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Abdelmonem ME, Nooh HA, El Ashry MS. Clinical Relevance of Interferon Regulatory Family-4 (IRF4) Expression in Newly Diagnosed Patients with Multiple Myeloma. Indian J Hematol Blood Transfus 2023; 39:525-536. [PMID: 37786826 PMCID: PMC10542031 DOI: 10.1007/s12288-023-01628-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 01/06/2023] [Indexed: 01/19/2023] Open
Abstract
Multiple myeloma (MM) is a malignant plasma cell neoplasm with complex biology and heterogenous course. Interferon regulatory factor 4 (IRF4) transcription factor, important key developmental stages of hematopoiesis, represents an excellent potential therapeutic target. The present work aimed to investigate the expression status of IRF4 in the diagnostic bone marrow biopsy (BMB) cores of MM patients. This prospective study included 62 newly diagnosed MM patients. The expression of IRF4 was assessed in the BMB by immunohistochemistry (IHC). The data were correlated to the patients' clinico-pathological features, response to treatment and survival rates. IRF4 expression was observed in 50% of MM patients (31/62). IRF-4 positive patients were more frequently male patients (P = 0.018), have immunoglobulin heavy chain (IgH) translocations (P = 0.05) and tended to present with a higher platelets count (P = 0.07). Multiple myeloma patients presenting with urine M-protein had worse overall survival (OS) than negative cases (P = 0.012). Normocellular BM aspirate (BMA) was associated with better OS than hypercellular and hypocellular BMA (P = 0.006). Patchy distribution of plasma cells in BMB was associated with better disease-free survival (DFS) while diffuse infiltration had the worst (P = 0.019). Of note, after treatment, MM patients had significantly lower percentage of BMA plasma cells, platelet count, β2 microglobulin and creatinine levels (P = 0.037, < 0.001, 0.022 and 0.026, respectively). Had higher albumin level (P = 0.007), compared to initial investigations. No significant association was found between IRF4 expression and the patients'clinical outcomes. Patterns of plasma cells distribution in BMB, BMA cellularity and urine M-protein are prognostically relevant in MM. Supplementary Information The online version contains supplementary material available at 10.1007/s12288-023-01628-3.
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Affiliation(s)
| | - Hend A. Nooh
- Clinical Pathology Department, National Cancer Institute, Cairo University, Kasr Al Eini Street, Fom El Khalig, P.O Box 11796, Cairo, Egypt
| | - Mona S. El Ashry
- Clinical Pathology Department, National Cancer Institute, Cairo University, Kasr Al Eini Street, Fom El Khalig, P.O Box 11796, Cairo, Egypt
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Evaluation of Genes and Molecular Pathways Involved in the Progression of Monoclonal Gammopathy of Undetermined Significance (MGUS) to Multiple Myeloma: A Systems Biology Approach. Mol Biotechnol 2022:10.1007/s12033-022-00634-6. [DOI: 10.1007/s12033-022-00634-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022]
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Abstract
PURPOSE OF REVIEW Despite tremendous advances in multiple myeloma (MM) care, the disease maintains considerable morbidity and requires long-term treatment associated with significant financial toxicity to patients and high costs to society. In this review, we explore why - despite treatment advances - value in MM treatment is largely a myth, then explain some ways the myth might become a reality. RECENT FINDINGS We discuss how value-based care in MM should include patient-centered outcomes such as financial toxicity and quality of life, which are heavily impacted by cost of drugs and the indefinite duration of therapy that is standard in MM treatment. We propose multiple paths to work toward reducing cost and augmenting value of care for patients with MM, including improving access to generic drugs, increasing federal funding for clinical trials, designing more patient-centric clinical trials, and exploring the utilization of minimal residual disease (MRD)-driven treatment de-escalation, among others. We remain optimistic that despite the challenges, we can work toward making progress in the realm of value-based care for patients with MM and make it a reality.
