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Leleu X, Hulin C, Lambert J, Bobin A, Perrot A, Karlin L, Roussel M, Montes L, Cherel B, Chalopin T, Slama B, Chretien ML, Laribi K, Dingremont C, Roul C, Mariette C, Rigaudeau S, Calmettes C, Dib M, Tiab M, Vincent L, Delaunay J, Santagostino A, Macro M, Bourgeois E, Orsini-Piocelle F, Gay J, Bareau B, Bigot N, Vergez F, Lebreton P, Tabrizi R, Waultier-Rascalou A, Frenzel L, Le Calloch R, Chalayer E, Braun T, Lachenal F, Corm S, Kennel C, Belkhir R, Bladé JS, Joly B, Richez-Olivier V, Gardeney H, Demarquette H, Robu-Cretu D, Garderet L, Newinger-Porte M, Kasmi A, Royer B, Decaux O, Arnulf B, Belhadj K, Touzeau C, Mohty M, Manier S, Moreau P, Avet-Loiseau H, Corre J, Facon T. Isatuximab, lenalidomide, dexamethasone and bortezomib in transplant-ineligible multiple myeloma: the randomized phase 3 BENEFIT trial. Nat Med 2024:10.1038/s41591-024-03050-2. [PMID: 38830994 DOI: 10.1038/s41591-024-03050-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 05/08/2024] [Indexed: 06/05/2024]
Abstract
CD38-targeting immunotherapy is approved in combination with lenalidomide and dexamethasone in patients with newly diagnosed multiple myeloma (NDMM) that are transplant ineligible (TI) and is considered the best standard of care (SOC). To improve current SOC, we evaluated the added value of weekly bortezomib (V) to isatuximab plus lenalidomide and dexamethasone (IsaRd versus Isa-VRd). This Intergroupe Francophone of Myeloma phase 3 study randomized 270 patients with NDMM that were TI, aged 65-79 years, to IsaRd versus Isa-VRd arms. The primary endpoint was a minimal residual disease (MRD) negativity rate at 10-5 by next-generation sequencing at 18 months from randomization. Key secondary endpoints included response rates, MRD assessment rates, survival and safety. The 18-month MRD negativity rates at 10-5 were reported in 35 patients (26%, 95% confidence interval (CI) 19-34) in IsaRd versus 71 (53%, 95% CI 44-61) in Isa-VRd (odds ratio for MRD negativity 3.16, 95% CI 1.89-5.28, P < 0.0001). The MRD benefit was consistent across subgroups at 10-5 and 10-6, and was already observed at month 12. The proportion of patients with complete response or better at 18 months was higher with Isa-VRd (58% versus 33%; P < 0.0001), as was the proportion of MRD negativity and complete response or better (37% versus 17%; P = 0.0003). At a median follow-up of 23.5 months, no difference was observed for survival times (immature data). The addition of weekly bortezomib did not significantly affect the relative dose intensity of IsaRd. Isa-VRd significantly increased MRD endpoints, including the 18-month negativity rate at 10-5, the primary endpoint, compared with IsaRd. This study proposes Isa-VRd as a new SOC for patients with NDMM that are TI. ClinicalTrials.gov identifier: NCT04751877 .
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Affiliation(s)
- Xavier Leleu
- Hematology, CIC 1082, U1313, CHU, University, Poitiers, France.
| | | | | | - Arthur Bobin
- Hematology, CIC 1082, U1313, CHU, University, Poitiers, France
| | - Aurore Perrot
- University Hospital, iUCT Oncopole, Toulouse, France
| | | | | | | | | | | | | | - Marie-Lorraine Chretien
- Hematology, University Hospital, Inserm U1231, University of Burgundy Franche-Comté, Dijon, France
| | | | | | | | | | | | | | | | - Mourad Tiab
- Hematology, CH Departemental de La Roche-sur-Yon, La Roche-sur-Yon, France
| | | | | | | | | | | | | | - Julie Gay
- Hematology, CH de la côte basque, Bayonne, France
| | - Benoit Bareau
- Hematology, Les Hôpitaux Privés Rennais Cesson Sévigné - Vivalto Santé, Cesson Sévigné, France
| | | | - François Vergez
- Unit for Genomics in Myeloma, iUCT Oncopole, Toulouse, France
| | | | - Reza Tabrizi
- Hematology, CHI de Mont De Marsan, Mont-de-Marsan, France
| | | | | | - Ronan Le Calloch
- Hematology, CH de Cornouaille, Quimper Concarneau, Concarneau, France
| | | | | | | | - Selim Corm
- Medipole de Savoie, Challes les Eaux, France
| | | | - Rakiba Belkhir
- Rheumatology, Hopital Bicetre, AP-HP, Universite Paris Saclay, Paris, France
| | | | | | | | - Helene Gardeney
- Hematology, CIC 1082, U1313, CHU, University, Poitiers, France
| | | | | | | | | | | | | | - Olivier Decaux
- Hematology, UMR U1236, University Hospital, Rennes, France
| | | | | | | | - Mohamad Mohty
- Hematology, Sorbonne University, Saint-Antoine Hôpital (AP-HP), UMRs 938, Paris, France
| | - Salomon Manier
- Hematology, University Hospital Inserm U-S1277 and CNRS UMR9020, Lille, France
| | | | | | - Jill Corre
- Unit for Genomics in Myeloma, iUCT Oncopole, Toulouse, France
| | - Thierry Facon
- Hematology, University Hospital Inserm U-S1277 and CNRS UMR9020, Lille, France
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Hoff FW, Banerjee R, Khan AM, McCaughan G, Wang B, Wang X, Roose J, Anderson LD, Cowan AJ, Rajkumar SV, Kaur G. Once-weekly versus twice-weekly bortezomib in newly diagnosed multiple myeloma: a real-world analysis. Blood Cancer J 2024; 14:52. [PMID: 38519476 PMCID: PMC10959949 DOI: 10.1038/s41408-024-01034-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 02/29/2024] [Accepted: 03/07/2024] [Indexed: 03/25/2024] Open
Abstract
Induction regimens for multiple myeloma (MM) commonly include bortezomib, which has typically been administered twice weekly despite studies demonstrating comparable efficacy and less peripheral neuropathy (PN) with once-weekly bortezomib. We aimed to analyze the real-world prevalence and efficacy of once-weekly versus twice-weekly bortezomib regimens in newly diagnosed MM. We analyzed 2497 US patients aged 18-70 years treated with commercial first-line bortezomib using nationwide Flatiron Health electronic health record-derived data, including 910 (36.4%) patients who received twice-weekly and 1522 (63.2%) who received once-weekly bortezomib. Once-weekly bortezomib use increased over time, from 57.7% in 2017 to 73.1% in 2022. Multivariate analysis identified worsened performance status and more recent year of diagnosis with higher odds of receiving once-weekly bortezomib. Real-world progression-free survival (median 37.2 months with once-weekly versus 39.6 months with twice-weekly, p = 0.906) and overall survival (medians not reached in either cohort, p = 0.800) were comparable. PN rates were higher in patients receiving twice-weekly bortezomib (34.7% versus 18.5%, p < 0.001). In conclusion, once-weekly bortezomib is clearly associated with similar efficacy and fewer toxicities compared to twice-weekly bortezomib. Our findings support once-weekly bortezomib as a standard-of-care regimen for newly diagnosed patients with MM.
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Affiliation(s)
- Fieke W Hoff
- Myeloma, Waldenstrom's, and Amyloidosis Program, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Rahul Banerjee
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Adeel M Khan
- Myeloma, Waldenstrom's, and Amyloidosis Program, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Georgia McCaughan
- Department of Haematology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Bo Wang
- Willamette Valley Cancer Institute, Eugene, OR, USA
| | | | | | - Larry D Anderson
- Myeloma, Waldenstrom's, and Amyloidosis Program, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Andrew J Cowan
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | | | - Gurbakhash Kaur
- Myeloma, Waldenstrom's, and Amyloidosis Program, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA.
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3
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Lee JY, Park SS, Jeon YW, Shin SH, Yahng SA, Min CK. Comparisons of efficacy between frontline treatment with bortezomib-melphalan-prednisone and lenalidomide-dexamethasone for transplant-ineligible multiple myeloma: a multicenter real-world based registry report, CAREMM-2102 study. J Cancer Res Clin Oncol 2023; 149:11907-11918. [PMID: 37418057 DOI: 10.1007/s00432-023-04993-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/15/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Bortezomib-melphalan-prednisone (VMP) and lenalidomide-dexamethasone (Rd) remain the standard treatments for transplant-ineligible patients with newly diagnosed multiple myeloma (NDMM). This study aimed to compare real-world benefits between the two regimens. We also were interested in exploring efficacy according to subsequent therapy following VMP or Rd. METHODS A total of 559 NDMM patients treated with VMP (n = 443, 79.2%) or Rd (n = 116, 20.8%) was recruited retrospectively from a multicenter database. RESULTS Rd provided more benefits than VMP-overall response rate: 92.2 vs. 81.8%, p = 0.018; median progression-free survival (PFS): 20.0 vs. 14.5 months, p <0.001; second PFS (PFS2): 43.9 vs. 36.9 months, p = 0.012; overall survival (OS): 100.1 vs. 85.0 months, p = 0.017. Multivariable analysis revealed significant benefits of Rd over VMP, with hazard ratios of 0.722, 0.627, and 0.586 for PFS, PFS2, and OS, respectively. In propensity score-matched cohorts with matched VMP (n = 201) and Rd (n = 67) arms to balance baseline characteristics, Rd still showed significantly better outcomes for PFS, PFS2, and OS than VMP. Following VMP failure, triplet therapy showed significant benefits for response and PFS2; after Rd failure, PFS2 with carfilzomib-dexamethasone was significantly better than bortezomib-based doublet treatment. CONCLUSION These real-world findings may assist with better selection between VMP and Rd as well as subsequent therapy for NDMM.
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Affiliation(s)
- Jung Yeon Lee
- Department of Hematology, Seoul St. Mary's Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Soo Park
- Department of Hematology, Seoul St. Mary's Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young-Woo Jeon
- Department of Hematology, Yeoido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung-Hwan Shin
- Department of Hematology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung-Ah Yahng
- Department of Hematology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Republic of Korea.
| | - Chang-Ki Min
- Department of Hematology, Seoul St. Mary's Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Nisar S, Ur Rehman A, Khan A, Wahab N, Shah SS. Immunoglobulin E (IgE)-Mediated Multiple Myeloma Presenting as Pleural Effusion. Cureus 2023; 15:e45802. [PMID: 37876394 PMCID: PMC10591024 DOI: 10.7759/cureus.45802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 10/26/2023] Open
Abstract
Multiple myeloma (MM) is a disease characterized by the abnormal production of plasma cells. These plasma cells have the property to produce immunoglobulins (Ig), on the basis of which MM can be classified. Immunoglobulin G is responsible for most of the cases, while IgE mediates the rarest form of MM. Since the first case was reported in 1967, knowledge regarding IgE-mediated MM is based on individual case reports. Based on the information available, it is thought that IgE-mediated MM presents clinically with the involvement of renal, bone, and hematological symptoms, which are the same as any other myeloma. However, the MM rarely involves the pleura, leading to malignant pleural effusion. We present a case of IgE-mediated MM with a unique feature of pleural effusion. The patient presented with constitutional symptoms of MM, which were followed by lab investigations revealing low hemoglobin, hypercalcemia, and high creatinine levels. An incidental computed tomography angiography (CTA) revealed lytic lesions in the spine. This was followed by skull and chest X-rays as part of the workup to determine the extent of the disease. It revealed further lytic lesions in the skull, humerus, and scapula, along with pleural effusion. This led to the suspicion of MM, which was ultimately confirmed by serum protein electrophoresis and a bone marrow biopsy. The patient was started on a triple regimen of bortezomib, thalidomide, and dexamethasone, which led to substantial improvement in his symptoms.
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Affiliation(s)
- Sarah Nisar
- Internal Medicine, Khyber Medical College, Peshawar, PAK
| | | | - Adil Khan
- Internal Medicine, Khyber Medical College, Peshawar, PAK
| | - Noor Wahab
- Medicine, Combined Military Hospital, Abbotabad, PAK
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Costa BA, Mouhieddine TH, Ortiz RJ, Richter J. Revisiting the Role of Alkylating Agents in Multiple Myeloma: Up-to-Date Evidence and Future Perspectives. Crit Rev Oncol Hematol 2023; 187:104040. [PMID: 37244325 DOI: 10.1016/j.critrevonc.2023.104040] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 05/29/2023] Open
Abstract
From the 1960s to the early 2000s, alkylating agents (e.g., melphalan, cyclophosphamide, and bendamustine) remained a key component of standard therapy for newly-diagnosed or relapsed/refractory multiple myeloma (MM). Later on, their associated toxicities (including second primary malignancies) and the unprecedented efficacy of novel therapies have led clinicians to increasingly consider alkylator-free approaches. Meanwhile, new alkylating agents (e.g., melflufen) and new applications of old alkylators (e.g., lymphodepletion before chimeric antigen receptor T-cell [CAR-T] therapy) have emerged in recent years. Given the expanding use of antigen-directed modalities (e.g., monoclonal antibodies, bispecific antibodies, and CAR-T therapy), this review explores the current and future role of alkylating agents in different treatment settings (e.g., induction, consolidation, stem cell mobilization, pre-transplant conditioning, salvage, bridging, and lymphodepleting chemotherapy) to ellucidate the role of alkylator-based regimens in modern-day MM management.
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Affiliation(s)
- Bruno Almeida Costa
- Department of Medicine, Mount Sinai Morningside and West, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tarek H Mouhieddine
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ricardo J Ortiz
- Department of Medicine, Mount Sinai Morningside and West, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua Richter
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Burgos L, Tamariz-Amador LE, Puig N, Cedena MT, Guerrero C, Jelínek T, Johnson S, Milani P, Cordon L, Perez JJ, Lasa M, Termini R, Oriol A, Hernandez MT, Palomera L, Martinez-Martinez R, de la Rubia J, de Arriba F, Rios R, Gonzalez ME, Gironella M, Cabañas V, Casanova M, Krsnik I, Perez-Montaña A, González-Calle V, Rodriguez-Otero P, Maisnar V, Hajek R, Van Rhee F, Jimenez-Zepeda V, Palladini G, Merlini G, Orfao A, de la Cruz J, Martinez-Lopez J, Lahuerta JJ, Rosiñol L, Blade J, Mateos MV, San-Miguel JF, Paiva B. Definition and Clinical Significance of the Monoclonal Gammopathy of Undetermined Significance-Like Phenotype in Patients With Monoclonal Gammopathies. J Clin Oncol 2023; 41:3019-3031. [PMID: 36930848 DOI: 10.1200/jco.22.01916] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
PURPOSE The existence of patients with multiple myeloma (MM) and light-chain (AL) amyloidosis who present with a monoclonal gammopathy of undetermined significance (MGUS)-like phenotype has been hypothesized, but methods to identify this subgroup are not standardized and its clinical significance is not properly validated. PATIENTS AND METHODS An algorithm to identify patients having MGUS-like phenotype was developed on the basis of the percentages of total bone marrow (BM) plasma cells (PC) and of clonal PC within the BM PC compartment, determined at diagnosis using flow cytometry in 548 patients with MGUS and 2,011 patients with active MM. The clinical significance of the algorithm was tested and validated in 488 patients with smoldering MM, 3,870 patients with active MM and 211 patients with AL amyloidosis. RESULTS Patients with smoldering MM with MGUS-like phenotype showed significantly lower rates of disease progression (4.5% and 0% at 2 years in two independent series). There were no statistically significant differences in time to progression between treatment versus observation in these patients. In active newly diagnosed MM, MGUS-like phenotype retained independent prognostic value in multivariate analyses of progression-free survival (PFS; hazard ratio [HR], 0.49; P = .001) and overall survival (OS; HR, 0.56; P = .039), together with International Staging System, lactate dehydrogenase, cytogenetic risk, transplant eligibility, and complete remission status. Transplant-eligible patients with active MM with MGUS-like phenotype showed PFS and OS rates at 5 years of 79% and 96%, respectively. In this subgroup, there were no differences in PFS and OS according to complete remission and measurable residual disease status. Application of the algorithm in two independent series of patients with AL predicted for different survival. CONCLUSION We developed an open-access algorithm for the identification of MGUS-like patients with distinct clinical outcomes. This phenotypic classification could become part of the diagnostic workup of MM and AL amyloidosis.
