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Gupta RK, Gupta A, Hillengass J, Holstein SA, Suman VJ, Taneja A, McCarthy PL. A review of the current status of lenalidomide maintenance therapy in multiple myeloma in 2022. Expert Rev Anticancer Ther 2022; 22:457-469. [PMID: 35503516 DOI: 10.1080/14737140.2022.2069564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Recent advances in the diagnosis and management of multiple myeloma (MM) have improved patient outcomes. This progress in our understanding of MM has resulted in continuous suppressive therapy concepts, including induction, high dose chemotherapy with autologous stem cell transplantation (ASCT), consolidation, and maintenance therapy. The foundation of maintenance therapy has been with lenalidomide. Other novel immunomodulatory drugs (IMiDs), proteasome inhibitors (PIs), and targeted monoclonal antibodies have also contributed to this evolution. AREAS COVERED This review summarizes the outcomes from phase II/III trials with long-term lenalidomide maintenance therapy alone or in combination with other agents in post-ASCT and non-transplant settings for newly diagnosed patients with MM. We review recent data considering a combination with newer medications and ongoing trials. We also review the optimal duration, MRD negativity rate, and safety and tolerability aspects of lenalidomide maintenance therapy. This review aims to present the current and emerging clinical evidence that supports using lenalidomide as a backbone for maintenance therapy in patients with MM. EXPERT OPINION There is increasing evidence to support lenalidomide as the backbone of combination therapy in the maintenance setting.
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Affiliation(s)
- Ravi Kumar Gupta
- Department of Internal Medicine, Larkin Community Hospital, South Miami, Florida, USA
| | - Ashish Gupta
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Jens Hillengass
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Sarah A Holstein
- Department of Internal Medicine, Division of Oncology and Hematology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Vera J Suman
- Department of Health Sciences, Division of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Alankrita Taneja
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Philip L McCarthy
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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Bertamini L, D'Agostino M, Gay F. MRD Assessment in Multiple Myeloma: Progress and Challenges. Curr Hematol Malig Rep 2021; 16:162-171. [PMID: 33950462 DOI: 10.1007/s11899-021-00633-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Over the last decade, the development of effective treatment approaches for multiple myeloma (MM) has been associated with higher response rates and longer survival. In patients who achieve complete response, several high sensitivity techniques have been studied to assess minimal residual disease (MRD) and detect residual neoplastic cells within the bone marrow (by flow cytometry or molecular biology techniques) or outside the bone marrow (by imaging or circulating disease markers in the peripheral blood). This is of utmost importance, since residual disease can drive clinical relapse. This review focuses on the progress made in the assessment of MRD in MM. RECENT FINDINGS The achievement of MRD negativity after therapy is considered prognostically important for MM patients, and data from clinical trials and meta-analyses have confirmed that it is strongly associated with better survival. Along with well-known techniques, such as next-generation sequencing (NGS), next-generation flow (NGF), and positron emission tomography/computed tomography (PET/CT), other methods such as mass spectrometry (MS) and circulating tumor cells are under study. Intensive treatment regimens at diagnosis can lead up to 70% of MRD negativity in MM patients, although the current proportion of curable patients is still unknown. Today, clinicians who treat MM deal with MRD assessment in routine clinical practice. Its appropriate use in therapeutic decision making may be the most fascinating and challenging issue to be addressed over the next few years.
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Affiliation(s)
- Luca Bertamini
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, via Genova 3, 10126, Torino, Italy
| | - Mattia D'Agostino
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, via Genova 3, 10126, Torino, Italy
| | - Francesca Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, via Genova 3, 10126, Torino, Italy.