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Rajkumar SV. The Path Forward in Multiple Myeloma: 2021 Jan Waldenstrom Award Lecture. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:666-669. [PMID: 35614010 DOI: 10.1016/j.clml.2022.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/18/2022] [Indexed: 06/15/2023]
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Rajkumar SV. Multiple myeloma: 2022 update on diagnosis, risk stratification, and management. Am J Hematol 2022; 97:1086-1107. [PMID: 35560063 PMCID: PMC9387011 DOI: 10.1002/ajh.26590] [Citation(s) in RCA: 270] [Impact Index Per Article: 135.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/05/2022] [Accepted: 05/06/2022] [Indexed: 12/22/2022]
Abstract
DISEASE OVERVIEW Multiple myeloma accounts for approximately 10% of hematologic malignancies. DIAGNOSIS The diagnosis requires ≥10% clonal bone marrow plasma cells or a biopsy-proven plasmacytoma plus evidence of one or more multiple myeloma defining events (MDE): CRAB (hypercalcemia, renal failure, anemia, or lytic bone lesions) attributable to the plasma cell disorder, bone marrow clonal plasmacytosis ≥60%, serum involved/uninvolved free light chain (FLC) ratio ≥ 100 (provided involved FLC is ≥100 mg/L), or >1 focal lesion on magnetic resonance imaging. RISK STRATIFICATION The presence of del(17p), t(4;14), t(14;16), t(14;20), gain 1q, or p53 mutation is considered high-risk multiple myeloma. The presence of any two high risk factors is considered double-hit myeloma, and three or more high risk factors is triple-hit myeloma. RISK-ADAPTED INITIAL THERAPY In patients who are candidates for autologous stem cell transplantation, induction therapy consists of bortezomib, lenalidomide, dexamethasone (VRd) given for approximately 3-4 cycles followed by autologous stem cell transplantation (ASCT). In high-risk patients, daratumumab, bortezomib, lenalidomide, dexamethasone (Dara-VRd) is an alternative to VRd. Selected standard-risk patients can collect stem cells, get additional cycles of induction therapy, and delay transplant until first relapse. Patients who are not candidates for transplant are treated with VRd for approximately 8-12 cycles followed by maintenance or alternatively with daratumumab, lenalidomide, dexamethasone (DRd) until progression. MAINTENANCE THERAPY Standard-risk patients need lenalidomide maintenance, while bortezomib plus lenalidomide maintenance is needed for high-risk myeloma. MANAGEMENT OF RELAPSED DISEASE A triplet regimen is usually needed at relapse, with the choice of regimen varying with each successive relapse.
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6
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Goel U, Usmani S, Kumar S. Current approaches to management of newly diagnosed multiple myeloma. Am J Hematol 2022; 97 Suppl 1:S3-S25. [PMID: 35234302 DOI: 10.1002/ajh.26512] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 12/16/2022]
Abstract
Major developments in the treatment of multiple myeloma (MM) over the past decade have led to a continued improvement in survival. Significant progress has been made with deeper and longer remissions seen with newer treatment approaches-both for induction as well as maintenance therapy. The treatment approach to MM is guided by several factors including patient age, frailty, comorbidities, eligibility for autologous stem cell transplantation (ASCT), and risk stratification into standard-risk or high-risk MM. High-risk MM is defined by the presence of t(4;14), t(14;16), t(14;20), del (17p), TP53 mutation, or gain (1q). Transplant eligible patients should receive 4-6 cycles of induction followed by stem cell collection. Patients can then undergo ASCT, or continue induction therapy and shift to maintenance, delaying ASCT till first relapse. Transplant ineligible patients should receive induction therapy followed by maintenance. For induction therapy prior to ASCT, a proteasome inhibitor-IMiD combination remains standard with monoclonal antibody-based quadruplets preferred in high-risk patients. Among transplant ineligible patients, those with standard-risk MM should receive DRd continued until disease progression, while bortezomib containing regimens (VRd or VRd lite) can be considered for high-risk patients. Finally, standard-risk patients should receive lenalidomide maintenance after induction/ASCT, while proteasome inhibitor-IMiD combinations should be used for high-risk patients.
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Affiliation(s)
- Utkarsh Goel
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota USA
| | - Saad Usmani
- Multiple Myeloma Service, Department of medicine Memorial Sloan Kettering Cancer Center New York New York USA
| | - Shaji Kumar
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota USA
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7
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Wong XY, Chng WJ, Aziz MIA, Ng K. Cost-effectiveness of daratumumab in combination with lenalidomide and dexamethasone for relapsed and/or refractory multiple myeloma. Expert Rev Pharmacoecon Outcomes Res 2021; 22:207-215. [PMID: 34904498 DOI: 10.1080/14737167.2022.2017285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study evaluates the cost-effectiveness of daratumumab (D) in combination with lenalidomide and dexamethasone (Rd) for treatment of relapsed and/or refractory multiple myeloma in patients who have received at least one prior therapy in Singapore. METHODS A 3-state partitioned survival model was developed to evaluate the cost-effectiveness of lenalidomide and dexamethasone with or without daratumumab from a healthcare system perspective over 10 years. Clinical inputs were obtained from the POLLUX trial. Health state utilities were derived from the literature and direct medical costs obtained from public healthcare institutions. Sensitivity and scenario analyses were conducted to explore uncertainties. RESULTS DRd was associated with a high base-case incremental cost-effectiveness ratio (ICER) of US$576,247 per quality-adjusted life year (QALY) gained, compared with Rd. According to one-way sensitivity analysis, ICER was most heavily influenced by time horizon, discount rate for outcomes, progression-free utility and cost of daratumumab. Regardless of the variation, DRd remained not cost-effective. Even when the cost of both daratumumab and lenalidomide dropped by 20% and 80%, the ICERs remained high at US$470,400 and US$152,860 per QALY gained. CONCLUSIONS At current prices, the addition of daratumumab to lenalidomide and dexamethasone does not represent cost-effective use of healthcare resources in Singapore.