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Affiliation(s)
- Leire Burgos
- Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Universidad de Navarra, CCUN, IDISNA, CIBERONC, Pamplona, Spain
| | - Luis-Esteban Tamariz-Amador
- Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Universidad de Navarra, CCUN, IDISNA, CIBERONC, Pamplona, Spain
| | - Noemi Puig
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | - Maria-Teresa Cedena
- Hematology Department, Hospital Universitario 12 de Octubre, CIBERONC, Instituto de Investigación IMAS12, Madrid, Spain
| | - Camila Guerrero
- Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Universidad de Navarra, CCUN, IDISNA, CIBERONC, Pamplona, Spain
| | - Tomas Jelínek
- Department of Haematooncology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Sarah Johnson
- Myeloma Center/Division of Hematology Oncology/Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Paolo Milani
- Department of Molecular Medicine, University of Pavia and Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Jose J Perez
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | - Marta Lasa
- Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Universidad de Navarra, CCUN, IDISNA, CIBERONC, Pamplona, Spain
| | - Rosalinda Termini
- Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Universidad de Navarra, CCUN, IDISNA, CIBERONC, Pamplona, Spain
| | - Albert Oriol
- Institut Català d'Oncologia and Institut Josep Carreras, Hospital Germans Trias i Pujol, Barcelona, Spain
| | | | - Luis Palomera
- Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | | | | | - Felipe de Arriba
- Hospital Morales Meseguer, IMIB-Arrixaca, Universidad de Murcia, Murcia, Spain
| | - Rafael Rios
- Hospital Universitario Puerta de Hierro, Hospital, Madrid, Spain
| | | | - Mercedes Gironella
- Department of Hematology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Valentin Cabañas
- Hospital Clínico Universitario Virgen de la Arrixaca. IMIB-Arrixaca. University of Murcia, Murcia, Spain
| | - Maria Casanova
- Hematology Department, Hospital Costa del Sol Marbella, Marbella, Spain
| | - Isabel Krsnik
- Hospital Universitario Puerta de Hierro, Hospital, Madrid, Spain
| | | | - Verónica González-Calle
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | - Paula Rodriguez-Otero
- Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Universidad de Navarra, CCUN, IDISNA, CIBERONC, Pamplona, Spain
| | - Vladimir Maisnar
- 4th Department of Medicine-Haematology, Charles University Hospital, Hradec Králové, Czech Republic
| | - Roman Hajek
- Department of Haematooncology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Fritz Van Rhee
- Myeloma Center/Division of Hematology Oncology/Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Victor Jimenez-Zepeda
- Tom Baker Cancer Center, Department of Hematology, University of Calgary, Calgary, AB, Canada
| | - Giovanni Palladini
- Department of Molecular Medicine, University of Pavia and Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giampaolo Merlini
- Department of Molecular Medicine, University of Pavia and Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alberto Orfao
- Hospital Universitario de Salamanca (HUSAL), IBSAL, Cancer Research Center (IBMCC, USAL-CSIC), Department of Medicine and Cytometry Service, University of Salamanca, CIBERONC, Salamanca, Spain
| | - Javier de la Cruz
- Hematology Department, Hospital Universitario 12 de Octubre, CIBERONC, Instituto de Investigación IMAS12, Madrid, Spain
| | - Joaquin Martinez-Lopez
- Hematology Department, Hospital Universitario 12 de Octubre, CIBERONC, Instituto de Investigación IMAS12, Madrid, Spain
| | - Juan-Jose Lahuerta
- Hematology Department, Hospital Universitario 12 de Octubre, CIBERONC, Instituto de Investigación IMAS12, Madrid, Spain
| | - Laura Rosiñol
- Amyloidosis and Myeloma Unit. Department of Hematology. Hospital Clínic de Barcelona. IDIBAPS., Barcelona, Spain
| | - Joan Blade
- Amyloidosis and Myeloma Unit. Department of Hematology. Hospital Clínic de Barcelona. IDIBAPS., Barcelona, Spain
| | - Maria-Victoria Mateos
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | - Jesus F San-Miguel
- Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Universidad de Navarra, CCUN, IDISNA, CIBERONC, Pamplona, Spain
| | - Bruno Paiva
- Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Universidad de Navarra, CCUN, IDISNA, CIBERONC, Pamplona, Spain
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Ficek J, Kalaitzaki E, Yuan SS, Tosolini A, Du L, Kremer BE, Davy K, Zhou H, Chen TT. Association of Minimal Residual Disease Negativity Rates With Progression Free Survival in Frontline Therapy Trials for Newly Diagnosed Multiple Myeloma: A Meta-analysis. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:e213-e221. [PMID: 36907767 DOI: 10.1016/j.clml.2023.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 02/25/2023]
Abstract
Current frontline therapies for newly diagnosed multiple myeloma patients have significantly prolonged progression-free survival (PFS). This has led to interest in minimal residual disease negativity (MRDng) as an efficacy-response biomarker and possible surrogate endpoint. A meta-analysis was conducted to explore the surrogacy of MRD for PFS and quantify the relationship between MRDng rates and PFS at the trial level. A systematic search was conducted on phase II and III trials reporting MRDng rates along with median PFS (mPFS) or PFS hazard ratios (HR). Weighted linear regressions were conducted relating mPFS to MRDng rates, and relating PFS HRs to either odds ratios (OR) or rate differences (RD) for MRDng in comparative trials. A total of 14 trials were available for the mPFS analysis. log(MRDng rate) was moderately associated with log (mPFS), with a slope of β = 0.37 (95% CI, 0.26-0.48) and R2 = 0.62. A total of 13 trials were available for the PFS HR analysis. Treatment effects on MRDng rates were correlated with the corresponding effects on PFS: log (PFS HR) and log (MRDng OR) had a moderate association with β = -0.36 (95% CI, -0.56 to -0.17) and R2 = 0.53 (95% CI, 0.21-0.77); log (PFS HR) and the MRDng RD had a stronger association with slope β = -0.03 (95% CI, -0.04 to -0.02) and R2 = 0.67 (95% CI, 0.31 to 0.86). MRDng rates moderately associate with PFS outcomes. MRDng RDs are more strongly associated with HRs than MRDng ORs, with evidence suggestive of potential surrogacy.
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Affiliation(s)
| | | | | | | | - Ling Du
- Oncology Experimental Medicine Unit, GSK, Waltham, MA
| | | | | | - Helen Zhou
- Oncology Statistics, GSK, Collegeville, PA
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Puła A, Robak P, Jarych D, Mikulski D, Misiewicz M, Drozdz I, Fendler W, Szemraj J, Robak T. The Relationship between Serum miRNAs and Early Mortality in Multiple Myeloma Patients Treated with Bortezomib-Based Regimens. Int J Mol Sci 2023; 24:ijms24032938. [PMID: 36769265 PMCID: PMC9917942 DOI: 10.3390/ijms24032938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/28/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
Multiple myeloma (MM) is a hematological malignancy characterized by the clonal proliferation of plasma cells in the bone marrow (BM) microenvironment. Despite the progress made in treatment, some MM patients still die within the first year of diagnosis. Numerous studies investigating microRNA (miRNA) expression patterns suggest they may be good prognostic markers. The primary aim of this study was to analyze the expression of selected miRNAs in the serum of MM patients who were later treated with bortezomib-based regimens, and to determine their potential to predict early mortality. The study was conducted in 70 prospectively recruited patients with newly diagnosed MM admitted to the Department of Hematology of the Copernicus Memorial Hospital, Lodz (Poland) between 2017 and 2021. Among them, 17 patients experienced death within 12 months of diagnosis. The expression of 31 selected miRNAs was determined using a miRCURY LNA miRNA Custom PCR Panel. The obtained clinical data included patient characteristics on diagnosis, treatment regimen, response to treatment, and follow-up. Differential expression analysis found two miRNAs to be significantly downregulated in the early mortality group: hsa-miR-328-3p (fold change-FC: 0.72, p = 0.0342) and hsa-miR-409-3p (FC: 0.49, p = 0.0357). Univariate and multivariate logistic regression analyses were performed to assess the early mortality rate. The final model consisted of hsa-miR-409-3p, hsa-miR-328-3p, age, and R-ISS 3. It yielded an area under the curve (AUC) of 0.863 (95%CI: 0.761-0.965) with 88.2% sensitivity and 77.5% specificity. Further external validation of our model is needed to confirm its clinical value.
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Affiliation(s)
- Anna Puła
- Department of Hematology, Medical University of Lodz, 93-510 Lodz, Poland
- Department of Hematooncology, Copernicus Memorial Hospital, 93-510 Lodz, Poland
| | - Paweł Robak
- Department of Hematooncology, Copernicus Memorial Hospital, 93-510 Lodz, Poland
- Department of Experimental Hematology, Medical University of Lodz, 93-510 Lodz, Poland
| | - Dariusz Jarych
- Laboratory of Virology, Institute of Medical Biology, Polish Academy of Sciences, 93-232 Lodz, Poland
| | - Damian Mikulski
- Department of Hematooncology, Copernicus Memorial Hospital, 93-510 Lodz, Poland
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, 92-215 Lodz, Poland
| | | | - Izabela Drozdz
- Department of Clinical Genetics, Medical University of Lodz, 92-213 Lodz, Poland
| | - Wojciech Fendler
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, 92-215 Lodz, Poland
| | - Janusz Szemraj
- Department of Medical Biochemistry, Medical University of Lodz, 92-215 Lodz, Poland
| | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz, 93-510 Lodz, Poland
- Department of General Hematology, Copernicus Memorial Hospital, 93-510 Lodz, Poland
- Correspondence:
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9
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Suzuki T, Terada M, Machida R, Kataoka T, Ito Y, Kataoka K, Maruyama D, Nagai H. Randomized phase III study of daratumumab versus bortezomib plus daratumumab as maintenance therapy after D-MPB for transplant-ineligible patients with untreated multiple myeloma (JCOG1911, B-DASH study). Jpn J Clin Oncol 2022. [DOI: 10.1093/jjco/hyac198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Abstract
Daratumumab, melphalan, prednisolone and bortezomib followed by daratumumab maintenance is a standard regimen for transplant-ineligible newly diagnosed multiple myeloma. A large-scale clinical trial demonstrated that progression-free survival declined more sharply during the maintenance phase than during the daratumumab, melphalan, prednisolone and bortezomib induction phase, which suggests the necessity of reinforcing maintenance therapy. This randomized phase III trial aims to confirm the superiority of daratumumab plus bortezomib to daratumumab as maintenance therapy in terms of progression-free survival for transplant-ineligible newly diagnosed multiple myeloma (JCOG1911, B-DASH). First registration (222 patients, within 5 years) was before daratumumab, melphalan, prednisolone and bortezomib administration; those who responded to daratumumab, melphalan, prednisolone and bortezomib were included in the second registration. They were randomized to the daratumumab or daratumumab plus bortezomib maintenance arm. This trial is registered in the Japan Registry for Clinical Trials as jRCT031200320 (https://jrct.niph.go.jp/). An ancillary study examining the association of genetic alterations in myeloma cells with prognosis and drug resistance, using next-generation sequencing, is ongoing.
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Affiliation(s)
- Tomotaka Suzuki
- Department of Hematology and Oncology, Nagoya City University Graduate School of Medical Science , Nagoya , Japan
| | - Mitsumi Terada
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center Hospital , Tokyo , Japan
| | - Ryunosuke Machida
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center Hospital , Tokyo , Japan
| | - Tomoko Kataoka
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center Hospital , Tokyo , Japan
| | - Yuta Ito
- Division of Molecular Oncology, National Cancer Center Research Institute , Tokyo , Japan
| | - Keisuke Kataoka
- Division of Molecular Oncology, National Cancer Center Research Institute , Tokyo , Japan
- Division of Hematology Department of Medicine, Keio University School of Medicine , Tokyo , Japan
| | - Dai Maruyama
- Department of Hematology Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research , Tokyo , Japan
| | - Hirokazu Nagai
- Department of Hematology and Oncology, National Hospital Organization Nagoya Medical Center , Nagoya , Japan
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10
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Costello CL. Newly diagnosed multiple myeloma: making sense of the menu. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:539-550. [PMID: 36485145 PMCID: PMC9820388 DOI: 10.1182/hematology.2022000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The development of new drugs and subsequent novel combinations for the treatment of newly diagnosed multiple myeloma (NDMM) has resulted in a plethora of treatment options that can make the choice of initial induction therapy a challenge. A greater understanding of both patient- and disease-specific factors can provide a personalized approach to help design a treatment course. Historically, the choice of an induction regimen has been tethered to an initial impression of transplant eligibility at the time of diagnosis. As more effective and better-tolerated induction regimens have emerged, there has been increasing overlap in the induction strategies used for all patients with NDMM, which increasingly provide the ultimate goal of deep and durable remissions. The current treatment options and strategies for the management of NDMM are evaluated using the best available data to provide a rationale for these decisions.
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Affiliation(s)
- Caitlin L. Costello
- Correspondence Caitlin L. Costello, UCSD, 3855 Health Sciences Drive, MC 0960, La Jolla, CA 92093, USA; e-mail:
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11
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D'Agostino M, Cairns DA, Lahuerta JJ, Wester R, Bertsch U, Waage A, Zamagni E, Mateos MV, Dall'Olio D, van de Donk NWCJ, Jackson G, Rocchi S, Salwender H, Bladé Creixenti J, van der Holt B, Castellani G, Bonello F, Capra A, Mai EK, Dürig J, Gay F, Zweegman S, Cavo M, Kaiser MF, Goldschmidt H, Hernández Rivas JM, Larocca A, Cook G, San-Miguel JF, Boccadoro M, Sonneveld P. Second Revision of the International Staging System (R2-ISS) for Overall Survival in Multiple Myeloma: A European Myeloma Network (EMN) Report Within the HARMONY Project. J Clin Oncol 2022; 40:3406-3418. [PMID: 35605179 DOI: 10.1200/jco.21.02614] [Citation(s) in RCA: 116] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Patients with newly diagnosed multiple myeloma (NDMM) show heterogeneous outcomes, and approximately 60% of them are at intermediate-risk according to the Revised International Staging system (R-ISS), the standard-of-care risk stratification model. Moreover, chromosome 1q gain/amplification (1q+) recently proved to be a poor prognostic factor. In this study, we revised the R-ISS by analyzing the additive value of each single risk feature, including 1q+. PATIENTS AND METHODS The European Myeloma Network, within the HARMONY project, collected individual data from 10,843 patients with NDMM enrolled in 16 clinical trials. An additive scoring system on the basis of top features predicting progression-free survival (PFS) and overall survival (OS) was developed and validated. RESULTS In the training set (N = 7,072), at a median follow-up of 75 months, ISS, del(17p), lactate dehydrogenase, t(4;14), and 1q+ had the highest impact on PFS and OS. These variables were all simultaneously present in 2,226 patients. A value was assigned to each risk feature according to their OS impact (ISS-III 1.5, ISS-II 1, del(17p) 1, high lactate dehydrogenase 1, and 1q+ 0.5 points). Patients were stratified into four risk groups according to the total additive score: low (Second Revision of the International Staging System [R2-ISS]-I, 19.2%, 0 points), low-intermediate (II, 30.8%, 0.5-1 points), intermediate-high (III, 41.2%, 1.5-2.5 points), high (IV, 8.8%, 3-5 points). Median OS was not reached versus 109.2 versus 68.5 versus 37.9 months, and median PFS was 68 versus 45.5 versus 30.2 versus 19.9 months, respectively. The score was validated in an independent validation set (N = 3,771, of whom 1,214 were with complete data to calculate R2-ISS) maintaining its prognostic value. CONCLUSION The R2-ISS is a simple prognostic staging system allowing a better stratification of patients with intermediate-risk NDMM. The additive nature of this score fosters its future implementation with new prognostic variables.