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Luttwak E, Gatt ME, Lebel E, Lavi N, Tadmor T, Natalia K, Benyamini N, Horowitz N, Geva M, Suriu C, Avivi I, Trestman S, Mittelman M, Rouvio O, Cohen YC. Bortezomib Maintenance Therapy as a Standard of Care Provides Favorable Outcomes in Newly Diagnosed Myeloma Patients: A Multisite Real-Life Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e850-e857. [PMID: 32624446 DOI: 10.1016/j.clml.2020.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/31/2020] [Accepted: 06/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lenalidomide and ixazomib maintenance improve long-term outcomes in newly diagnosed multiple myeloma (NDMM) patients. However, there is less evidence to support bortezomib (BTZ) maintenance therapy, and real-life data on maintenance are scarce. We investigated the efficacy and safety of BTZ maintenance therapy in NDMM. PATIENTS AND METHODS A retrospective multisite study was performed in 6 medical centers in Israel. All consecutive patients with NDMM diagnosed between January 1, 2010, and July 3, 2019, who received a BTZ-based induction, with or without an autologous transplantation, followed by BTZ maintenance therapy, were identified. Maintenance therapy was defined as BTZ (1.3 mg/m2) once every 2 weeks, administered subcutaneously alone or with dexamethasone, or weekly BTZ monotherapy. RESULTS A total of 105 patients were identified, 58 of whom had received a transplant (transplant eligible) and 47 who had not (not transplant eligible). During BTZ maintenance therapy, 96% had one or more adverse event, 11.5% had grade 3 or higher adverse events, and 11.5% discontinued treatment due to toxicity. Median progression-free survival (PFS) and overall survival were 45 and 91.5 months, respectively; 4-year survival was 88%. Adverse cytogenetics was associated with worse PFS (24 vs. 46 months, P = .001). In subgroup analysis, adverse cytogenetics were associated with worse PFS (P < .001) and OS (P < .001) among transplant-ineligible but not transplant-eligible patients. CONCLUSION Analysis of multisite real-life data showed that BTZ maintenance therapy is safe, well tolerated, and effective. Median PFS was similar to that reported with alternative maintenance strategies. Our findings further support its use among patients with adverse cytogenetics, it may also be relevant for patients with lenalidomide-intolerant disease.
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Affiliation(s)
- Efrat Luttwak
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Moshe E Gatt
- Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Eyal Lebel
- Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Noa Lavi
- Department of Hematology & Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Tamar Tadmor
- Hematology Unit, Bnai-Zion Medical Center, Haifa, Israel
| | | | - Noam Benyamini
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Netanel Horowitz
- Department of Hematology & Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Mika Geva
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Celia Suriu
- Department of Haematology, Galilee Medical Centre, Nahariya, Israel
| | - Irit Avivi
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Svetlana Trestman
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Moshe Mittelman
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ory Rouvio
- Soroka University Medical Center, Beersheba, Israel
| | - Yael C Cohen
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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D'Agostino M, Zaccaria GM, Ziccheddu B, Rustad EH, Genuardi E, Capra A, Oliva S, Auclair D, Yesil J, Colucci P, Keats JJ, Gambella M, Bringhen S, Larocca A, Boccadoro M, Bolli N, Maura F, Gay F. Early Relapse Risk in Patients with Newly Diagnosed Multiple Myeloma Characterized by Next-generation Sequencing. Clin Cancer Res 2020; 26:4832-4841. [DOI: 10.1158/1078-0432.ccr-20-0951] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/29/2020] [Accepted: 06/30/2020] [Indexed: 11/16/2022]
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Oliva S, D'Agostino M, Boccadoro M, Larocca A. Clinical Applications and Future Directions of Minimal Residual Disease Testing in Multiple Myeloma. Front Oncol 2020; 10:1. [PMID: 32076595 PMCID: PMC7006453 DOI: 10.3389/fonc.2020.00001] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 01/02/2020] [Indexed: 12/20/2022] Open
Abstract
In the last years, the life expectancy of multiple myeloma (MM) patients has substantially improved thanks to the availability of many new drugs. Our ability to induce deep responses has improved as well, and the treatment goal in patients tolerating treatment moved from the delay of progression to the induction of the deepest possible response. As a result of these advances, a great scientific effort has been made to redefine response monitoring, resulting in the development and validation of high-sensitivity techniques to detect minimal residual disease (MRD). In 2016, the International Myeloma Working Group (IMWG) updated MM response categories defining MRD-negative responses both in the bone marrow (assessed by next-generation flow cytometry or next-generation sequencing) and outside the bone marrow. MRD is an important factor independently predicting prognosis during MM treatment. Moreover, using novel combination therapies, MRD-negative status can be achieved in a fairly high percentage of patients. However, many questions regarding the clinical use of MRD status remain unanswered. MRD monitoring can guide treatment intensity, although well-designed clinical trials are needed to demonstrate this potential. This mini-review will focus on currently available techniques and data on MRD testing and their potential future applications.