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Affiliation(s)
- Xin Yi Wong
- Agency for Care Effectiveness, Ministry of Health, Singapore
| | - Wee Joo Chng
- Division of Haematology, Department of Haematology-Oncology, National University Cancer Institute, Singapore.,Cancer Science Institute of Singapore, National University of Singapore (NUS), Singapore.,Yong Loo Lin School of Medicine, NUS, Singapore
| | | | - Kwong Ng
- Agency for Care Effectiveness, Ministry of Health, Singapore
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Davis AE, Lowe JM, Hilinski MK. Vinylazaarenes as dienophiles in Lewis acid-promoted Diels-Alder reactions. Chem Sci 2021; 12:15947-15952. [PMID: 35024118 PMCID: PMC8672738 DOI: 10.1039/d1sc05095h] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/24/2021] [Indexed: 11/25/2022] Open
Abstract
Described are the first examples of Lewis acid-promoted Diels–Alder reactions of vinylpyridines and other vinylazaarenes with unactivated dienes. Cyclohexyl-appended azaarenes constitute a class of substructures of rising prominence in drug discovery. Despite this, thermal variants of the vinylazaarene Diels–Alder reaction are rare and have not been adopted for synthesis, and Lewis acid-promoted variants are virtually unexplored. The presented work addresses this gap and in the process furnishes increased scope, dramatically higher yields, improved regioselectivity, and high levels of diastereoselectivity compared to prior thermal examples. These reactions provide scalable access to druglike scaffolds not readily available through other methods. More broadly, these studies establish a useful new class of dienophiles that, based on preliminary mechanistic studies, should be amenable to conventional strategies for enantioselective catalysis. Vinyl-substituted azaarenes are rare and challenging substrates as dienophiles in Diels–Alder reactions; by employing Lewis acid activation, high yielding and highly selective cycloadditions with unactivated dienes are enabled.![]()
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Affiliation(s)
- Anna E Davis
- Department of Chemistry, University of Virginia Charlottesville Virginia 22904-4319 USA
| | - Jared M Lowe
- Department of Chemistry, University of Virginia Charlottesville Virginia 22904-4319 USA
| | - Michael K Hilinski
- Department of Chemistry, University of Virginia Charlottesville Virginia 22904-4319 USA
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9
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Malacrida A, Cavalloro V, Martino E, Costa G, Ambrosio FA, Alcaro S, Rigolio R, Cassetti A, Miloso M, Collina S. Anti-Multiple Myeloma Potential of Secondary Metabolites from Hibiscus sabdariffa-Part 2. Molecules 2021; 26:molecules26216596. [PMID: 34771006 PMCID: PMC8588054 DOI: 10.3390/molecules26216596] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 12/20/2022] Open
Abstract
Multiple Myeloma (MM) is an aggressive tumor causing millions of deaths every year and currently available therapies are often unsuccessful or correlated with severe side effects. In our previous work we demonstrated that the Hibiscus sabdariffa hydroalcoholic extract inhibits the growth of the MM cell line and we isolated two metabolites responsible for the activity: Hib-ester and Hib-carbaldehyde. Herein we report their interaction with proteasome, one of the main targets in the fight against MM. The molecular modelling study outlined a good interaction of both compounds with the target and these results prompted us to investigate their potential to inhibit proteasome. Metabolites were then isolated from the calyces and an extract with a high content of Hib-ester and Hib-carbaldehyde was prepared. An anticancer profile was drawn, evaluating apoptosis, autophagy and proteasome inhibition, with the anticancer properties being mainly attributed to the Hib-ester and Hib-carbaldehyde, while the proteasome inhibition of the extract could also be ascribed to the presence of anthocyanins, a class of secondary metabolites already known for their proteasome inhibitory activity.
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Affiliation(s)
- Alessio Malacrida
- School of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy; (A.M.); (R.R.)