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Affiliation(s)
- Mattia D'Agostino
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - David A Cairns
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Juan José Lahuerta
- Instituto de Investigación del Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ruth Wester
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Uta Bertsch
- University Hospital Heidelberg, Internal Medicine V and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Anders Waage
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Elena Zamagni
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli," Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - María-Victoria Mateos
- Complejo Asistencial Universitario de Salamanca/IBSAL/CIC/Ciberonc, Salamanca, Spain
| | - Daniele Dall'Olio
- Dipartimento di Fisica e Astronomia, Università di Bologna, Bologna, Italy
| | - Niels W C J van de Donk
- Department of Hematology, Amsterdam UMC, Cancer Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Graham Jackson
- University of Newcastle upon Tyne, Newcastle upon Tyne, United Kingdom
| | - Serena Rocchi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli," Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Hans Salwender
- Asklepios Tumorzentrum Hamburg, AK Altona and AK St Georg, Hamburg, Germany
| | | | - Bronno van der Holt
- HOVON Data Center, Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Gastone Castellani
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Francesca Bonello
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Andrea Capra
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Elias K Mai
- University Hospital Heidelberg, Internal Medicine V and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Jan Dürig
- Department of Hematology, University Clinic Essen, Essen, Germany
| | - Francesca Gay
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Sonja Zweegman
- Department of Hematology, Amsterdam UMC, Cancer Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Michele Cavo
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli," Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Martin F Kaiser
- The Institute of Cancer Research, London, United Kingdom and The Royal Marsden Hospital, London, United Kingdom
| | - Hartmut Goldschmidt
- University Hospital Heidelberg, Internal Medicine V and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Jesús María Hernández Rivas
- Department of Medicine, University of Salamanca, Institute of Biomedical Research of Salamanca (IBSAL), University of Salamanca-Cancer Research Center of Salamanca (IBMCC, USAL-CSIG). Hematology Department, Hospital Universitario de Salamanca (CAUSA/IBSAL), Salamanca, Spain
| | - Alessandra Larocca
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Gordon Cook
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Jesús F San-Miguel
- Clínica Universidad de Navarra, CIMA, IDISNA, CIBER-ONC (CB16/12/00369), Pamplona, Spain
| | - Mario Boccadoro
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Pieter Sonneveld
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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12
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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 DOI: 10.1002/ajh.26590] [Citation(s) in RCA: 220] [Impact Index Per Article: 110.0] [Reference Citation Analysis] [Abstract] [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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13
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Encinas C, Hernandez-Rivas JÁ, Oriol A, Rosiñol L, Blanchard MJ, Bellón JM, García-Sanz R, de la Rubia J, de la Guía AL, Jímenez-Ubieto A, Jarque I, Iñigo B, Dourdil V, de Arriba F, Pérez-Ávila CC, Gonzalez Y, Hernández MT, Bargay J, Granell M, Rodríguez-Otero P, Silvent M, Cabrera C, Rios R, Alegre A, Gironella M, Gonzalez MS, Sureda A, Sampol A, Ocio EM, Krsnik I, García A, García-Mateo A, Soler JA, Martín J, Arguiñano JM, Mateos MV, Bladé J, San-Miguel JF, Lahuerta JJ, Martínez-López J. A simple score to predict early severe infections in patients with newly diagnosed multiple myeloma. Blood Cancer J 2022; 12:68. [PMID: 35440057 PMCID: PMC9018751 DOI: 10.1038/s41408-022-00652-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/21/2022] [Accepted: 03/21/2022] [Indexed: 12/30/2022] Open
Abstract
Infections remain a common complication in patients with multiple myeloma (MM) and are associated with morbidity and mortality. A risk score to predict the probability of early severe infection could help to identify the patients that would benefit from preventive measures. We undertook a post hoc analysis of infections in four clinical trials from the Spanish Myeloma Group, involving a total of 1347 patients (847 transplant candidates). Regarding the GEM2010 > 65 trial, antibiotic prophylaxis was mandatory, so we excluded it from the final analysis. The incidence of severe infection episodes within the first 6 months was 13.8%, and majority of the patients experiencing the first episode before 4 months (11.1%). 1.2% of patients died because of infections within the first 6 months (1% before 4 months). Variables associated with increased risk of severe infection in the first 4 months included serum albumin ≤30 g/L, ECOG > 1, male sex, and non-IgA type MM. A simple risk score with these variables facilitated the identification of three risk groups with different probabilities of severe infection within the first 4 months: low-risk (score 0-2) 8.2%; intermediate-risk (score 3) 19.2%; and high-risk (score 4) 28.3%. Patients with intermediate/high risk could be candidates for prophylactic antibiotic therapies.
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Affiliation(s)
- Cristina Encinas
- Hospital General Universitario Gregorio Marañón (HGUGM), IiSGM, Madrid, Spain
| | | | - Albert Oriol
- Hospital Universitario Germans Trias i Pujol, Badalona (Barcelona), Barcelona, Spain
| | | | | | - José-María Bellón
- Hospital General Universitario Gregorio Marañón (HGUGM), IiSGM, Madrid, Spain
| | - Ramón García-Sanz
- University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), Salamanca, Spain
| | | | | | | | - Isidro Jarque
- Hospital Universitario la Fe, CIBERONC, Valencia, Spain
| | | | - Victoria Dourdil
- Hospital Clínico Universitario "Lozano Blesa", Zaragoza, IIS Aragón, Spain
| | | | | | | | | | - Joan Bargay
- Hospital Son Llatzer, Palma de Mallorca, Spain
| | | | | | | | | | - Rafael Rios
- Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Adrián Alegre
- Hospital Universitario de la Princesa y Hospital Universitario Quirónsalud, Madrid, Spain
| | | | | | - Anna Sureda
- ICO-L'Hospitalet, IDIBELL, Universitat de Barcelona, Barcelona, Spain
| | - Antonia Sampol
- Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Enrique M Ocio
- Hospital Universitario Marqués de Valdecilla, (IDIVAL). Universidad de Cantabria, Santander, Spain
| | - Isabel Krsnik
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | | | | | | | - Jesús Martín
- Complejo Hospitalario Regional Virgen del Rocío, CIBERONC, Sevilla, Spain
| | | | - María-Victoria Mateos
- University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), Salamanca, Spain
| | - Joan Bladé
- Hospital Clinic, CIBERONC, Barcelona, Spain
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14
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Vekemans MC, Doyen C, Caers J, Wu K, Kentos A, Mineur P, Michaux L, Delforge M, Meuleman N. Recommendations on the management of multiple myeloma in 2020. Acta Clin Belg 2022; 77:445-461. [PMID: 33355041 DOI: 10.1080/17843286.2020.1860411] [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: 12/29/2022]
Abstract
With the introduction of immunomodulatory drugs, proteasome inhibitors, and anti-CD38 monoclonal antibodies, major improvements have been achieved in the treatment of multiple myeloma (MM), with a significant impact on the outcome of this disease. Different treatment combinations are now in use and other therapies are being developed. Based on an extensive review of the recent literature, we propose practical recommendations on myeloma management, to be used by hematologists as a reference for daily practice.
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Affiliation(s)
| | - Chantal Doyen
- Centre Hospitalier Universitaire de Namur, UCL, Yvoir, Belgium
| | - Jo Caers
- Centre Hospitalier Universitaire de Liège, Ulg, Liège, Belgium
| | - Kalung Wu
- Zienkenhuis Netwerk Antwerpen, Antwerp, Belgium
| | | | | | - Lucienne Michaux
- Universitair Ziekenhuis Leuven Gasthuisberg, KUL, Leuven, Belgium
| | - Michel Delforge
- Universitair Ziekenhuis Leuven Gasthuisberg, KUL, Leuven, Belgium
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15
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Yue L, Zeng P, Li Y, Chai Y, Wu C, Gao B. Nontargeted and targeted metabolomics approaches reveal the key amino acid alterations involved in multiple myeloma. PeerJ 2022; 10:e12918. [PMID: 35186493 PMCID: PMC8840056 DOI: 10.7717/peerj.12918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 01/20/2022] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Multiple myeloma (MM), a kind of malignant neoplasm of clonal plasma cells in the bone marrow, is a refractory disease. Understanding the metabolism disorders and identification of metabolomics pathways as well as key metabolites will provide new insights for exploring diagnosis and therapeutic targets of MM. METHODS We conducted nontargeted metabolomics analysis of MM patients and normal controls (NC) using ultra-high-performance liquid chromatography (UHPLC) combined with quadrupole time-of-flight mass spectrometry (Q-TOF-MS) in 40 cases of cohort 1 subjects. The targeted metabolomics analysis of amino acids using multiple reaction monitoring-mass spectrometry (MRM-MS) was also performed in 30 cases of cohort 1 and 30 cases of cohort 2 participants, to comprehensively investigate the metabolomics disorders of MM. RESULTS The nontargeted metabolomics analysis in cohort 1 indicated that there was a significant metabolic signature change between MM patients and NC. The differential metabolites were mainly enriched in metabolic pathways related to amino acid metabolism, such as protein digestion and absorption, and biosynthesis of amino acids. Further, the targeted metabolomics analysis of amino acids in both cohort 1 and cohort 2 revealed differential metabolic profiling between MM patients and NC. We identified 12 and 14 amino acid metabolites with altered abundance in MM patients compared to NC subjects, in cohort 1 and cohort 2, respectively. Besides, key differential amino acid metabolites, such as choline, creatinine, leucine, tryptophan, and valine, may discriminate MM patients from NC. Moreover, the differential amino acid metabolites were associated with clinical indicators of MM patients. CONCLUSIONS Our findings indicate that amino acid metabolism disorders are involved in MM. The differential profiles reveal the potential utility of key amino acid metabolites as diagnostic biomarkers of MM. The alterations in metabolome, especially the amino acid metabolome, may provide more evidences for elucidating the pathogenesis and development of MM.
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Affiliation(s)
- Lingling Yue
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Pengyun Zeng
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Yanhong Li
- Institute of Hematology, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Ye Chai
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Chongyang Wu
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Bingren Gao
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
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16
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Medina A, Jiménez C, Puig N, Sarasquete ME, Flores-Montero J, García-Álvarez M, Prieto-Conde I, Chillón C, Alcoceba M, González-Calle V, Gutiérrez NC, Jacobsen A, Vigil E, Hutt K, Huang Y, Orfao A, González M, Miller J, García-Sanz R. Interlaboratory Analytical Validation of a Next-Generation Sequencing Strategy for Clonotypic Assessment and Minimal Residual Disease Monitoring in Multiple Myeloma. Arch Pathol Lab Med 2021; 146:862-871. [PMID: 34619755 DOI: 10.5858/arpa.2021-0088-oa] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Minimal residual disease (MRD) is a major prognostic factor in multiple myeloma, although validated technologies are limited. OBJECTIVE.— To standardize the performance of the LymphoTrack next-generation sequencing (NGS) assays (Invivoscribe), targeting clonal immunoglobulin rearrangements, in order to reproduce the detection of tumor clonotypes and MRD quantitation in myeloma. DESIGN.— The quantification ability of the assay was evaluated through serial dilution experiments. Paired samples from 101 patients were tested by LymphoTrack, using Sanger sequencing and EuroFlow's next-generation flow (NGF) assay as validated references for diagnostic and follow-up evaluation, respectively. MRD studies using LymphoTrack were performed in parallel at 2 laboratories to evaluate reproducibility. RESULTS.— Sensitivity was set as 1.3 tumor cells per total number of input cells. Clonality was confirmed in 99% and 100% of cases with Sanger and NGS, respectively, showing great concordance (97.9%), although several samples had minor discordances in the nucleotide sequence of rearrangements. Parallel NGS was performed in 82 follow-up cases, achieving a median sensitivity of 0.001%, while for NGF, median sensitivity was 0.0002%. Reproducibility of LymphoTrack-based MRD studies (85.4%) and correlation with NGF (R2 > 0.800) were high. Bland-Altman tests showed highly significant levels of agreement between flow and sequencing. CONCLUSIONS.— Taken together, we have shown that LymphoTrack is a suitable strategy for clonality detection and MRD evaluation, with results comparable to gold standard procedures.
