International Myeloma Working Group consensus criteria for response and minimal residual disease assessment in multiple myeloma

Time to progression predicts outcome of patients with multiple myeloma that can be influenced by autologous hematopoietic stem cell transplantation

OBJECTIVES

Currently, there is limited understanding regarding the prognostic significance of time to progression (TTP) after first remission in multiple myeloma (MM).

METHODS

We conducted a retrospective analysis of clinical data from 209 patients with MM. These patients were categorized into ≤ 6 months, ≤ 12 months, ≤ 24 months, > 24 months, 6-12 months, and 12-24 months subgroups based on TTP.

RESULTS

Patients in ≤ 12 months group exhibited shorter median overall survival (OS) and OS-1 compared to those in ≤ 24 months group (61.73 vs 96.10 months, P = 0.02; 54.00 vs 74.17 months, P = 0.048). ≤ 6 months group exhibited shorter median OS and OS-1 compared to 6-12 months group (33.63 vs 79.60 months, P = 0.022; 19.93 vs 65.17 months, P = 0.015). Patients in 6-12 months group had shorter median OS and OS-1 compared to those in 12-24 months group (79.60 vs 100.43 months, P < 0.001; 65.17 vs 77.17 months, P = 0.012).No significant difference in OS was observed between patients in 12-24 months and > 24 months groups. For patients who experienced progression within 12 or 24 months after remission, undergoing autologous hematopoietic stem cell transplantation (ASCT) after progression conferred a median OS and OS-2 advantage over receiving post-progression chemotherapy. Multivariable analysis confirmed that TTP was an independent predictor for OS in patients with MM.

CONCLUSION

Patients with MM who experience earlier disease progression within 12 months after remission have a worse prognosis, and post-progression ASCT can improve their survival outcomes.

Belantamab Mafodotin Monotherapy for Multiply-Relapsed Myeloma: A Retrospective Study From the United Kingdom and the Republic of Ireland

Introduction

Belantamab mafodotin (belamaf) was the first BCMA-targeting immunotherapy licensed in myeloma and was available as monotherapy for a fifth or greater line of treatment. Outcomes for patients in the United Kingdom and the Republic of Ireland potentially differ from those of other regions and may illuminate factors predicting response to therapy.

Methods and Results

We performed a retrospective study of patients treated with belamaf monotherapy in the United Kingdom and the Republic of Ireland. In our cohort of 88 patients, we saw an overall response rate (ORR) of 60%, a median progression-free survival (PFS) of 8.7 months and a median duration of response (DoR) of 15.8 months. The spectrum of adverse events was as expected, with 84% (71/85) of patients experiencing toxicity. Eye-related adverse events were the most common, affecting 66% (56/85), leading to dose reduction or delay in 41% (35/85) and discontinuation in 6% (5/85). We specifically assessed physician decision-making in the context of ocular side effects and found a relatively high frequency of the drug being administered despite moderate levels of toxicity.

Conclusion

Our cohort's ORR is significantly different from those of the DREAMM-2 and -3 trials and other real-world studies, though a long-duration response has been reported in other cohorts. Comparative analysis with other real-world studies did not reveal any significant factors predictive of ORR. The frequent administration of belamaf to patients with eye disease may well reflect a more pragmatic approach than was originally prescribed in the landmark trials.

Trial Registration

The authors have confirmed clinical trial registration is not needed for this submission.

Anti-GPRC5D CAR T-cell therapy as a salvage treatment in patients with progressive multiple myeloma after anti-BCMA CAR T-cell therapy: a single-centre, single-arm, phase 2 trial

BACKGROUND

For patients with multiple myeloma progression after anti-BCMA chimeric antigen receptor (CAR) T-cell therapy, the optimal salvage treatment strategies remain unclear. GPRC5D-directed CAR T cell might be a potential option. The aim of this trial was to investigate the activity and safety of anti-GPRC5D CAR T cells in patients with progressive multiple myeloma after anti-BCMA CAR T-cell therapy.

METHODS

In this phase 2, open-label, single-arm, phase 2 trial, at the Affiliated Hospital of Xuzhou Medical University in China, we enrolled patients (aged 18-70 years old) with relapsed or refractory multiple myeloma who had progressed disease after anti-BCMA CAR T-cell therapy and a life expectancy of more than 12 weeks without active infections, serious liver, heart, or other diseases. Patients were assigned to receive a single dose of intravenous anti-GPRC5D CAR T cell at 2 × 106 cells per kg. The primary endpoint was the overall response rate, including stringent complete response, complete response, very good partial response, and partial response, according to the standard International Myeloma Working Group response assessment criteria. Activity and safety analyses were done in the patients who received a dose of anti-GPRC5D CAR T cell as defined in the protocol. This trial is registered with the Chinese Clinical Trial Registration Center, ChiCTR2100048888, and is ongoing.

FINDINGS

Between Dec 1, 2021, and May 1, 2024, 42 patients were screened, 37 were enrolled and received anti-GPRC5D CAR T-cell therapy. Median age was 59 years (IQR 51-65), 17 (46%) of 37 patients were male and 20 (54%) female. All patients were Asian. At a median follow-up of 12·6 months (IQR 8·2-20·8), the overall response rate was 84% (95% CI 68-94, 31 of 37 patients), including 13 (35%) complete responses or better. The most common grade 3-4 adverse events were haematological toxicities, including leukopenia (34 [92%] of 37 patients), lymphopenia (36 [97%]), neutropenia (29 [78%]), anaemia (23 [62%]), and thrombocytopenia (23 [62%]). 26 (70%) of 37 patients had cytokine release syndrome, which was of grade 3 in two (5%) patients. One case of grade 1 immune effector cell-associated neurotoxicity syndrome was observed. There were no treatment-related deaths in the trial.

