgD型（22例）、IgG型（101例）MM患者中位PFS期分别为11.17（10.27~13.13）、35.43(22.69~48.17)个月（P=0.007），中位OS期分别为30.83(0.24~61.42)、70.70（53.52~87.88）个月（P=0.039），IgD型患者发生疾病进展的风险是IgG型患者的2.47倍。⑥接受一线诱导（132例）和更换诱导治疗方案（69例）患者的中位PFS期分别为25.43（16.09~34.77）、20.27(15.04~25.50)个月（P=0.042），后者发生疾病进展的风险较前者高1.48倍，两组中位OS期差异无统计学意义（P=0.415）。⑦Cox多因素回归分析显示，移植后达CR和ISS分期是影响OS的独立预后因素，IgD型、移植后达CR是影响PFS的独立预后因素。

结论

移植后达CR、ISS分期是影响MM患者OS的独立预后因素。移植后达CR、IgD型也是影响PFS的独立预后因素。