- Experimental Neurology Unit, University of Milano-Bicocca, 20900 Monza, Italy
| | - Valeria Cavalloro
- Department of Earth and Environmental Sciences, University of Pavia, 27100 Pavia, Italy;
| | - Emanuela Martino
- Department of Earth and Environmental Sciences, University of Pavia, 27100 Pavia, Italy;
- Correspondence: (E.M.); (M.M.)
| | - Giosuè Costa
- Department of Health Sciences, Campus “S. Venuta”, “Magna Græcia” University of Catanzaro, Viale Europa, 88100 Catanzaro, Italy; (G.C.); (F.A.A.); (S.A.)
- Net4Science Academic Spin-Off, Campus “S. Venuta”, “Magna Græcia” University of Catanzaro, Viale Europa, 88100 Catanzaro, Italy
- Associazione CRISEA-Centro di Ricerca e Servizi Avanzati per l’Innovazione Rurale, Località Condoleo di Belcastro (CZ), 88050 Belcastro, Italy
| | - Francesca Alessandra Ambrosio
- Department of Health Sciences, Campus “S. Venuta”, “Magna Græcia” University of Catanzaro, Viale Europa, 88100 Catanzaro, Italy; (G.C.); (F.A.A.); (S.A.)
| | - Stefano Alcaro
- Department of Health Sciences, Campus “S. Venuta”, “Magna Græcia” University of Catanzaro, Viale Europa, 88100 Catanzaro, Italy; (G.C.); (F.A.A.); (S.A.)
- Net4Science Academic Spin-Off, Campus “S. Venuta”, “Magna Græcia” University of Catanzaro, Viale Europa, 88100 Catanzaro, Italy
- Associazione CRISEA-Centro di Ricerca e Servizi Avanzati per l’Innovazione Rurale, Località Condoleo di Belcastro (CZ), 88050 Belcastro, Italy
| | - Roberta Rigolio
- School of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy; (A.M.); (R.R.)
- Experimental Neurology Unit, University of Milano-Bicocca, 20900 Monza, Italy
| | - Arianna Cassetti
- CREA, Research Centre for Vegetable and Ornamental Crops, 18038 Sanremo, Italy;
| | - Mariarosaria Miloso
- School of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy; (A.M.); (R.R.)
- Experimental Neurology Unit, University of Milano-Bicocca, 20900 Monza, Italy
- Correspondence: (E.M.); (M.M.)
| | - Simona Collina
- Department of Drug Sciences, University of Pavia, 27100 Pavia, Italy;
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10
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Treatment of relapsed and refractory multiple myeloma: recommendations from the International Myeloma Working Group. Lancet Oncol 2021; 22:e105-e118. [PMID: 33662288 DOI: 10.1016/s1470-2045(20)30756-7] [Citation(s) in RCA: 126] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/07/2020] [Accepted: 12/14/2020] [Indexed: 12/13/2022]
Abstract
This Policy Review presents the International Myeloma Working Group's clinical practice recommendations for the treatment of relapsed and refractory multiple myeloma. Based on the results of phase 2 and phase 3 trials, these recommendations are proposed for the treatment of patients with relapsed and refractory disease who have received one previous line of therapy, and for patients with relapsed and refractory multiple myeloma who have received two or more previous lines of therapy. These recommendations integrate the issue of drug access in both low-income and middle-income countries and in high-income countries to help guide real-world practice and thus improve patient outcomes.
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Patel KK, Giri S, Parker TL, Bar N, Neparidze N, Huntington SF. Cost-Effectiveness of First-Line Versus Second-Line Use of Daratumumab in Older, Transplant-Ineligible Patients With Multiple Myeloma. J Clin Oncol 2021; 39:1119-1128. [PMID: 33411586 DOI: 10.1200/jco.20.01849] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The MAIA trial found that addition of daratumumab to lenalidomide and dexamethasone (DRd) significantly prolonged progression-free survival in transplant-ineligible patients with newly diagnosed multiple myeloma, compared with lenalidomide and dexamethasone alone (Rd). However, daratumumab is a costly treatment and is administered indefinitely until disease progression. Therefore, it is unclear whether it is cost-effective to use daratumumab in the first-line setting compared with reserving its use until later lines of therapy. METHODS We created a Markov model to compare healthcare costs and clinical outcomes of transplant-ineligible patients treated with daratumumab in the first-line setting compared with a strategy of reserving daratumumab until the second-line. We estimated transition probabilities from randomized trials using parametric survival modeling. Lifetime direct healthcare costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for first-line daratumumab versus second-line daratumumab from a US payer perspective. RESULTS First-line daratumumab was associated with an improvement of 0.52 QALYs and 0.66 discounted life-years compared with second-line daratumumab. While both treatment strategies were associated with considerable lifetime expenditures ($1,434,937 v $1,112,101 in US dollars), an incremental cost of $322,836 for first-line daratumumab led to an ICER of $618,018 per QALY. The cost of daratumumab would need to be decreased by 67% for first-line daratumumab to be cost-effective at a willingness-to-pay threshold of $150,000 per QALY. CONCLUSION Using daratumumab in the first-line setting for transplant-ineligible patients may not be cost-effective under current pricing. Delaying daratumumab until subsequent lines of therapy may be a reasonable strategy to limit healthcare costs without significantly compromising clinical outcomes. Mature overall survival data are necessary to more fully evaluate cost-effectiveness in this setting.