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Affiliation(s)
- Stefania Oliva
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Cittá Della Salute e Della Scienza di Torino, Turin, Italy
| | - Mattia D'Agostino
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Cittá Della Salute e Della Scienza di Torino, Turin, Italy
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Cittá Della Salute e Della Scienza di Torino, Turin, Italy
| | - Alessandra Larocca
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Cittá Della Salute e Della Scienza di Torino, Turin, Italy
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D’Agostino M, Bertamini L, Oliva S, Boccadoro M, Gay F. Pursuing a Curative Approach in Multiple Myeloma: A Review of New Therapeutic Strategies. Cancers (Basel) 2019; 11:E2015. [PMID: 31847174 PMCID: PMC6966449 DOI: 10.3390/cancers11122015] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/05/2019] [Accepted: 12/09/2019] [Indexed: 12/28/2022] Open
Abstract
Multiple myeloma (MM) is still considered an incurable hematologic cancer and, in the last decades, the treatment goal has been to obtain a long-lasting disease control. However, the recent availability of new effective drugs has led to unprecedented high-quality responses and prolonged progression-free survival and overall survival. The improvement of response rates has prompted the development of new, very sensitive methods to measure residual disease, even when monoclonal components become undetectable in patients' serum and urine. Several scientific efforts have been made to develop reliable and validated techniques to measure minimal residual disease (MRD), both within and outside the bone marrow. With the newest multidrug combinations, a good proportion of MM patients can achieve MRD negativity. Long-lasting MRD negativity may prove to be a marker of "operational cure", although the follow-up of the currently ongoing studies is still too short to draw conclusions. In this article, we focus on results obtained with new-generation multidrug combinations in the treatment of high-risk smoldering MM and newly diagnosed MM, including the potential role of MRD and MRD-driven treatment strategies in clinical trials, in order to optimize and individualize treatment.
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Affiliation(s)
| | | | | | | | - Francesca Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Torino, Italy
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Dempsey JL, Johns A, Rosko AE, Lazarus HM. The pharmacologic management of multiple myeloma in older adults. Expert Opin Pharmacother 2019; 20:887-902. [PMID: 30785310 PMCID: PMC6559717 DOI: 10.1080/14656566.2019.1577822] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 01/30/2019] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Multiple myeloma is a disease predominately affecting older adults. Pivotal to treating older adults is understanding their physiologic differences compared to younger subjects and how the complexity of therapies has an impact upon this patient population. AREAS COVERED Herein, the authors address the efficacy of chemotherapy regimens, decision-making for older adults, chemotherapy-associated toxicity and the approach to management. This review focuses on the complex treatment of older multiple myeloma patients and management of treatment-related adverse events. EXPERT OPINION Balancing efficacy and managing toxicity is a challenge for older myeloma patients. This group is more susceptible to treatment toxicities due to a higher incidence of pre-existing comorbidities and underlying diminished physiologic reserve. Intensive therapies such as autologous hematopoietic cell transplant (AHCT), however, still should be considered for all multiple myeloma patients, including older adults. The continued development of novel therapies and increased use of multi-drug regimens has changed the treatment paradigms yet understanding the complexity of the aging adult in the context of various drugs is warranted.
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Affiliation(s)
- Jessica L. Dempsey
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Andrew Johns
- Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Ashley E. Rosko
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Hillard M. Lazarus
- Department of Medicine, Division of Hematology and Oncology, Case Western Reserve University, Cleveland, OH, USA
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