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Affiliation(s)
- Alejandro Medina
- From Departamento de Hematología, Hospital Universitario de Salamanca (HUSAL/IBSAL), Centro de Investigación del Cáncer - IBMCC (USAL-CSIC), CIBERONC-CB16/12/00233, Salamanca, Spain (Medina, Jiménez, Puig, Sarasquete, García-Álvarez, Prieto-Conde, Chillón, Alcoceba, González-Calle, Gutiérrez, González, García-Sanz)
| | - Cristina Jiménez
- From Departamento de Hematología, Hospital Universitario de Salamanca (HUSAL/IBSAL), Centro de Investigación del Cáncer - IBMCC (USAL-CSIC), CIBERONC-CB16/12/00233, Salamanca, Spain (Medina, Jiménez, Puig, Sarasquete, García-Álvarez, Prieto-Conde, Chillón, Alcoceba, González-Calle, Gutiérrez, González, García-Sanz)
| | - Noemí Puig
- From Departamento de Hematología, Hospital Universitario de Salamanca (HUSAL/IBSAL), Centro de Investigación del Cáncer - IBMCC (USAL-CSIC), CIBERONC-CB16/12/00233, Salamanca, Spain (Medina, Jiménez, Puig, Sarasquete, García-Álvarez, Prieto-Conde, Chillón, Alcoceba, González-Calle, Gutiérrez, González, García-Sanz)
| | - María Eugenia Sarasquete
- From Departamento de Hematología, Hospital Universitario de Salamanca (HUSAL/IBSAL), Centro de Investigación del Cáncer - IBMCC (USAL-CSIC), CIBERONC-CB16/12/00233, Salamanca, Spain (Medina, Jiménez, Puig, Sarasquete, García-Álvarez, Prieto-Conde, Chillón, Alcoceba, González-Calle, Gutiérrez, González, García-Sanz)
| | - Juan Flores-Montero
- Departamento de Citometría de Flujo, Laboratorio 11, Centro de Investigación del Cáncer - IBMCC (USAL-CSIC), CIBERONC-CB16/12/00400, Salamanca, Spain (Flores-Montero, Orfao)
| | - María García-Álvarez
- From Departamento de Hematología, Hospital Universitario de Salamanca (HUSAL/IBSAL), Centro de Investigación del Cáncer - IBMCC (USAL-CSIC), CIBERONC-CB16/12/00233, Salamanca, Spain (Medina, Jiménez, Puig, Sarasquete, García-Álvarez, Prieto-Conde, Chillón, Alcoceba, González-Calle, Gutiérrez, González, García-Sanz)
| | - Isabel Prieto-Conde
- From Departamento de Hematología, Hospital Universitario de Salamanca (HUSAL/IBSAL), Centro de Investigación del Cáncer - IBMCC (USAL-CSIC), CIBERONC-CB16/12/00233, Salamanca, Spain (Medina, Jiménez, Puig, Sarasquete, García-Álvarez, Prieto-Conde, Chillón, Alcoceba, González-Calle, Gutiérrez, González, García-Sanz)
| | - Carmen Chillón
- From Departamento de Hematología, Hospital Universitario de Salamanca (HUSAL/IBSAL), Centro de Investigación del Cáncer - IBMCC (USAL-CSIC), CIBERONC-CB16/12/00233, Salamanca, Spain (Medina, Jiménez, Puig, Sarasquete, García-Álvarez, Prieto-Conde, Chillón, Alcoceba, González-Calle, Gutiérrez, González, García-Sanz)
| | - Miguel Alcoceba
- From Departamento de Hematología, Hospital Universitario de Salamanca (HUSAL/IBSAL), Centro de Investigación del Cáncer - IBMCC (USAL-CSIC), CIBERONC-CB16/12/00233, Salamanca, Spain (Medina, Jiménez, Puig, Sarasquete, García-Álvarez, Prieto-Conde, Chillón, Alcoceba, González-Calle, Gutiérrez, González, García-Sanz)
| | - Verónica González-Calle
- From Departamento de Hematología, Hospital Universitario de Salamanca (HUSAL/IBSAL), Centro de Investigación del Cáncer - IBMCC (USAL-CSIC), CIBERONC-CB16/12/00233, Salamanca, Spain (Medina, Jiménez, Puig, Sarasquete, García-Álvarez, Prieto-Conde, Chillón, Alcoceba, González-Calle, Gutiérrez, González, García-Sanz)
| | - Norma C Gutiérrez
- From Departamento de Hematología, Hospital Universitario de Salamanca (HUSAL/IBSAL), Centro de Investigación del Cáncer - IBMCC (USAL-CSIC), CIBERONC-CB16/12/00233, Salamanca, Spain (Medina, Jiménez, Puig, Sarasquete, García-Álvarez, Prieto-Conde, Chillón, Alcoceba, González-Calle, Gutiérrez, González, García-Sanz)
| | - Austin Jacobsen
- Invivoscribe, Inc, San Diego, California (Jacobsen, Vigil, Hutt, Huang, Miller)
| | - Edgar Vigil
- Invivoscribe, Inc, San Diego, California (Jacobsen, Vigil, Hutt, Huang, Miller)
| | - Kasey Hutt
- Invivoscribe, Inc, San Diego, California (Jacobsen, Vigil, Hutt, Huang, Miller)
| | - Ying Huang
- Invivoscribe, Inc, San Diego, California (Jacobsen, Vigil, Hutt, Huang, Miller)
| | - Alberto Orfao
- Departamento de Citometría de Flujo, Laboratorio 11, Centro de Investigación del Cáncer - IBMCC (USAL-CSIC), CIBERONC-CB16/12/00400, Salamanca, Spain (Flores-Montero, Orfao)
| | - Marcos González
- From Departamento de Hematología, Hospital Universitario de Salamanca (HUSAL/IBSAL), Centro de Investigación del Cáncer - IBMCC (USAL-CSIC), CIBERONC-CB16/12/00233, Salamanca, Spain (Medina, Jiménez, Puig, Sarasquete, García-Álvarez, Prieto-Conde, Chillón, Alcoceba, González-Calle, Gutiérrez, González, García-Sanz)
| | - Jeffrey Miller
- Invivoscribe, Inc, San Diego, California (Jacobsen, Vigil, Hutt, Huang, Miller)
| | - Ramón García-Sanz
- From Departamento de Hematología, Hospital Universitario de Salamanca (HUSAL/IBSAL), Centro de Investigación del Cáncer - IBMCC (USAL-CSIC), CIBERONC-CB16/12/00233, Salamanca, Spain (Medina, Jiménez, Puig, Sarasquete, García-Álvarez, Prieto-Conde, Chillón, Alcoceba, González-Calle, Gutiérrez, González, García-Sanz)
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Tacchetti P, Rocchi S, Barbato S, Zamagni E, Pantani L, Mancuso K, Rizzello I, Cavo M. Emerging and current treatment combinations for transplant-ineligible multiple myeloma patients. Expert Rev Hematol 2021; 14:1085-1098. [PMID: 34602012 DOI: 10.1080/17474086.2021.1983426] [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: 10/20/2022]
Abstract
INTRODUCTION Availability of new classes of novel agents has led to a radical switch in treatment paradigms for newly diagnosed transplant-ineligible multiple myeloma (NDTIMM) patients, providing an opportunity to significantly enhance the depth of response and extend survival outcomes. AREAS COVERED Treatment regimens including proteasome inhibitors (PIs), immunomodulatory drugs (IMiDs) and/or monoclonal antibodies (mAbs), have achieved recent regulatory approval for NDTIMM, while novel combinations and newer agents are currently being explored. This review discusses the current landscape and possible treatment development of NDTIMM. EXPERT OPINION Bortezomib-lenalidomide-dexamethasone (VRd), daratumumab-bortezomib-melphalan-prednisone (DaraVMP) and daratumumab-lenalidomide-dexamethasone (DaraRd) represent new standard of care (SOC) treatments for NDTIMM patients, based on phase III trials showing their superior efficacy as compared with previous SOCs. The possibility of improving results by incorporating second generation PIs or using quadruple regimens has also been explored and different trials are still ongoing. Newer agents and innovative immunotherapies targeting B-cell maturation antigen have the potential to change the therapeutic landscape in coming years. Personalized approaches based on frailty-adapted, risk-based and minimal residual disease driven paradigms are under investigation.
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Affiliation(s)
- Paola Tacchetti
- Irccs Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Serena Rocchi
- Irccs Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Simona Barbato
- Irccs Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Elena Zamagni
- Irccs Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Lucia Pantani
- Irccs Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Katia Mancuso
- Irccs Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Ilaria Rizzello
- Irccs Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Michele Cavo
- Irccs Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
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18
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Sandecká V, Pour L, Špička I, Minařík J, Radocha J, Jelínek T, Heindorfer A, Pavlíček P, Sýkora M, Jungová A, Kessler P, Wróbel M, Starostka D, Ullrychová J, Stejskal L, Štork M, Straub J, Pika T, Brožová L, Ševčíková S, Maisnar V, Hájek R. Bortezomib-based therapy for newly diagnosed multiple myeloma patients ineligible for autologous stem cell transplantation: Czech Registry Data. Eur J Haematol 2021; 107:466-474. [PMID: 34272773 DOI: 10.1111/ejh.13683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study compared the use of bortezomib in different combination regimens in newly diagnosed multiple myeloma (NDMM) patients who were transplant ineligible. PATIENTS AND METHODS We analyzed data from the Registry of Monoclonal Gammopathies (RMG) of the Czech Myeloma Group (CMG) to provide real-world evidence of outcome for 794 newly diagnosed MM transplant ineligible patients. The most frequently used regimen was VCd (bortezomib-cyclophosphamide-dexamethasone) (47.5%) over VMP (bortezomib-melphalan-prednisone) (21.7%), BDd (bortezomib-doxorubicin-dexamethasone) (9.8%), and VTd (bortezomib-thalidomide-dexamethasone) (2.9%). RESULTS The overall response rate (ORR) was 69.2% (478/691), including 12.6% (≥ CR); 34.7% very good partial responses (VGPR); and 21.9% partial responses (PR). Among triplet regimens, VMP was the most effective regimen compared to VCd, BDd, and VTd. Median PFS was 22.3 vs. 18.5 vs. 13.7 vs. 13.8 mo, (P = .275), respectively, and median OS was 49 vs. 41.7 vs. 37.9 vs. 32.2 mo (P = .004), respectively. The most common grade 3-4 toxicities were anemia in 17.4% and infections in 18% of patients. CONCLUSION Our study confirmed that bortezomib-based treatment is effective and safe in NDMM transplant ineligible patients, especially VMP, which was identified as superior between bortezomib-based induction regimens not only in clinical trials, but also in real clinical practice.
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Affiliation(s)
- Viera Sandecká
- Department of Internal Medicine, Hematology and Oncology, University Hospital, Brno, Czech Republic
| | - Luděk Pour
- Department of Internal Medicine, Hematology and Oncology, University Hospital, Brno, Czech Republic
| | - Ivan Špička
- 1st Department of Medicine, Department of Hematology, Charles University and General Hospital, Prague, Czech Republic
| | - Jiří Minařík
- Department of Hemato-Oncology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Jakub Radocha
- 4th Department of Internal Medicine, Hematology, University Hospital and Charles University in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Tomáš Jelínek
- Department of Hematooncology, University Hospital Ostrava, University of Ostrava, Ostrava, Czech Republic
| | | | - Petr Pavlíček
- Department of Internal Medicine and Hematology, Charles University and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Michal Sýkora
- Department of Clinical Hematology, Hospital Ceske Budejovice, Ceske Budejovice, Czech Republic
| | - Alexandra Jungová
- Hematology and Oncology Department, Charles University Hospital Pilsen, Pilsen, Czech Republic
| | - Petr Kessler
- Department of Hematology and Transfusion Medicine, Hospital Pelhrimov, Czech Republic
| | - Marek Wróbel
- Department of Clinical Hematology, Hospital Novy Jicin, Czech Republic
| | - David Starostka
- Department of Clinical Hematology, Hospital Havirov, Czech Republic
| | - Jana Ullrychová
- Department of Clinical Hematology, Regional Health Corporation, Masaryk Hospital, Usti nad Labem, Czech Republic
| | - Lukáš Stejskal
- Department of Hematology, Silesian Hospital in Opava, Opava, Czech Republic
| | - Martin Štork
- Department of Internal Medicine, Hematology and Oncology, University Hospital, Brno, Czech Republic
| | - Jan Straub
- 1st Department of Medicine, Department of Hematology, Charles University and General Hospital, Prague, Czech Republic
| | - Tomáš Pika
- Department of Hemato-Oncology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Lucie Brožová
- Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic
| | - Sabina Ševčíková
- Babak Myeloma Group, Department of Pathophysiology, Masaryk University, Brno, Czech Republic
| | - Vladimír Maisnar
- 4th Department of Internal Medicine, Hematology, University Hospital and Charles University in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Roman Hájek
- Department of Hematooncology, University Hospital Ostrava, University of Ostrava, Ostrava, Czech Republic
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19
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Larocca A, Bonello F, Gaidano G, D'Agostino M, Offidani M, Cascavilla N, Capra A, Benevolo G, Tosi P, Galli M, Marasca R, Giuliani N, Bernardini A, Antonioli E, Rota-Scalabrini D, Cellini C, Pompa A, Monaco F, Patriarca F, Caravita di Toritto T, Corradini P, Tacchetti P, Boccadoro M, Bringhen S. Dose/schedule-adjusted Rd-R vs continuous Rd for elderly, intermediate-fit patients with newly diagnosed multiple myeloma. Blood 2021; 137:3027-3036. [PMID: 33739404 DOI: 10.1182/blood.2020009507] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/26/2021] [Indexed: 01/02/2023] Open
Abstract
Lenalidomide-dexamethasone (Rd) is standard treatment for elderly patients with multiple myeloma (MM). In this randomized phase 3 study, we investigated efficacy and feasibility of dose/schedule-adjusted Rd followed by maintenance at 10 mg per day without dexamethasone (Rd-R) vs continuous Rd in elderly, intermediate-fit newly diagnosed patients with MM. Primary end point was event-free survival (EFS), defined as progression/death from any cause, lenalidomide discontinuation, or hematologic grade 4 or nonhematologic grade 3 to 4 adverse event (AE). Of 199 evaluable patients, 101 received Rd-R and 98 continuous Rd. Median follow-up was 37 months. EFS was 10.4 vs 6.9 months (hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.51-0.95; P = .02); median progression-free survival, 20.2 vs 18.3 months (HR, 0.78; 95% CI, 0.55-1.10; P = .16); and 3-year overall survival, 74% vs 63% (HR, 0.62; 95% CI, 0.37-1.03; P = .06) with Rd-R vs Rd, respectively. Rate of ≥1 nonhematologic grade ≥3 AE was 33% vs 43% (P = .14) in Rd-R vs Rd groups, with neutropenia (21% vs 18%), infections (10% vs 12%), and skin disorders (7% vs 3%) the most frequent; constitutional and central nervous system AEs mainly related to dexamethasone were more frequent with Rd. Lenalidomide was discontinued for AEs in 24% vs 30% and reduced in 45% vs 62% of patients receiving Rd-R vs Rd, respectively. In intermediate-fit patients, switching to reduced-dose lenalidomide maintenance without dexamethasone after 9 Rd cycles was feasible, with similar outcomes to standard continuous Rd. This trial was registered at www.clinicaltrials.gov as #NCT02215980.
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Affiliation(s)
- Alessandra Larocca
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Francesca Bonello
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Mattia D'Agostino
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Massimo Offidani
- Clinica di Ematologia, Azienda Ospedaliero Universitaria Ospedali Riuniti Umberto I-G.M. Lancisi-G. Salesi di Ancona, Ancona, Italy
| | - Nicola Cascavilla
- Ematologia, Ospedale "Casa Sollievo della Sofferenza," Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), San Giovanni Rotondo, Italy
| | - Andrea Capra
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Giulia Benevolo
- SC Hematology, AO Città della Salute e della Scienza, Turin, Italy
| | | | - Monica Galli
- Dipartimento di Oncologia ed Ematologia, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Roberto Marasca
- Section of Hematology, Department of Medical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Annalisa Bernardini
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | | | - Delia Rota-Scalabrini
- Candiolo Cancer Institute, Fondazione del Piemonte per l'Oncologia, IRCCS, Candiolo, Italy
| | - Claudia Cellini
- Ospedale Santa Maria delle Croci, UOC Ematologia Ravenna, Ravenna, Italy
| | - Alessandra Pompa
- UOC Ematologia, Fondazione IRCCS Cà Granda, OM Policlinico, Milano, Italy
| | - Federico Monaco
- Hematology Division, Az Ospedaliera Santi Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Francesca Patriarca
- Division of Hematology, Azienda Sanitaria Universitaria Friuli Centrale, Dipartimento di Area Medica, Udine University, Udine, Italy
| | | | - Paolo Corradini
- Divisione di Ematologia, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Università degli Studi di Milano, Milano, Italy; and
| | - Paola Tacchetti
- Istituto di Ematologia "Seràgnoli," Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Azienda Ospedaliero-Universitaria di Bologna, Università degli Studi di Bologna, Bologna, Italy
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Sara Bringhen
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
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20
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Cheng CN, Huang SY, Lien PW, Huang ST, Lin FJ. Survival, health care resource utilization and expenditures of first-line treatments for multiple myeloma patients ineligible for transplant in Taiwan. PLoS One 2021; 16:e0252124. [PMID: 34038463 PMCID: PMC8153459 DOI: 10.1371/journal.pone.0252124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 05/10/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND We aimed to provide real-world information on survival, health care resource utilization (HCRU), and expenditures related to various first lines of therapy (1LOTs) in newly diagnosed multiple myeloma (NDMM) patients who were transplant ineligible (TI). PATIENTS AND METHODS From the Taiwan National Health Insurance Database (2008-2016), we identified 1,511 NDMM-TI patients who had received 1LOT since June 2012. We categorized 1LOT regimens into four groups: bortezomib (V)+thalidomide (T), V, T, and non-V/T. Patients' characteristics were collected. The overall survival (OS), event-free survival (EFS), frequencies of HCRU (hospitalization, visiting outpatient and emergency departments), and related expenditures within one year after commencement of the 1LOT were evaluated and compared. RESULTS The mean age of the included patients was 71.3 (SD 10.7) years, and 40.4% of patients had a CCI score ≥3. Most patients (747; 49.4%) were in the V+T group and, after adjusting for covariates, had a significantly longer OS (median, 22.2 months) and EFS (9.1 months) than those in the T group (12.6 and 4.5 months, respectively) and the non-V/T group (12.2 and 3.2 months, respectively), but they were mostly comparable with patients in the V group (23.8 and 6.6 months, respectively). Compared to those in the V+T group, patients in the T and non-V/T groups had 29% and 39% fewer outpatient visits and 15% and 24% lower total expenditure, respectively. CONCLUSION Our real-world data consolidate evidence for the effectiveness of bortezomib-containing regimens as the 1LOT in NDMM-TI patients at the expense of more outpatient visits and higher total costs.