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Affiliation(s)
- Kishan K Patel
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT
| | - Smith Giri
- Department of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Terri L Parker
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT
| | - Noffar Bar
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT
| | - Natalia Neparidze
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT
| | - Scott F Huntington
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT.,Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
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Rajkumar SV. Multiple myeloma: 2020 update on diagnosis, risk-stratification and management. Am J Hematol 2020; 95:548-567. [PMID: 32212178 DOI: 10.1002/ajh.25791] [Citation(s) in RCA: 462] [Impact Index Per Article: 115.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/18/2020] [Indexed: 12/11/2022]
Abstract
DISEASE OVERVIEW Multiple myeloma accounts for approximately 10% of hematologic malignancies. DIAGNOSIS The diagnosis requires ≥10% clonal bone marrow plasma cells or a biopsy proven plasmacytoma plus evidence of one or more multiple myeloma defining events (MDE) namely CRAB (hypercalcemia, renal failure, anemia, or lytic bone lesions) features felt related to the plasma cell disorder, bone marrow clonal plasmacytosis ≥60%, serum involved/uninvolved free light chain (FLC) ratio ≥100 (provided involved FLC is ≥100 mg/L), or >1 focal lesion on magnetic resonance imaging (MRI). RISK STRATIFICATION The presence of del(17p), t(4;14), t(14;16), t(14;20), gain 1q, or p53 mutation is considered high-risk multiple myeloma. Presence of any two high risk factors is considered double-hit myeloma; three or more high risk factors is triple-hit myeloma. RISK-ADAPTED INITIAL THERAPY In transplant eligible patients, induction therapy consists of bortezomib, lenalidomide, dexamethasone (VRd) given for approximately 3-4 cycles followed by autologous stem cell transplantation (ASCT). In high-risk patients, daratumumab, bortezomib, lenalidomide, dexamethasone (Dara-VRd) is an alternative to VRd. Selected standard risk patients can get additional cycles of induction, and delay transplant until first relapse. Patients not candidates for transplant are typically treated with VRd for approximately 8-12 cycles followed by lenalidomide; alternatively these patients can be treated with daratumumab, lenalidomide, dexamethasone (DRd). MAINTENANCE THERAPY After ASCT, standard risk patients need lenalidomide maintenance, while bortezomib-based maintenance is needed for patients with high-risk myeloma. MANAGEMENT OF REFRACTORY DISEASE Most patients require a triplet regimen at relapse, with the choice of regimen varying with each successive relapse.
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13
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Roshal M. Measurable disease evaluation in patients with myeloma. Best Pract Res Clin Haematol 2020; 33:101154. [PMID: 32139019 DOI: 10.1016/j.beha.2020.101154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 01/30/2020] [Indexed: 01/09/2023]
Abstract
Recent years saw significant breakthroughs in treatment of multiple myeloma. Durable remissions are now seen in a significant proportion of patients with the previously uniformly incurable and progressive disease. Yet because of deep suppression of the neoplastic myeloma clones by the newer therapies, older disease monitoring techniques are insufficient to distinguish between the patients at high risk of imminent relapse and those in whom durable remission is expected. This review briefly describes prognostic and therapeutic implications of measurable disease (MRD) evaluation, explains why deep MRD evaluation is needed for patients without morphologic evidence of disease, and reviews the state of the art of evaluation of myeloma MRD by flow cytometry.