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Affiliation(s)
- Chih-Ning Cheng
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shang-Yi Huang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Pei-Wen Lien
- Takeda Pharmaceuticals Taiwan, Ltd, Taipei, Taiwan
| | | | - Fang-Ju Lin
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
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21
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Ibarra G, Peña M, Abril L, Senín A, Maluquer C, Clapés V, Baca C, Bustamante G, Sureda A, Oriol A. Dose intensity and treatment duration of bortezomib in transplant-ineligible newly diagnosed multiple myeloma. Eur J Haematol 2021; 107:246-254. [PMID: 33934417 DOI: 10.1111/ejh.13643] [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: 02/05/2021] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Bortezomib-related peripheral neuropathy (PN) affects a relevant proportion of multiple myeloma (MM) patients treated with melphalan, prednisone, and bortezomib (VMP). Empirical dose modifications have attempted to reduce toxicity without compromising efficacy. PATIENTS AND METHODS We retrospectively evaluated the dose-response and dose-toxicity relationships in 114 unselected untreated MM patients intended for treatment with VMP with subcutaneous bortezomib. RESULTS Sixty-two patients (54%) completed the 9 scheduled cycles. Median treatment duration was 48 weeks (range 1-57), cumulative bortezomib dose was 41.8 mg/m2 (2.6-67.6) and median dose intensity was 1.0 mg/m2 /wk (0.2-2.6). Median progression-free survival (PFS) and overall survival (OS) for the full cohort were 86 weeks (95%CI 77-104) and 209 weeks (95% CI 157-259) respectively. Patients who progressed <60 days after discontinuing bortezomib had received a significantly inferior mean cumulative dose, 34.6 mg/m2 than the remaining individuals, 45.5 (P = .023). PFS was significantly improved for patients achieving a very good partial response (VGPR) or better (P = .00007). Additional variables with a prognostic impact on PFS on univariate analysis included completion of the 9 scheduled cycles (P = .00002), patients with at least 50 weeks of treatment (P = .02) and patients receiving a cumulative dose of at least 49 mg/m2 (P = .05). Achievement of a VGPR (HR 0.23; 95%CI 0.12-0.46; P = .00002) and a cumulative dose of 49 mg/m2 (HR 0.46, 95%CI 0.27-0.78; P = .003) were statistically independent prognostic factors for PFS. Toxicity-related treatment dose reductions occurred in 75 individuals (66%). PN was observed in 50 individuals (44.6%), grade 3 in 9 (8%). The only prognostic factor for emergence of PN in multivariate analysis was the presence of baseline PN. CONCLUSIONS Biweekly full-dose treatment in the first cycles has a major impact in depth of response. Depth of response, cumulative bortezomib dose, and treatment duration had an impact in prolongation of PFS.
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Affiliation(s)
- Gladys Ibarra
- Hematology Department, Catalan Institute of Oncology, Germans Trias i Pujol Hospital and Josep Carreras Research Institute, Badalona, Spain
| | - Marta Peña
- Hematology Department, Catalan Institute of Oncology, Duran i Reynals Hospital, L'Hospitalet, Spain.,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Universitat de Barcelona, Barcelona, Spain
| | - Laura Abril
- Hematology Department, Catalan Institute of Oncology, Germans Trias i Pujol Hospital, Badalona, Spain
| | - Alicia Senín
- Hematology Department, Catalan Institute of Oncology, Germans Trias i Pujol Hospital, Badalona, Spain
| | - Clara Maluquer
- Hematology Department, Catalan Institute of Oncology, Duran i Reynals Hospital, L'Hospitalet, Spain.,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Universitat de Barcelona, Barcelona, Spain
| | - Victoria Clapés
- Hematology Department, Catalan Institute of Oncology, Duran i Reynals Hospital, L'Hospitalet, Spain.,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Universitat de Barcelona, Barcelona, Spain
| | - Cristina Baca
- Hematology Department, Catalan Institute of Oncology, Duran i Reynals Hospital, L'Hospitalet, Spain.,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Universitat de Barcelona, Barcelona, Spain
| | - Gabriela Bustamante
- Hematology Department, Catalan Institute of Oncology, Duran i Reynals Hospital, L'Hospitalet, Spain.,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Universitat de Barcelona, Barcelona, Spain
| | - Anna Sureda
- Hematology Department, Catalan Institute of Oncology, Duran i Reynals Hospital, L'Hospitalet, Spain.,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Universitat de Barcelona, Barcelona, Spain
| | - Albert Oriol
- Hematology Department, Catalan Institute of Oncology, Germans Trias i Pujol Hospital and Josep Carreras Research Institute, Badalona, Spain
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22
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Schjesvold F, Oriol A. Current and Novel Alkylators in Multiple Myeloma. Cancers (Basel) 2021; 13:2465. [PMID: 34070213 PMCID: PMC8158783 DOI: 10.3390/cancers13102465] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/22/2021] [Accepted: 05/11/2021] [Indexed: 12/22/2022] Open
Abstract
A large number of novel treatments for myeloma have been developed and approved; however, alkylating drugs continue to be part of standard regimens. Additionally, novel alkylators are currently being developed. We performed a non-systematized literary search for relevant papers and communications at large conferences, as well as exploiting the authors' knowledge of the field, to review the history, current use and novel concepts around the traditional alkylators cyclophosphamide, bendamustine and melphalan and current data on the newly developed pro-drug melflufen. Even in the era of targeted treatment and personalized medicine, alkylating drugs continue to be part of the standard-of-care in myeloma, and new alkylators are coming to the market.
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Affiliation(s)
- Fredrik Schjesvold
- Oslo Myeloma Center, Oslo University Hospital, 0450 Oslo, Norway
- K.G. Jebsen Centre for B-Cell Malignancies, University of Oslo, 4950 Oslo, Norway
| | - Albert Oriol
- Institut Josep Carreras and Institut Català d’Oncologia, Hospital Germans Trias I Pujol, 08916 Badalona, Spain;
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23
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Cejalvo MJ, Bustamante G, González E, Vázquez-Álvarez J, García R, Ramírez-Payer Á, Pérez-Persona E, Abella E, Garzón S, García A, Jarque I, González MS, Sampol A, Motlló C, Martí JM, Alcalá M, Duro R, González Y, Sastre JL, Sarrà J, Lostaunau G, López R, de la Rubia J. Treatment patterns and outcomes in real-world transplant-ineligible patients newly diagnosed with multiple myeloma. Ann Hematol 2021; 100:1769-1778. [PMID: 33885924 DOI: 10.1007/s00277-021-04529-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
Despite the significant proportion of older patients with newly diagnosed multiple myeloma (MM), most clinical trials driving therapeutic decisions in routine practice include younger and presumably healthier patients than those in the real world. Furthermore, longitudinal studies suggest that elderly, transplant-ineligible patients with MM are not benefitting enough from new anti-MM agents. We retrospectively analyzed the profile of and treatment patterns and outcomes in 675 transplant-ineligible patients with MM who started frontline therapy in routine practice. The mean (SD) age was 75.6 (6.7) years; 152 (47.4%) had Eastern Cooperative Oncology Group performance status (ECOG PS) 2-4, and 73 (25.1%) had high cytogenetic risk. The most frequent frontline therapy was non-VMP bortezomib-based regimens (n=207; 30.7%), which were more frequent among patients with ECOG PS 0/1 and higher risk (e.g., international staging system (ISS) stage III, severely impaired glomerular filtrate rate (GFR), high lactate dehydrogenase (LDH), and high-risk cytogenetics); 185 patients (27.4%) started an attenuated (lite) VMP regimen, and 159 (23.6%) a VMP (VISTA) regimen. Median progression-free survival and overall survival (OS) were 15.3 months (95%CI 14.0-16.9) and 33.5 months (95%CI 29.1-37.2), respectively; 405 patients (78.2%) achieved partial response or better. Age, ECOG PS, ISS stage, serum LDH, GFR, cytogenetic risk, and treatment regimen significantly influenced OS. In this study, a remarkable proportion of transplant-ineligible patients with MM were older, frontline regimens were highly heterogeneous, and patients at higher risk often received less efficacious combinations. These findings suggest that clinicians have limited objective criteria for therapeutic decisions for this patient group.
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Affiliation(s)
- María José Cejalvo
- Department of Hematology, Hospital Universitario Doctor Peset, Av. de Gaspar Aguilar, 90 46017, Valencia, Spain
| | - Gabriela Bustamante
- Department of Hematology, Institut Català d'Oncologia, Hospital Duran i Reynals, Barcelona, Spain
| | - Esther González
- Department of Hematology, Hospital de Cabueñes, Gijón, Spain
| | | | - Ricarda García
- Department of Hematology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Ángel Ramírez-Payer
- Department of Hematology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Eugenia Abella
- Department of Hematology, Hospital del Mar, Barcelona, Spain
| | - Sebastián Garzón
- Department of Hematology, Hospital de Jerez, Jerez de la Frontera, Spain
| | - Antoni García
- Department of Hematology, Hospital Arnau de Vilanova, Lleida, Spain
| | - Isidro Jarque
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia & CIBERONC, Instituto de Salud Carlos III, Valencia, Spain
| | | | - Antonia Sampol
- Department of Hematology, Hospital Son Espases, Palma de Mallorca, Spain
| | | | - Josep María Martí
- Department of Hematology, Hospital Mútua de Terrassa, Terrassa, Spain
| | - Magdalena Alcalá
- Department of Hematology, Hospital Universitario Carlos Haya, Málaga, Spain
| | - Rafael Duro
- Department of Hematology, Hospital Universitario Virgen de la Macarena, Sevilla, Spain
| | - Yolanda González
- Department of Hematology, Hospital Universitario de Girona Doctor Josep Trueta, Girona, Spain
| | - José Luis Sastre
- Department of Hematology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Josep Sarrà
- Department of Hematology, Hospital Universitario Joan XXIII, Tarragona, Spain
| | | | - Rocío López
- Celgene S.L.U., Bristol-Myers Squibb Company, Madrid, Spain
| | - Javier de la Rubia
- Department of Hematology, Hospital Universitario Doctor Peset, Av. de Gaspar Aguilar, 90 46017, Valencia, Spain. .,Departamento de Medicina Interna y Odontología, Universidad Católica de Valencia, Valencia, Spain.
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24
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Maclachlan KH, Came N, Diamond B, Roshal M, Ho C, Thoren K, Mayerhoefer ME, Landgren O, Harrison S. Minimal residual disease in multiple myeloma: defining the role of next generation sequencing and flow cytometry in routine diagnostic use. Pathology 2021; 53:385-399. [PMID: 33674146 DOI: 10.1016/j.pathol.2021.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 12/11/2022]
Abstract
For patients diagnosed with multiple myeloma (MM) there have been significant treatment advances over the past decade, reflected in an increasing proportion of patients achieving durable remissions. Clinical trials repeatedly demonstrate that achieving a deep response to therapy, with a bone marrow assessment proving negative for minimal residual disease (MRD), confers a significant survival advantage. To accurately assess for minute quantities of residual cancer requires highly sensitive methods; either multiparameter flow cytometry or next generation sequencing are currently recommended for MM response assessment. Under optimal conditions, these methods can detect one aberrant cell amongst 1,000,000 normal cells (a sensitivity of 10-6). Here, we will review the practical use of MRD assays in MM, including challenges in implementation for the routine diagnostic laboratory, standardisation across laboratories and clinical trials, the clinical integration of MRD status assessment into MM management and future directions for ongoing research.
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Affiliation(s)
- Kylee H Maclachlan
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Haematology Service, Peter MacCallum Cancer Centre, East Melbourne, Vic, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Vic, Australia.
| | - Neil Came
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Vic, Australia; Pathology Department, Peter MacCallum Cancer Centre, East Melbourne, Vic, Australia
| | - Benjamin Diamond
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mikhail Roshal
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Caleb Ho
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katie Thoren
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marius E Mayerhoefer
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Myeloma Program, Department of Medicine, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Simon Harrison
- Haematology Service, Peter MacCallum Cancer Centre, East Melbourne, Vic, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Vic, Australia
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25
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Kaweme NM, Changwe GJ, Zhou F. Approaches and Challenges in the Management of Multiple Myeloma in the Very Old: Future Treatment Prospects. Front Med (Lausanne) 2021; 8:612696. [PMID: 33718400 PMCID: PMC7947319 DOI: 10.3389/fmed.2021.612696] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/03/2021] [Indexed: 12/14/2022] Open
Abstract
The increasing incidence of geriatric patients with multiple myeloma has elevated concerns in clinical practice. While the introduction of novel therapeutic agents has substantially improved outcomes in younger patients with myeloma, poorer outcomes remain in older patients. Managing older patients requires a multidisciplinary team approach to consider factors that may influence both treatment selection and outcomes. Aging is associated with remodeling of vital organs, physiological downregulations of basal metabolism, susceptibility to multiple comorbidities with ultimate frailty, thereby contributing to the underrepresentation and exclusion of very old patients from clinical trials. Therefore, timely confirmation of a precise diagnosis is crucial for prompt initiation of treatment if the desired outcome is to be achieved. Adequate and judicious assessment using comprehensive geriatric assessment tools minimizes toxicities and treatment discontinuation. Initiating treatment with combinational therapy requires knowledge of indications and anticipated outcomes, as well as individualized therapy with appropriate dose-adjustment. Individualized therapy based on good clinical acumen and best practices obverts unwanted polypharmacy, preventing iatrogenic harm. This review will therefore address the approaches and challenges faced in managing myeloma in geriatric patients aged 80 years and older, highlighting recommended therapeutic strategies and future prospective regimens.