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Affiliation(s)
- Mikhail Roshal
- Hematopathology Service, Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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14
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Kumar S, Rajkumar SV. Surrogate endpoints in randomised controlled trials: a reality check. Lancet 2019; 394:281-283. [PMID: 31354129 DOI: 10.1016/s0140-6736(19)31711-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 06/13/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA
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15
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Kapoor P, Rajkumar SV. MAIA under the microscope - bringing trial design into focus. Nat Rev Clin Oncol 2019; 16:339-340. [PMID: 30850718 DOI: 10.1038/s41571-019-0198-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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16
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Moreau P, Zamagni E, Mateos MV. Treatment of patients with multiple myeloma progressing on frontline-therapy with lenalidomide. Blood Cancer J 2019; 9:38. [PMID: 30894516 PMCID: PMC6426995 DOI: 10.1038/s41408-019-0200-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/07/2019] [Accepted: 03/12/2019] [Indexed: 12/20/2022] Open
Abstract
Over the last years, there has been great progress in the treatment of multiple myeloma with many new agents and combinations having been approved and being now routinely incorporated into treatment strategies. As a result, patients are experiencing benefits in terms of survival and better tolerance. However, the multitude of treatment options also presents a challenge to select the best options tailored to the specific patient situation. Lenalidomide is increasingly being used as part of frontline therapy in newly diagnosed multiple myeloma. This agent is typically administered until disease progression. It is currently unclear, how to best manage patients, who relapse while receiving lenalidomide as part of their frontline treatment. We conducted a review to summarize the available evidence in this setting. Our summary shows that there are very few data from current trials testing new combinations based on carfilzomib, pomalidomide, or daratumumab that address this specific patient population. Our review is aimed to summarize the available evidence to assist treatment decision making and to raise awareness of this lack of data to encourage further analyses and the incorporation of sequencing questions in future trial designs.
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Abstract
Major advances have occurred in the treatment of multiple myeloma, including several new drugs that typically cost more than $100,000 per year. Although the gains in myeloma therapy improve overall survival considerably, they are available to only a fraction of the population of patients with myeloma in the world because of regulatory barriers and cost. Myeloma is an example of what is happening in cancer on a much larger scale. Many of the problems discussed call for a wider discussion across all cancers, but they are amplified in myeloma because of the need for multidrug regimens that combine three or more expensive new drugs for prolonged periods of time. In this article, the reasons for the high cost of cancer drugs and possible solutions are examined. The lack of correlation of value and price, the remarkable rise in prices of existing old medications over time, and the lack of access to lifesaving drugs across various countries are also discussed.
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BH3-mimetic toolkit guides the respective use of BCL2 and MCL1 BH3-mimetics in myeloma treatment. Blood 2018; 132:2656-2669. [PMID: 30309889 DOI: 10.1182/blood-2018-03-836718] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 09/28/2018] [Indexed: 02/07/2023] Open
Abstract
BH3 mimetics are promising drugs for hematologic malignancies that trigger cell death by promoting the release of proapoptotic BCL2 family members from antiapoptotic proteins. Multiple myeloma is considered to be a disease dependent mainly on MCL1 for survival, based mostly on studies using cell lines. We used a BH3-mimetic toolkit to study the dependency on BCL2, BCLXL, or MCL1 in malignant plasma cells from 60 patients. Dependencies were analyzed using an unbiased BH3 mimetics cell-death clustering by k-means. In the whole cohort of patients, BCL2 dependency was mostly found in the CCND1 subgroup (83%). Of note, MCL1 dependence significantly increased from 33% at diagnosis to 69% at relapse, suggesting a plasticity of the cellular dependency favoring MCL1 dependencies at relapse. In addition, 35% of overall patient samples showed codependencies on either BCL2/MCL1 or BCLXL/MCL1. Finally, we identified a group of patients not targeted by any of the BH3 mimetics, predominantly at diagnosis in patients not presenting the common recurrent translocations. Mechanistically, we demonstrated that BAK is crucial for cell death induced by MCL1 mimetic A1210477, according to the protection from cell death observed by BAK knock-down, as well as the complete and early disruption of MCL1/BAK complexes on A1210477 treatment. Interestingly, this complex was also dissociated in A1210477-resistant cells, but free BAK was simultaneously recaptured by BCLXL, supporting the role of BCLXL in A1210477 resistance. In conclusion, our study opens the way to rationally use venetoclax and/or MCL1 BH3 mimetics for clinical evaluation in myeloma at both diagnosis and relapse.
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Multiple myeloma: 2018 update on diagnosis, risk‐stratification, and management. Am J Hematol 2018; 93:981-1114. [PMID: 30400719 PMCID: PMC6223128 DOI: 10.1002/ajh.25117] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 04/17/2018] [Indexed: 12/22/2022]
Abstract
Disease overview Multiple myeloma accounts for approximately 10% of hematologic malignancies. Diagnosis The diagnosis requires ≥10% clonal bone marrow plasma cells or a biopsy proven plasmacytoma plus evidence of one or more multiple myeloma defining events (MDE): CRAB (hyperc alcemia, r enal failure, a nemia, or lytic b one lesions) features felt related to the plasma cell disorder, bone marrow clonal plasmacytosis ≥60%, serum involved/uninvolved free light chain (FLC) ratio ≥100 (provided involved FLC is ≥100 mg/L), or >1 focal lesion on magnetic resonance imaging. Risk stratification Patients with del(17p), t(14;16), and t(14;20) have high-risk multiple myeloma. Patients with t(4;14) translocation and gain(1q) have intermediate-risk. All others are considered standard-risk. Risk-adapted initial therapy Initial treatment consists of bortezomib, lenalidomide, dexamethasone (VRd). In high-risk patients, carfilzomib, lenalidomide, dexamethasone (KRd) is an alternative to VRd. In eligible patients, initial therapy is given for approximately 3–4 cycles followed by autologous stem cell transplantation (ASCT). Standard risk patients can opt for delayed ASCT at first relapse. Patients not candidates for transplant are treated with VRd for approximately 8–12 cycles followed by lenalidomide or lenalidomide plus dexamethasone. Maintenance therapy After ASCT, lenalidomide maintenance is recommended for standard risk patients, while maintenance with a bortezomib-based regimen is needed for patients with intermediate or high-risk disease. Management of refractory disease Most patients require a triplet regimen at relapse, with the choice of regimen varying with each successive relapse. Aggressive relapse with extramedullary plasmacytomas or plasma cell leukemia may require anthracycline containing combination chemotherapy regimens.