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Affiliation(s)
| | | | - Fuling Zhou
- Department of Hematology, Zhongnan Hospital, Wuhan University, Wuhan, China
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26
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A Quantitative Paradigm for Decision-Making in Precision Oncology. Trends Cancer 2021; 7:293-300. [PMID: 33637444 DOI: 10.1016/j.trecan.2021.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/16/2021] [Accepted: 01/20/2021] [Indexed: 11/24/2022]
Abstract
The complexity and variability of cancer progression necessitate a quantitative paradigm for therapeutic decision-making that is dynamic, personalized, and capable of identifying optimal treatment strategies for individual patients under substantial uncertainty. Here, we discuss the core components and challenges of such an approach and highlight the need for comprehensive longitudinal clinical and molecular data integration in its development. We describe the complementary and varied roles of mathematical modeling and machine learning in constructing dynamic optimal cancer treatment strategies and highlight the potential of reinforcement learning approaches in this endeavor.
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27
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Biological and clinical significance of dysplastic hematopoiesis in patients with newly diagnosed multiple myeloma. Blood 2021; 135:2375-2387. [PMID: 32299093 DOI: 10.1182/blood.2019003382] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 03/15/2020] [Indexed: 02/07/2023] Open
Abstract
Risk of developing myelodysplastic syndrome (MDS) is significantly increased in both multiple myeloma (MM) and monoclonal gammopathy of undetermined significance, suggesting that it is therapy independent. However, the incidence and sequelae of dysplastic hematopoiesis at diagnosis are unknown. Here, we used multidimensional flow cytometry (MFC) to prospectively screen for the presence of MDS-associated phenotypic alterations (MDS-PA) in the bone marrow of 285 patients with MM enrolled in the PETHEMA/GEM2012MENOS65 trial (#NCT01916252). We investigated the clinical significance of monocytic MDS-PA in a larger series of 1252 patients enrolled in 4 PETHEMA/GEM protocols. At diagnosis, 33 (11.6%) of 285 cases displayed MDS-PA. Bulk and single-cell-targeted sequencing of MDS recurrently mutated genes in CD34+ progenitors (and dysplastic lineages) from 67 patients revealed clonal hematopoiesis in 13 (50%) of 26 cases with MDS-PA vs 9 (22%) of 41 without MDS-PA; TET2 and NRAS were the most frequently mutated genes. Dynamics of MDS-PA at diagnosis and after autologous transplant were evaluated in 86 of 285 patients and showed that in most cases (69 of 86 [80%]), MDS-PA either persisted or remained absent in patients with or without MDS-PA at diagnosis, respectively. Noteworthy, MDS-associated mutations infrequently emerged after high-dose therapy. Based on MFC profiling, patients with MDS-PA have altered hematopoiesis and T regulatory cell distribution in the tumor microenvironment. Importantly, the presence of monocytic MDS-PA at diagnosis anticipated greater risk of hematologic toxicity and was independently associated with inferior progression-free survival (hazard ratio, 1.5; P = .02) and overall survival (hazard ratio, 1.7; P = .01). This study reveals the biological and clinical significance of dysplastic hematopoiesis in newly diagnosed MM, which can be screened with moderate sensitivity using cost-effective MFC.
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28
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Abstract
Multiple myeloma is the second most common haematological malignancy in high-income countries, and typically starts as asymptomatic precursor conditions-either monoclonal gammopathy of undetermined significance or smouldering multiple myeloma-in which initiating genetic abnormalities, such as hyperdiploidy and translocations involving the immunoglobulin heavy chain, are already present. The introduction of immunomodulatory drugs, proteasome inhibitors, and CD38-targeting antibodies has extended survival, but ultimately the majority of patients will die from their disease, and some from treatment-related complications. Disease progression and subsequent relapses are characterised by subclonal evolution and increasingly resistant disease. Patients with multiple myeloma usually have hypercalcaemia, renal failure, anaemia, or osteolytic bone lesions-and a detailed diagnostic investigation is needed to differentiate between symptomatic multiple myeloma that requires treatment, and precursor states. Risk stratification using both patient-specific (eg, performance status) and disease-specific (eg, presence of high-risk cytogenetic abnormalities) is important for prognosis and to define the best treatment strategy. Current research strategies include the use of minimal residual disease assays to guide therapy, refining immunotherapeutic approaches, and intercepting disease early in smouldering multiple myeloma.
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Affiliation(s)
- Niels W C J van de Donk
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Hematology, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Charlotte Pawlyn
- The Institute of Cancer Research, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Kwee L Yong
- University College London Cancer Institute, London, UK.
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29
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Hu C, Zhang Y, Xiong X, Meng Q, Yao F, Ye A, Hao Z. Quantitative evaluation of bone marrow infiltration using dual-energy spectral computed tomography in patients with multiple myeloma. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2021; 29:463-475. [PMID: 33720868 DOI: 10.3233/xst-200811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To explore the potential value of quantitative parameters derived from dual-energy spectral computed tomography (DESCT) as comparing to the parameters derived from magnetic resonance imaging (MRI) in detecting bone marrow (BM) infiltration and distinguishing different patterns of BM infiltration in patients diagnosed with Multiple myeloma (MM). METHODS This study involved 35MM patients and 15 healthy control subjects who had undergone spinal DESCT and MRI. Pattern assignment was based on visual assessment of MR images, and the regions of interest were defined on both DESCT and apparent diffusion coefficient maps. Quantitative values of DESCT parameters were measured and compared between infiltrated and healthy bone marrow. Receiver operating characteristic (ROC) analysis was performed to determine potential utility of DESCT parameters in identifying BM infiltration and different patterns defined by MRI. Sensitivity and specificity under the optimal thresholds determined by the Youden Index were also calculated. RSULTS Statistical differences were observed between the DESCT parameters including Ca(Water), Water(Ca), HAP(Fat), Fat(HAP) and Effective atomic number (Eff-Z) but not for the 70-keV CT value between the infiltrated and healthy BM (all P < 0.001). The 70keV CT value and Ca(Water), HAP(Fat) and Eff-Z values were also found to be statistically different in comparing different infiltration patterns (all P < 0.05). Performance of the model-based parameter Ca/Water was superior in differentiating between infiltrated and healthy BM in which the area under ROC curve, AUC = 0.856 [95% CI, 81.4-89.1%] with sensitivity = 0.841 and specificity = 0.768, as well as between MM patients and control subjects (AUC = 0.910 [95% CI, 79.5-97.3%], sensitivity = 0.829 and specificity = 1.000). CONCLUSIONS Analysis of DESCT offers potential as a quantitative method to detect infiltrated BM and evaluate infiltration patterns of BM in patients diagnosed with MM.
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Affiliation(s)
- Chunhong Hu
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Medical Imaging, State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, Jiangsu, China
| | - Yu Zhang
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Medical Imaging, State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, Jiangsu, China
| | - Xing Xiong
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Qian Meng
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Feirong Yao
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Aihua Ye
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zhengmei Hao
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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30
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Xavier FD, Ferreira FSB, Abreu RM. Treatment of elderly patients with refractory/relapsed multiple myeloma: oral drugs adherence and the COVID-19 outbreak. Oncotarget 2020; 11:4371-4386. [PMID: 33316011 PMCID: PMC7720774 DOI: 10.18632/oncotarget.27819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 10/17/2020] [Indexed: 01/10/2023] Open
Abstract
Once the treatment of refractory/relapsed multiple myeloma in the elderly is greatly influenced by the adherence of patients and family members, clinicians should be aware of patients’ behavior and lifestyle, as it may influence the individual treatment plan for each patient. Furthermore, treatment with oral chemotherapy is of special value during the COVID-19 outbreak. Multidisciplinary healthcare involvement is crucial in the management of polypharmacy, adverse events and dose adjustment due to comorbidities and natural loss of renal function with age. Oral drugs simplify intake, reduce hospital visits, and improve autonomy and quality of life. However, although oral drugs have advantages, they also transfer control and responsibility from the healthcare professional to the patient, who must be able to understand and follow the directions given. Therefore, patient education and communication with healthcare professionals are critical for adherence.
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Affiliation(s)
- Flávia Dias Xavier
- Department of Hematology, Hospital Universitario de Brasilia-UNB/Ebserh, Brasilia, DF, Brazil.,Hospital Sirio Libanes, Centro de Oncologia, Unidade Brasilia, Brasilia, DF, Brazil
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31
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Medina A, Puig N, Flores-Montero J, Jimenez C, Sarasquete ME, Garcia-Alvarez M, Prieto-Conde I, Chillon C, Alcoceba M, Gutierrez NC, Oriol A, Rosinol L, Bladè J, Gironella M, Hernandez MT, Gonzalez-Calle V, Cedena MT, Paiva B, San-Miguel JF, Lahuerta JJ, Mateos MV, Martinez-Lopez J, Orfao A, Gonzalez M, Garcia-Sanz R. Comparison of next-generation sequencing (NGS) and next-generation flow (NGF) for minimal residual disease (MRD) assessment in multiple myeloma. Blood Cancer J 2020; 10:108. [PMID: 33127891 PMCID: PMC7603393 DOI: 10.1038/s41408-020-00377-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/14/2020] [Accepted: 10/02/2020] [Indexed: 12/12/2022] Open
Abstract
Detecting persistent minimal residual disease (MRD) allows the identification of patients with an increased risk of relapse and death. In this study, we have evaluated MRD 3 months after transplantation in 106 myeloma patients using a commercial next-generation sequencing (NGS) strategy (LymphoTrack®), and compared the results with next-generation flow (NGF, EuroFlow). The use of different marrow pulls and the need of concentrating samples for NGS biased the applicability for MRD evaluation and favored NGF. Despite that, correlation between NGS and NGF was high (R2 = 0.905). The 3-year progression-free survival (PFS) rates by NGS and NGF were longer for undetectable vs. positive patients (NGS: 88.7% vs. 56.6%; NGF: 91.4% vs. 50%; p < 0.001 for both comparisons), which resulted in a 3-year overall survival (OS) advantage (NGS: 96.2% vs. 77.3%; NGF: 96.6% vs. 74.9%, p < 0.01 for both comparisons). In the Cox regression model, NGS and NGF negativity had similar results but favoring the latter in PFS (HR: 0.20, 95% CI: 0.09–0.45, p < 0.001) and OS (HR: 0.21, 95% CI: 0.06–0.75, p = 0.02). All these results reinforce the role of MRD detection by different strategies in patient prognosis and highlight the use of MRD as an endpoint for multiple myeloma treatment.
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Affiliation(s)
- Alejandro Medina
- Departamento de Hematología, Hospital Universitario de Salamanca (HUSA/IBSAL), CIBERONC, CIC-IBMCC (USAL-CSIC), Salamanca, Spain
| | - Noemi Puig
- Departamento de Hematología, Hospital Universitario de Salamanca (HUSA/IBSAL), CIBERONC, CIC-IBMCC (USAL-CSIC), Salamanca, Spain
| | - Juan Flores-Montero
- Centro de Investigación del Cáncer-IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | - Cristina Jimenez
- Departamento de Hematología, Hospital Universitario de Salamanca (HUSA/IBSAL), CIBERONC, CIC-IBMCC (USAL-CSIC), Salamanca, Spain
| | - M-Eugenia Sarasquete
- Departamento de Hematología, Hospital Universitario de Salamanca (HUSA/IBSAL), CIBERONC, CIC-IBMCC (USAL-CSIC), Salamanca, Spain.
| | - María Garcia-Alvarez
- Departamento de Hematología, Hospital Universitario de Salamanca (HUSA/IBSAL), CIBERONC, CIC-IBMCC (USAL-CSIC), Salamanca, Spain
| | - Isabel Prieto-Conde
- Departamento de Hematología, Hospital Universitario de Salamanca (HUSA/IBSAL), CIBERONC, CIC-IBMCC (USAL-CSIC), Salamanca, Spain
| | - Carmen Chillon
- Departamento de Hematología, Hospital Universitario de Salamanca (HUSA/IBSAL), CIBERONC, CIC-IBMCC (USAL-CSIC), Salamanca, Spain
| | - Miguel Alcoceba
- Departamento de Hematología, Hospital Universitario de Salamanca (HUSA/IBSAL), CIBERONC, CIC-IBMCC (USAL-CSIC), Salamanca, Spain
| | - Norma C Gutierrez
- Departamento de Hematología, Hospital Universitario de Salamanca (HUSA/IBSAL), CIBERONC, CIC-IBMCC (USAL-CSIC), Salamanca, Spain
| | - Albert Oriol
- Hospital Germans Trias i Pujol, Institut Català d'Oncología (ICO), Institut Josep Carreras, Badalona, Spain
| | - Laura Rosinol
- Hospital Clínic i Provincial, Institut de Investicacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Joan Bladè
- Hospital Clínic i Provincial, Institut de Investicacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | | | - Veronica Gonzalez-Calle
- Departamento de Hematología, Hospital Universitario de Salamanca (HUSA/IBSAL), CIBERONC, CIC-IBMCC (USAL-CSIC), Salamanca, Spain
| | - Maria-Teresa Cedena
- Hospital 12 de Octubre, i + 12, CNIO, Universidad Complutense, Madrid, Spain
| | - Bruno Paiva
- Clínica Universidad de Navarra (CUN), Centro de Investigación Médica Aplicada, IDISNA, CIBERONC, Pamplona, Spain
| | - Jesus F San-Miguel
- Clínica Universidad de Navarra (CUN), Centro de Investigación Médica Aplicada, IDISNA, CIBERONC, Pamplona, Spain
| | - Juan-Jose Lahuerta
- Hospital 12 de Octubre, i + 12, CNIO, Universidad Complutense, Madrid, Spain
| | - Maria-Victoria Mateos
- Departamento de Hematología, Hospital Universitario de Salamanca (HUSA/IBSAL), CIBERONC, CIC-IBMCC (USAL-CSIC), Salamanca, Spain
| | | | - Alberto Orfao
- Centro de Investigación del Cáncer-IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | - Marcos Gonzalez
- Departamento de Hematología, Hospital Universitario de Salamanca (HUSA/IBSAL), CIBERONC, CIC-IBMCC (USAL-CSIC), Salamanca, Spain
| | - Ramon Garcia-Sanz
- Departamento de Hematología, Hospital Universitario de Salamanca (HUSA/IBSAL), CIBERONC, CIC-IBMCC (USAL-CSIC), Salamanca, Spain
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Diagnostic and Therapeutic Challenges in the Management of Intermediate and Frail Elderly Multiple Myeloma Patients. Cancers (Basel) 2020; 12:cancers12113106. [PMID: 33114320 PMCID: PMC7690866 DOI: 10.3390/cancers12113106] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/11/2022] Open
Abstract
Simple Summary Choosing the optimal therapy for elderly patients with multiple myeloma (MM) poses a difficult challenge for clinicians. Older patients are an extremely heterogeneous population, they are underrepresented in clinical trials, and data on octogenarians have been mainly limited to real-life settings. Treatment options for intermediate and frail patients might include dose-adapted combinations and less toxic combinations based on novel agents. Moreover, the discriminative power of the International Myeloma Working Group (IMWG) frailty score in detecting frailty and vulnerability could be improved by combining together aging-related factors (performance status, comorbidities, functional status) with disease-related factors (International Staging System stage, cytogenetic risk). Objective parameters could improve the reproducibility of this score and limit the subjectivity determined by patient-reported questionnaires on functional evaluations. Efforts are ongoing to simplify the IMWG frailty score and expand its use in real-life clinical practice. Abstract Multiple myeloma (MM) mostly affects elderly patients, which represent a highly heterogeneous population. Indeed, comorbidities, frailty status and functional reserve may vary considerably among patients with similar chronological age. For this reason, the choice of treatment goals and intensity is particularly challenging in elderly patients, and it requires a multidimensional evaluation of the patients and the disease. In recent years, different tools to detect patient frailty have been developed, and the International Myeloma Working Group frailty score currently represents the gold standard. It identifies intermediate-fit and frail patients requiring gentler treatment approaches compared to fit patients, aiming to preserve quality of life and prevent toxicities. This subset of patients is underrepresented in clinical trials, and studies exploring frailty-adapted approaches are scarce, making the choice of therapy extremely challenging. Treatment options for intermediate-fit and frail patients might include dose-adapted combinations, doublets, and less toxic combinations based on novel agents. This review analyzes the available tools for the assessment of frailty and possible strategies to improve the discriminative power of the scores and expand their use in real-life and clinical trial settings. Moreover, it addresses the main therapeutic challenges in the management of intermediate-fit and frail MM patients at diagnosis and at relapse.
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Multiple myeloma current treatment algorithms. Blood Cancer J 2020; 10:94. [PMID: 32989217 PMCID: PMC7523011 DOI: 10.1038/s41408-020-00359-2] [Citation(s) in RCA: 161] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/11/2020] [Accepted: 08/20/2020] [Indexed: 12/22/2022] Open
Abstract
The treatment of multiple myeloma (MM) continues to evolve rapidly with arrival of multiple new drugs, and emerging data from randomized trials to guide therapy. Along the disease course, the choice of specific therapy is affected by many variables including age, performance status, comorbidities, and eligibility for stem cell transplantation. In addition, another key variable that affects treatment strategy is risk stratification of patients into standard and high-risk MM. High-risk MM is defined by the presence of t(4;14), t(14;16), t(14;20), gain 1q, del(17p), or p53 mutation. In this paper, we provide algorithms for the treatment of newly diagnosed and relapsed MM based on the best available evidence. We have relied on data from randomized controlled trials whenever possible, and when appropriate trials to guide therapy are not available, our recommendations reflect best practices based on non-randomized data, and expert opinion. Each algorithm has been designed to facilitate easy decision-making for practicing clinicians. In all patients, clinical trials should be considered first, prior to resorting to the standard of care algorithms we outline.
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Derudas D, Capraro F, Martinelli G, Cerchione C. How I manage frontline transplant-ineligible multiple myeloma. Hematol Rep 2020; 12:8956. [PMID: 33042505 PMCID: PMC7520858 DOI: 10.4081/hr.2020.8956] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Indexed: 12/24/2022] Open
Abstract
The Multiple Myeloma (MM) is a plasma cells hematological malignancy with a median age of 69 years at diagnosis. The autologous stem cell transplantation is the standard of care for this disease but less than half of newly diagnosed patients are assessed for this treatment due to comorbidities or complications of disease. The management of transplant ineligible MM patients is based on the balance safety and efficacy of the new available regimen and a careful assessment of the frailty status is mandatory to define the goals. In this review we discuss of the clinical dilemmas in the management and define how to manage them based on the evidence from clinical trials and "real life" experience.
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Affiliation(s)
- Daniele Derudas
- S.C. di Ematologia e C.T.M.O., Ospedale Oncologico di Riferimento Regionale “A. Businco”, Cagliari
| | - Francesca Capraro
- S.C. di Ematologia e C.T.M.O., Ospedale Oncologico di Riferimento Regionale “A. Businco”, Cagliari
| | - Giovanni Martinelli
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola (FC), Italy
| | - Claudio Cerchione
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola (FC), Italy
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Modification and application of polysaccharide from traditional Chinese medicine such as Dendrobium officinale. Int J Biol Macromol 2020; 157:385-393. [DOI: 10.1016/j.ijbiomac.2020.04.141] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 04/08/2020] [Accepted: 04/18/2020] [Indexed: 01/17/2023]
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36
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Atrash S, Bhutani M, Paul B, Voorhees PM, Usmani SZ. Management of newly diagnosed transplant ineligible multiple myeloma. Leuk Lymphoma 2020; 61:2549-2560. [PMID: 32623918 DOI: 10.1080/10428194.2020.1786558] [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: 10/23/2022]
Abstract
Multiple myeloma (MM) is a chronically managed blood cancer with a median age of 69 years at the time of diagnosis. Although high dose melphalan and autologous stem cell transplantation (ASCT) remains a standard of care for eligible patients, more than half of the newly diagnosed MM patients are deemed ineligible due to comorbidities or complications of the disease by itself. In this setting, where ASCT is deemed inappropriate, patients could still achieve durable and deep responses if given the appropriate treatment plan. The key concepts of optimizing induction and maintenance strategies while minimizing side-effects are discussed in this review, especially in the context of employing novel agent combinations. It is important to understand the balance between safety and efficacy for each regimen, utilizing maintenance strategy and the best supportive care measures (bone health, infection prevention, and treatment, pain management, etc.). Here, we examine the evidence behind each of those principles and review results from clinical trials for transplant-ineligible (TI) MM.
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Affiliation(s)
- Shebli Atrash
- Department of Hematologic Oncology & Blood Disorders, Division of Plasma Cell Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | - Manisha Bhutani
- Department of Hematologic Oncology & Blood Disorders, Division of Plasma Cell Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | - Barry Paul
- Department of Hematologic Oncology & Blood Disorders, Division of Plasma Cell Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | - Peter M Voorhees
- Department of Hematologic Oncology & Blood Disorders, Division of Plasma Cell Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | - Saad Z Usmani
- Department of Hematologic Oncology & Blood Disorders, Division of Plasma Cell Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
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Zanwar S, Abeykoon JP, Kapoor P. Challenges and Strategies in the Management of Multiple Myeloma in the Elderly Population. Curr Hematol Malig Rep 2020; 14:70-82. [PMID: 30820879 DOI: 10.1007/s11899-019-00500-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Approximately one half of the patient-population in multiple myeloma (MM) is > 70 years at diagnosis. Despite notable strides in the management and improved survival, MM remains incurable, with an increasing proportion of elderly patients comprising the relapsed-refractory cohort. RECENT FINDINGS The arbitrary age cutoff at 65 years to define the elderly patient-population has evolved to a more nuanced categorization, incorporating a comprehensive assessment for determining frailty prior to commencing treatment. This step is critical in determining the therapy-intensity, including transplant-eligibility, to minimize toxicity. Dose-modifications are crucial, as the merits of continuous therapy are becoming evident in this patient-population. Bortezomib, lenalidomide, and dexamethasone (VRd) combination has emerged as standard of care for newly diagnosed MM. Fixed-duration Rd followed by reduced-dosed continuous R may be considered in select frail patients with standard-risk MM. Herein, we review the unique challenges encountered in elderly MM and discuss strategies for optimal management.
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Affiliation(s)
- Saurabh Zanwar
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Prashant Kapoor
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Cavo M, Dimopoulos MA, San-Miguel J, Mateos MV, Jakubowiak A, Deraedt W, Lam A, Kampfenkel T, Qi M, He J. Comparative Efficacy of Bortezomib, Melphalan, and Prednisone (VMP) With or Without Daratumumab Versus VMP Alone in the Treatment of Newly Diagnosed Multiple Myeloma: Propensity Score Matching of ALCYONE and VISTA Phase III Studies. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:480-489. [DOI: 10.1016/j.clml.2020.02.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/21/2020] [Accepted: 02/27/2020] [Indexed: 12/19/2022]
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Maruyama D, Iida S, Ogawa G, Fukuhara N, Seo S, Miyazaki K, Yoshimitsu M, Kuroda J, Tsukamoto N, Tsujimura H, Hangaishi A, Yamauchi T, Utsumi T, Mizuno I, Takamatsu Y, Nagata Y, Minauchi K, Ohtsuka E, Hanamura I, Yoshida S, Yamasaki S, Suehiro Y, Kamiyama Y, Tsukasaki K, Nagai H. Randomised phase II study to optimise melphalan, prednisolone, and bortezomib in untreated multiple myeloma (JCOG1105). Br J Haematol 2020; 192:531-541. [PMID: 32583431 PMCID: PMC7891591 DOI: 10.1111/bjh.16878] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/21/2020] [Accepted: 05/21/2020] [Indexed: 01/04/2023]
Abstract
We conducted a randomised phase II study to determine the optimal dose and schedule of melphalan, prednisone, and bortezomib (MPB) (jRCTs031180097). Transplant‐ineligible untreated multiple myeloma patients were randomised to Arm A (twice weekly bortezomib in one six‐week cycle followed by eight five‐week cycles of four times once weekly bortezomib with melphalan and prednisolone on days 1–4) or Arm B (nine four‐week cycles of three times once weekly bortezomib with melphalan and prednisolone on days 1–4). The primary end‐point was complete response (CR) rate. Of 91 patients randomised to two arms, 88 were eligible. The median cumulative bortezomib doses were 45·8 and 35·1 mg/m2, CR rate was 18·6% [95% confidence interval (CI) 8·4–33·4] and 6·7% (95% CI 1·4–18·3), and the median progression‐free survival (PFS) was 2·5 and 1·4 years in Arms A and B [hazard ratio (HR) 1·93 (95% CI 1·09–3·42)], respectively. Frequent grade ≥3 haematologic toxicities in Arms A and B were neutropenia (64·4% vs. 28·3%) and thrombocytopenia (35·6% vs. 10·9%). Grade 2/3 peripheral neuropathy was observed in 24·4/2·2% in Arm A and 8·7/0% in Arm B. In conclusion, Arm A was the more promising regimen, suggesting that the twice weekly schedule of bortezomib in the first cycle and higher cumulative dose of both bortezomib and melphalan influences the efficacy of modified MPB.
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Affiliation(s)
- Dai Maruyama
- Department of Hematology, National Cancer Center Hospital, Tokyo, Japan
| | - Shinsuke Iida
- Department of Hematology and Oncology, Nagoya City University Hospital, Nagoya, Japan
| | - Gakuto Ogawa
- JCOG Data Center/Operating Office, National Cancer Center Hospital, Tokyo, Japan
| | - Noriko Fukuhara
- Department of Hematology and Rheumatology, Tohoku University Hospital, Sendai, Japan
| | - Sachiko Seo
- Department of Hematology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Kana Miyazaki
- Department of Hematology and Oncology, Mie University School of Medicine, Tsu, Japan
| | - Makoto Yoshimitsu
- Department of Hematology and Rheumatology, Kagoshima University Hospital, Kagoshima, Japan
| | - Junya Kuroda
- Division of Hematology and Oncology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | | | - Hideki Tsujimura
- Division of Hematology-Oncology, Chiba Cancer Center, Chiba, Japan
| | - Akira Hangaishi
- Division of Hematology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Takahiro Yamauchi
- Department of Hematology and Oncology, University of Fukui Hospital, Fukui, Japan
| | - Takahiko Utsumi
- Department of Hematology, Shiga General Hospital, Moriyama, Japan
| | | | - Yasushi Takamatsu
- Division of Medical Oncology, Hematology and Infectious Diseases, Fukuoka University Hospital, Fukuoka, Japan
| | - Yasuyuki Nagata
- Department of Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | | | - Eiichi Ohtsuka
- Department of Hematology, Oita Prefectural Hospital, Oita, Japan
| | - Ichiro Hanamura
- Division of Hematology, Aichi Medical University, Nagakute, Japan
| | - Shinichiro Yoshida
- Department of Hematology, National Hospital Organization Nagasaki Medical Center, Ohmura, Japan
| | - Satoshi Yamasaki
- Department of Hematology and Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Japan
| | - Youko Suehiro
- Department of Hematology, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Yutaro Kamiyama
- Department of Clinical Oncology and Hematology, The Jikei University Hospital, Tokyo, Japan
| | - Kunihiro Tsukasaki
- Department of Hematology, Comprehensive Cancer Center, International Medical Center, Saitama Medical University, Saitama, Japan
| | - Hirokazu Nagai
- Department of Hematology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
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Wu P, Oren O, Gertz MA, Yang EH. Proteasome Inhibitor-Related Cardiotoxicity: Mechanisms, Diagnosis, and Management. Curr Oncol Rep 2020; 22:66. [DOI: 10.1007/s11912-020-00931-w] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Knauf W, Dingeldein G, Schlag R, Welslau M, Moehler T, Terzer T, Walter S, Habermehl C, Kunz C, Goldschmidt H, Raab MS. First-line therapy with bendamustine/prednisone/bortezomib-A GMMG trial for non-transplant eligible symptomatic multiple myeloma patients. Eur J Haematol 2020; 105:116-125. [PMID: 32155662 DOI: 10.1111/ejh.13409] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The German-speaking Myeloma Multicenter Group (GMMG) conducted this trial to investigate efficacy and safety of the three-drug combination bendamustine/prednisone/bortezomib (BPV) as first-line therapy for elderly patients with multiple myeloma (MM). METHODS Elderly MM patients requiring first-line therapy and not eligible for intensive treatment were enrolled in this phase IIb multicenter study. Patients were treated with BPV regimen for a maximum of nine cycles. RESULTS Forty-six patients were included in the trial with a median age of 76 years. Nineteen patients had renal impairment at baseline. The ORR was 78.8% for patients treated with 3 and more BPV cycles and 71.1% for all evaluable patients. The median progression-free survival was 25 months, and overall survival at 24 months was 83.3%. The clinical benefit rate including MR was 91.2%. In patients with renal impairment at baseline, a renal response was observed in 11 pts. with complete recovery of the renal function in six patients. The most frequent CTC grade 3/4 AEs experienced by patients were hematological (17.5%) and infectious (9.8%) complications. No new safety signals were observed for the study drugs under investigation. CONCLUSIONS Bendamustine/prednisone/bortezomib may serve as a first-line regimen for transplant-ineligible elderly MM patients in particular for patients with renal impairment requiring a fast and durable renal response.