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Cost-effectiveness of Daratumumab-based Triplet Therapies in Patients With Relapsed or Refractory Multiple Myeloma. Clin Ther 2018; 40:1122-1139. [DOI: 10.1016/j.clinthera.2018.05.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 05/11/2018] [Accepted: 05/15/2018] [Indexed: 12/20/2022]
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Moreau P, Touzeau C. Global Approaches in Myeloma: Critical Trials That May Change Practice. Am Soc Clin Oncol Educ Book 2018; 38:656-661. [PMID: 30231332 DOI: 10.1200/edbk_200841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The treatment of multiple myeloma (MM) has changed dramatically in the past decade with the introduction of new drugs into therapeutic strategies both in the frontline and relapse settings. With the availability of at least six different classes of agents that can be combined in doublet, triplet, or even quadruplet regimens and used together with high-dose therapy and autologous stem cell transplantation, the choice of the optimal strategy at diagnosis and at relapse represents a challenge for physicians. Also problematic is the lack of trials addressing questions, such as sequencing or the duration of maintenance. This review will focus on the results of recent clinical trials both in the frontline and relapse settings that have induced changes in clinical practice and will discuss the impact of important ongoing trials. A specific section will discuss therapeutic strategies when new drugs are not available.
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Abstract
Abstract
At present, multiple classes of agents with distinct mechanisms of action are available for the treatment of patients with multiple myeloma (MM), including alkylators, steroids, immunomodulatory agents (IMiDs), proteasome inhibitors (PIs), histone deacetylase inhibitors (DACIs), and monoclonal antibodies (mAbs). Over the last 5 years, several new agents, such as the third-generation IMiD pomalidomide, the second-generation PIs carfilzomib and ixazomib, the DACI panobinostat, and 2 mAbs, elotuzumab and daratumumab, have been approved, incorporated into clinical guidelines, and have transformed our approach to the treatment of patients. These agents may be part of doublet or triplet combinations, or incorporated into intensive strategies with autologous stem cell transplantation. In this review, I discuss the different treatment options available today for the treatment of MM in frontline and relapse settings.
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Moreau P. New drugs in myeloma: beware of phase I trial results, beware of cost and demand for new trials. Leukemia 2017; 31:1843-1844. [DOI: 10.1038/leu.2017.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 05/23/2017] [Indexed: 11/09/2022]
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Zhang Y, Zhou L, Leng Y, Dai Y, Orlowski RZ, Grant S. Positive transcription elongation factor b (P-TEFb) is a therapeutic target in human multiple myeloma. Oncotarget 2017; 8:59476-59491. [PMID: 28938651 PMCID: PMC5601747 DOI: 10.18632/oncotarget.19761] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 07/03/2017] [Indexed: 02/05/2023] Open
Abstract
The role of the positive RNA Pol II regulator, P-TEFb (positive transcription elongation factor b), in maintenance of the anti-apoptotic protein Mcl-1 and bortezomib (btz) resistance was investigated in human multiple myeloma (MM) cells. Mcl-1 was up-regulated in all MM lines tested, including bortezomib-resistant lines, human MM xenograft mouse models, and primary CD138+ MM cells. Mcl-1 over-expression significantly reduced bortezomib lethality, indicating a functional role for Mcl-1 in bortezomib resistance. MM cell lines, primary MM specimens, and murine xenografts exhibited constitutive P-TEFb activation, manifested by high CTD (carboxy-terminal domain) S2 phosphorylation, associated with a) P-TEFb subunit up-regulation i.e., CDK9 (42 and 55 kDa isoforms) and cyclin T1; and b) marked CDK9 (42 kDa) T186 phosphorylation. In marked contrast, normal hematopoietic cells failed to exhibit up-regulation of p-CTD, CDK9, cyclin T1, or Mcl-1. CDK9 or cyclin T1 shRNA knock-down dramatically inhibited CTD S2 phosphorylation and down-regulated Mcl-1. Moreover, CRISPR-Cas CDK9 knock-out triggered apoptosis in MM cells and dramatically diminished cell growth. Pan-CDK e.g., dinaciclib or alvocidib and selective CDK9 inhibitors (CDK9i) recapitulated the effects of genetic P-TEFb disruption. CDK9 shRNA or CDK9 inhibitors significantly potentiated the susceptibility of MM cells, including bortezomib-resistant cells, to proteasome inhibitors. Analogously, CDK9 or cyclin T1 knock-down or CDK9 inhibitors markedly increased BH3-mimetic lethality in bortezomib-resistant cells. Finally, pan-CDK inhibition reduced human drug-naïve or bortezomib-resistant CD138+ cells and restored bone marrow architecture in vivo. Collectively, these findings implicate constitutive P-TEFb activation in high Mcl-1 maintenance in MM, and validate targeting the P-TEFb complex to circumvent bortezomib-resistance.