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Affiliation(s)
- Wolfgang Knauf
- Centrum Haematologie & Onkologie Bethanien, Frankfurt, Germany
| | | | - Rudolf Schlag
- Hämatologisch-Onkologische Schwerpunktpraxis, Würzburg, Germany
| | | | | | - Tobias Terzer
- Department of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - Sarah Walter
- Koordinierungszentrum für klinische Studien Heidelberg, FRG, Heidelberg, Germany
| | - Christina Habermehl
- Department of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - Christina Kunz
- Department of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - Hartmut Goldschmidt
- Department of Medicine V, University of Heidelberg, Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Marc-Steffen Raab
- Department of Medicine V, University of Heidelberg, Heidelberg, Germany
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Mina R, Belotti A, Petrucci MT, Zambello R, Capra A, Di Lullo G, Ronconi S, Pescosta N, Grasso M, Monaco F, Cellini C, Gobbi M, Ballanti S, de Fabritiis P, Mosca-Siez ML, Marchetti M, Liberati AM, Offidani M, Giuliani N, Ria R, Musto P, Romano A, Sonneveld P, Boccadoro M, Larocca A. Bortezomib-dexamethasone as maintenance therapy or early retreatment at biochemical relapse versus observation in relapsed/refractory multiple myeloma patients: a randomized phase II study. Blood Cancer J 2020; 10:58. [PMID: 32424154 PMCID: PMC7234990 DOI: 10.1038/s41408-020-0326-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/27/2020] [Accepted: 04/30/2020] [Indexed: 12/03/2022] Open
Affiliation(s)
- Roberto Mina
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Angelo Belotti
- Division of Hematology, Spedali Civili di Brescia, Brescia, Italy
| | - Maria Teresa Petrucci
- Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Renato Zambello
- Padova University School of Medicine, Hematology and Clinical Immunology, Padova, Italy
| | - Andrea Capra
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Giacomo Di Lullo
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Sonia Ronconi
- Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Norbert Pescosta
- Reparto di Ematologia e Centro TMO, Ospedale Centrale, Bolzano, Italy
| | - Mariella Grasso
- S.C. Ematologia, Azienda Ospedaliera Santa Croce - Carle, Cuneo, Italy
| | - Federico Monaco
- Dipartimento di Ematologia e Medicina Trasfusionale, Azienda Ospedaliera 'SS. Antonio e Biagio e Cesare Arrigo', Alessandria, Italy
| | - Claudia Cellini
- U.O.C. EMATOLOGIA, Ospedale Santa Maria delle Croci, Ravenna, Italy
| | - Marco Gobbi
- Clinical Hematology, Ospedale Policlinico S. Martino, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
| | - Stelvio Ballanti
- Ematologia con TMO, Ospedale Santa Maria della Misericordia di Perugia, Perugia, Italy
| | | | | | - Monia Marchetti
- Day Hospital Ematologico, Ospedale Cardinal Massaia, Asti, Italy.,Unità di Ematologia, Azienda Sanitaria Ospedaliera 'Ss. Antonio e Biagio e Cesare Arrigo', Alessandria, Italy
| | - Anna Marina Liberati
- Università degli Studi di Perugia - Azienda Ospedaliera Santa Maria, Terni, Italy
| | - Massimo Offidani
- Clinica di Ematologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, Ancona, Italy
| | - Nicola Giuliani
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Roberto Ria
- Internal Medicine "G. Baccelli", Department of Biomedical Science, University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Pellegrino Musto
- Hematology, IRCCS CROB, Rionero in Vulture (Pz), Italy.,Unit of Hematology and Stem Cell Transplantation, AOU Policlinico Giovanni XXIII, School of Medicine, Aldo Moro University, Bari, Italy
| | - Alessandra Romano
- Division of Hematology, AOU Policlinico-OVE, University of Catania, Catania, Italy
| | - Pieter Sonneveld
- Department of Hematology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Alessandra Larocca
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy.
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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: 448] [Impact Index Per Article: 112.0] [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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Optimizing Immunomodulatory Drug With Proteasome Inhibitor Combinations in Newly Diagnosed Multiple Myeloma. ACTA ACUST UNITED AC 2020; 25:2-10. [PMID: 30694854 DOI: 10.1097/ppo.0000000000000348] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In the modern era of multiple myeloma therapeutics, proteasome inhibitor (PI) and immunomodulatory drugs (IMiDs) have replaced chemotherapy regimens for newly diagnosed multiple myeloma patients. Treatment combinations that comprise both first- and next-generation PIs, including bortezomib, carfilzomib, and ixazomib and IMiDs, including thalidomide and lenalidomide, have been evaluated in phases II and III clinical trials and have shown significant efficacy with manageable toxicity profiles. Bortezomib or carfilzomib with lenalidomide and dexamethasone (VRD and KRD) are the most promising regimens resulting in significant survival improvement. Disease and patient characteristics should lead the individualization of treatment, with the eligibility for autologous transplant being of principal importance. The addition of a monoclonal antibody to PI with IMiD combinations is currently under clinical investigation and may lead to further treatment optimization.
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Bortezomib-based consolidation or maintenance therapy for multiple myeloma: a meta-analysis. Blood Cancer J 2020; 10:33. [PMID: 32144237 PMCID: PMC7060191 DOI: 10.1038/s41408-020-0298-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 02/11/2020] [Accepted: 02/18/2020] [Indexed: 01/22/2023] Open
Abstract
Bortezomib-based regimens are widely used as induction therapy for multiple myeloma (MM). Unlike lenalidomide, the role of bortezomib in consolidation and maintenance therapy for MM is less clear. We performed a meta-analysis to evaluate the impact of bortezomib-based consolidation and maintenance therapy on survival outcomes and adverse events. PubMed, Web of Science, Embase databases, and major conference proceedings were searched for randomized controlled trials (RCTs) of bortezomib-based regimens as consolidation or maintenance therapy for MM. Ten RCTs enrolling 3147 patients were included in the meta-analysis. Bortezomib-based regimens were compared with regimens without bortezomib or observation. The meta-analysis suggested that bortezomib-based maintenance therapy improved progression-free survival (PFS; hazard ratio [HR] = 0.72, 95% CI 0.55-0.95, P = 0.02) and overall survival (OS; HR = 0.71, 95% CI 0.58-0.87, P = 0.001). Bortezomib-based consolidation therapy improved PFS (HR = 0.77, 95% CI 0.68-0.88, P < 0.001) but not OS (HR = 0.98, 95% CI 0.78-1.24, P = 0.87). Bortezomib-based consolidation/maintenance therapy led to a trend toward increased risk of grade ≥ 3 neurologic symptoms, gastrointestinal symptoms, and fatigue. More research is warranted to further assess the role of bortezomib-based consolidation and maintenance therapy for multiple myeloma.
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Moreau P, Touzeau C, Vij R, Goldsmith SR, Rosko AE. Newly Diagnosed Myeloma in 2020. Am Soc Clin Oncol Educ Book 2020; 40:1-15. [PMID: 32315239 DOI: 10.1200/edbk_280221] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Over the last few years, there has been great progress in the treatment of multiple myeloma (MM), with many new agents and combinations having been approved and being now routinely incorporated into treatment strategies for newly diagnosed patients. 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. Frontline autologous stem cell transplantation (ASCT) is the standard of care for fit patients younger than age 71 who are newly diagnosed with MM, and triplet combinations are the backbone of induction therapy before ASCT. Post-transplant consolidation and prolonged lower-intensity maintenance are two strategies that have been used to deepen responses and delay progression. For older patients not eligible for ASCT, lenalidomide (len) is increasingly being used as part of frontline therapy, and current approaches are now targeting combinations of anti-CD38 antibodies. Strategies for selecting therapeutic regimens for older adults newly diagnosed with MM can be augmented with use of predictive tools to better capture physiologic age and estimate treatment tolerance. Here we review a decade of trials identifying clinical endpoints and toxicities relevant for the frontline treatment of younger patients and older adults.
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Affiliation(s)
- Philippe Moreau
- Department of Hematology, University Hospital, Nantes, France
| | - Cyrille Touzeau
- Department of Hematology, University Hospital, Nantes, France
| | - Ravi Vij
- Washington University School of Medicine, St. Louis, MO
| | | | - Ashley E Rosko
- Division of Hematology, The Ohio State University, Columbus, OH
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Parasrampuria DA, He J, Zhang L, Muresan B, Hu P, Nemat S, Hashim M, Lam A, Appiani C, Cavo M, Dimopoulos MA, San-Miguel J, Mateos MV. Comparison of efficacy from two different dosing regimens of bortezomib: an exposure-response analysis. Br J Haematol 2020; 189:860-868. [PMID: 32068255 DOI: 10.1111/bjh.16446] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 11/08/2019] [Indexed: 11/30/2022]
Abstract
Bortezomib is a first-in-class proteasome inhibitor, approved for the treatment of multiple myeloma. The originally approved dosing schedule of bortezomib results in significant toxicities that require dose interruptions and discontinuations. Consequentially, less frequent dosing has been explored to optimise bortezomib's benefit-risk profile. Here, we performed exposure-response analysis to compare the efficacy of the original bortezomib dosing regimen with less frequent dosing of bortezomib over nine 6-week treatment cycles using data from the VISTA clinical trial and the control arm of the ALCYONE clinical trial. The relationship between cumulative bortezomib dose and clinical response was evaluated with a univariate logit model. The median cumulative bortezomib dose was higher in ALCYONE versus VISTA (42·2 vs. 38·5 mg/m2 ) and ALCYONE patients stayed on treatment longer (mean: 7·2 vs. 5·8 cycles). For all endpoints and regimens, probability of clinical response correlated with cumulative bortezomib dose. Similar to results observed for VISTA, overall survival was longer in ALCYONE patients with ≥ 39·0 versus < 39·0 mg/m2 cumulative dose (hazard ratio, 0·119; P < 0·0001). Less frequent bortezomib dosing results in comparable efficacy, and a higher cumulative dose than the originally approved bortezomib dosing schedule, which may be in part be due to reduced toxicity and fewer dose reductions/interruptions.
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Affiliation(s)
| | - Jianming He
- Janssen Global Services, LLC, Raritan, NJ, USA
| | - Liping Zhang
- Janssen Research & Development, LLC, Spring House, PA, USA
| | | | - Peter Hu
- Janssen Research and Development, LLC, Raritan, NJ, USA
| | | | | | - Annette Lam
- Janssen Global Services, LLC, Raritan, NJ, USA
| | | | - Michele Cavo
- Seràgnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
| | | | - Jesus San-Miguel
- Clínica Universidad de Navarra-CIMA, IDISNA, CIBERONC, Pamplona, Spain
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Medina A, Jiménez C, Sarasquete ME, González M, Chillón MC, Balanzategui A, Prieto-Conde I, García-Álvarez M, Puig N, González-Calle V, Alcoceba M, Cuenca I, Barrio S, Escalante F, Gutiérrez NC, Gironella M, Hernández MT, Sureda A, Oriol A, Bladé J, Lahuerta JJ, San Miguel JF, Mateos MV, Martínez-López J, Calasanz MJ, García-Sanz R. Molecular profiling of immunoglobulin heavy-chain gene rearrangements unveils new potential prognostic markers for multiple myeloma patients. Blood Cancer J 2020; 10:14. [PMID: 32029700 PMCID: PMC7004993 DOI: 10.1038/s41408-020-0283-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 01/16/2020] [Accepted: 01/21/2020] [Indexed: 01/09/2023] Open
Abstract
Multiple myeloma is a heterogeneous disease whose pathogenesis has not been completely elucidated. Although B-cell receptors play a crucial role in myeloma pathogenesis, the impact of clonal immunoglobulin heavy-chain features in the outcome has not been extensively explored. Here we present the characterization of complete heavy-chain gene rearrangements in 413 myeloma patients treated in Spanish trials, including 113 patients characterized by next-generation sequencing. Compared to the normal B-cell repertoire, gene selection was biased in myeloma, with significant overrepresentation of IGHV3, IGHD2 and IGHD3, as well as IGHJ4 gene groups. Hypermutation was high in our patients (median: 8.8%). Interestingly, regarding patients who are not candidates for transplantation, a high hypermutation rate (≥7%) and the use of IGHD2 and IGHD3 groups were associated with improved prognostic features and longer survival rates in the univariate analyses. Multivariate analysis revealed prolonged progression-free survival rates for patients using IGHD2/IGHD3 groups (HR: 0.552, 95% CI: 0.361-0.845, p = 0.006), as well as prolonged overall survival rates for patients with hypermutation ≥7% (HR: 0.291, 95% CI: 0.137-0.618, p = 0.001). Our results provide new insights into the molecular characterization of multiple myeloma, highlighting the need to evaluate some of these clonal rearrangement characteristics as new potential prognostic markers.
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Affiliation(s)
- Alejandro Medina
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | - Cristina Jiménez
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | - M Eugenia Sarasquete
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain.
| | - Marcos González
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | - M Carmen Chillón
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | - Ana Balanzategui
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | - Isabel Prieto-Conde
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | - María García-Álvarez
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | - Noemí Puig
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | - Verónica González-Calle
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | - Miguel Alcoceba
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | | | | | | | - Norma C Gutiérrez
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | | | | | - Anna Sureda
- Hospital Duran i Reynals, Institut Català d'Oncología (ICO), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Albert Oriol
- Hospital Germans Trias i Pujol, Institut Català d'Oncología (ICO), Institut Josep Carreras, Badalona, Spain
| | - Joan Bladé
- Hospital Clínic i Provincial, Institut de Investicacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Jesús F San Miguel
- Clínica Universidad de Navarra (CUN), Centro de Investigación Médica Aplicada, IDISNA, CIBERONC, Pamplona, Spain
| | - María-Victoria Mateos
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | | | - María-José Calasanz
- Clínica Universidad de Navarra (CUN), Centro de Investigación Médica Aplicada, IDISNA, CIBERONC, Pamplona, Spain
| | - Ramón García-Sanz
- Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
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Vaxman I, Gertz M. Non-transplant eligible multiple myeloma: deciphering optimal first line regimens. Leuk Lymphoma 2020; 61:504-506. [PMID: 31975634 DOI: 10.1080/10428194.2020.1716223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Iuliana Vaxman
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.,Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Petah-Tikvah, Israel.,Israel Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Morie Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
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50
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Goto D, Khairnar R, Yared JA, Yong C, Romanus D, Onukwugha E, Slejko JF. Utilization of novel systemic therapies for multiple myeloma: A retrospective study of front-line regimens using the SEER-Medicare data. Cancer Med 2020; 9:626-639. [PMID: 31801177 PMCID: PMC6970041 DOI: 10.1002/cam4.2698] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 09/20/2019] [Accepted: 10/13/2019] [Indexed: 11/17/2022] Open
Abstract
The landscape of treatment for multiple myeloma (MM) has significantly changed over the last decade due to novel agents that have shown superiority in efficacy such as proteasome inhibitors (PIs) and immunomodulatory drugs (IMiDs) over traditional therapies. However, the real-world utilization of these new agents has not been studied well. This study evaluated year-to-year changes in treatment choices in a cohort of patients aged 66 or older in the Surveillance, Epidemiology, and End Results (SEER) registry linked with Medicare claims (SEER-Medicare) data who were diagnosed with MM between 2007 and 2011. We identified 2477 symptomatic newly diagnosed patients who were followed for 6 months or more postdiagnosis and treated with systemic therapies but not with stem cell transplantation. Symptomatic patients were identified by evidence of hypercalcemia, renal failure, anemia, or bone lesions (CRAB criteria). The minimum follow-up was imposed to ensure sufficient data to characterize treatment. Our analysis found that the proportion of treated patients increased from 75% in the 2007 cohort to 79% in the 2011 cohort. The share of PI-based regimens including PI plus alkylating agents, PI plus IMiD, and PI-only increased from 9% to 21%, 3% to 11%, and 16% to 22%, respectively, between 2007 and 2011. These findings translate to the share of PI-based regimens having increased from 28% to 55% and that of IMiDs-based regimens (excluding PI plus IMiD) having decreased from 43% to 27%. In conclusion, while the usage of PIs among elderly MM patients increased significantly replacing IMiD-based regimens (with or without alkylating agents but not with PI) between 2007 and 2011, this significant shift did not increase the proportion of treated patients.
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Affiliation(s)
| | - Rahul Khairnar
- Department of Pharmaceutical Health Services ResearchUniversity of Maryland School of PharmacyBaltimoreMDUSA
| | - Jean A. Yared
- Department of MedicineUniversity of Maryland School of MedicineBaltimoreMDUSA
| | | | - Dorothy Romanus
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company LimitedCambridgeMAUSA
| | - Eberechukwu Onukwugha
- Department of Pharmaceutical Health Services ResearchUniversity of Maryland School of PharmacyBaltimoreMDUSA
| | - Julia F. Slejko
- Department of Pharmaceutical Health Services ResearchUniversity of Maryland School of PharmacyBaltimoreMDUSA
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