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Affiliation(s)
- Yu Zhang
- Division of Hematology/Oncology, Department of Medicine, Virginia Commonwealth University and The Massey Cancer Center, Richmond, VA, USA
| | - Liang Zhou
- Division of Hematology/Oncology, Department of Medicine, Virginia Commonwealth University and The Massey Cancer Center, Richmond, VA, USA
| | - Yun Leng
- Division of Hematology/Oncology, Department of Medicine, Virginia Commonwealth University and The Massey Cancer Center, Richmond, VA, USA.,Department of Hematology, Beijing Chaoyang Hospital of Capital Medical University, Beijing, China
| | - Yun Dai
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Robert Z Orlowski
- Department of Myeloma and Lymphoma, MD Anderson Cancer Center, Houston, TX, USA
| | - Steven Grant
- Division of Hematology/Oncology, Department of Medicine, Virginia Commonwealth University and The Massey Cancer Center, Richmond, VA, USA.,Virginia Institute of Molecular Medicine, Virginia Commonwealth University, Richmond, VA, USA.,Department of Biochemistry, Virginia Commonwealth University, Richmond, VA, USA.,Department of Pharmacology Virginia Commonwealth University, Richmond, VA, USA
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Esma F, Salvini M, Troia R, Boccadoro M, Larocca A, Pautasso C. Melphalan hydrochloride for the treatment of multiple myeloma. Expert Opin Pharmacother 2017; 18:1127-1136. [DOI: 10.1080/14656566.2017.1349102] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Fabrizio Esma
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Marco Salvini
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Rossella Troia
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Alessandra Larocca
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Chiara Pautasso
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
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Affiliation(s)
| | - Morie A Gertz
- a Division of Hematology , Mayo Clinic , Rochester , MN , USA
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Kapoor P, Rajkumar SV. Multiple myeloma in 2016: Fresh perspectives on treatment and moments of clarity. Nat Rev Clin Oncol 2017; 14:73-74. [PMID: 28071678 DOI: 10.1038/nrclinonc.2016.221] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Prashant Kapoor
- Division of Hematology, Mayo Clinic, 200 First Street South West, Rochester, Minnesota 55905, USA
| | - S Vincent Rajkumar
- Division of Hematology, Mayo Clinic, 200 First Street South West, Rochester, Minnesota 55905, USA
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Next-generation multiple myeloma treatment: a pharmacoeconomic perspective. Blood 2016; 128:2757-2764. [PMID: 27742709 DOI: 10.1182/blood-2016-09-692947] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 10/12/2016] [Indexed: 01/07/2023] Open
Abstract
Advances in the diagnosis and treatment of multiple myeloma have come at a rapid pace, especially with several new drugs entering the market in the last few years. However, access to and affordability of new treatments poses a major challenge, both in the United States and around the world. High costs of life-saving drugs are detrimental to both the personal finances of the individual patient, as well as society which must bear the increasing costs in terms of increased health insurance premiums, taxes, or both. The challenges are not unique to myeloma, but are commonly encountered in several other cancers as well. But to some extent these pharmacoeconomic concerns are amplified in myeloma due to the need for multidrug regimens that combine 2 or more expensive new drugs, continuous therapy, and the prolonged disease course in most patients. We examine current myeloma therapy from a pharmacoeconomic perspective, and discuss the costs involved. We outline the underlying reasons why cancer drugs are so expensive, the measures that are required to lower cost, and propose potential ways in which costs can be reduced while still delivering high-quality care.
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