INTERPRETATION

Anti-GPRC5D CAR T-cell salvage therapy induced a high response rate, and could be a potential treatment option in relapsed or refractory multiple myeloma patients who have progressed after anti-BCMA CAR T-cell treatment. Further investigations are warranted to establish the long-term efficacy and safety of this therapeutic approach.

FUNDING

National Natural Science Foundation of China and the General Project of Jiangsu Commission of Health.

Engaging a New Treatment Paradigm: Elranatamab in Relapsed/Refractory Multiple Myeloma

OBJECTIVE

To review the therapeutic profile of elranatamab, a novel bispecific T-cell-redirecting therapy, in treating relapsed or refractory (R/R) multiple myeloma (MM).

DATA SOURCES

A PubMed search was conducted for English-language articles published from January 2000 through June 2024, using the search terms: PF-06863135, elranatamab, Elrexfio, and "Multiple Myeloma." Additional data were obtained from ClinicalTrials.gov and other pertinent publications and meeting abstracts.

STUDY SELECTION AND DATA EXTRACTION

Clinical trials, guidelines, and prescribing information pertaining to elranatamab were included.

DATA SYNTHESIS

The phase II MagentisMM-3 trial demonstrated an overall response rate of 61.0% (95% confidence interval, 51.8-69.6) in patients naïve to B-cell maturation antigen targeting therapy (cohort A, n = 123), establishing elranatamab monotherapy as a viable treatment option for patients with R/R MM who have received at least 4 prior lines of therapy. The duration of response and progression-free survival at 12 months were 75.3% and 56.6%, respectively.Relevance to patient care and clinical practice in comparison with existing drugs:Despite the promising activity of elranatamab in R/R MM, the significant treatment-related adverse effects (AEs) associated with this therapy necessitate careful monitoring and expert management. Common AEs include cytokine release syndrome, neurotoxicity, hematologic toxicity, and infectious complications. The cost-effectiveness of elranatamab has yet to be evaluated.

CONCLUSIONS

Elranatamab is approved by the Food and Drug Administration as a treatment option for patients with heavily pretreated R/R MM. Further studies are warranted to identify the optimal treatment strategy for elranatamab and other bispecific antibodies in the management of R/R MM.

Disease Characteristics and Treatment Outcomes of Myeloma Patients Under 50 Years of Age: An Analysis of the Balkan Myeloma Study Group

BACKGROUND

Multiple myeloma (MM) is predominantly a disease of the elderly, but approximately 10% of patients are younger than 50 years at diagnosis.   METHODS: This study aimed to investigate the clinical characteristics, treatment outcomes, and prognostic factors in younger MM patients using retrospective data from the Balkan Myeloma Study Group registry.   RESULTS: A total of 350 patients under 50 years old were included, comprising 10.4% of the overall cohort. The study found that younger patients had lower rates of renal impairment and anemia but a higher incidence of lytic bone disease and adverse cytogenetics. Treatment regimens, including proteasome inhibitors and immunomodulatory agents, were comparable between younger and older patients, but younger patients had significantly better complete response rates and overall survival (OS). The 5- and 10-year OS rates were 76% and 64%, respectively, with a projected median OS exceeding 15 years. Factors such as anemia, hypercalcemia, and high-risk cytogenetics were associated with worse survival outcomes. Autologous stem cell transplantation (ASCT) emerged as a key contributor to improved progression-free survival (PFS) and OS.

CONCLUSION

In conclusion, younger MM patients exhibit distinct disease features and benefit from intensified treatment approaches, underscoring the need for tailored therapies to achieve potential disease cure.

Real-world safety and efficacy of teclistamab in relapsed/refractory multiple myeloma: results from a multicenter, retrospective study and descriptive meta-analysis

Patients participating in clinical trials are highly selected and may not represent the general population. The pivotal study of teclistamab (MajesTEC-1), a B-cell maturation antigen (BCMA)xCD3 bispecific antibody, demonstrated impressive response rates and progression free survival in relapsed/refractory multiple myeloma (RRMM) with acceptable toxicity. We performed a retrospective study of 58 patients treated as standard of care at four US academic centers to determine how these results translated to the real-world. Most patients (87.9%) would not have been eligible for the MajesTEC-1 study due to either disease related factors, patient related comorbidities or socio-economic/geographical factors. Despite these 'less-favorable' characteristics we observed similar efficacy and toxicity to MajesTEC-1. A meta-analysis with six other published real-world series (n = 546) confirmed these results. These data support the significant clinical activity of teclistamab in RRMM and highlights the importance of real-world data to accompany the pivotal trial data to further inform daily clinical practice.

Nephrotoxicity of CAR-T therapy in patients with relapsed and refractory multiple myeloma

OBJECTIVE

Chimeric antigen receptor T (CAR-T) cell therapy has achieved impressive efficacy in treating relapsed and refractory multiple myeloma (R/R MM). Nephrotoxicity after CAR-T cell therapy has rarely been reported.

METHODS

We investigated the occurrence and clinical outcomes of acute kidney injury (AKI) in 111 patients with R/R MM after CAR-T cell therapy.

RESULTS

Thirteen patients (12.1%) developed AKI within 1 month of CAR-T cell therapy, of which 11 had grade 1 AKI, 1 had grade 2, and 1 had grade 3. Eleven (84.6%) cases resolved within 1 month after CAR-T cell therapy. The baseline tumor burden was an independent risk factor for the development of AKI. The finding of a high baseline tumor burden or hyponatremia after CAR-T cell therapy and close monitoring of lactate dehydrogenase, uric acid, interleukin (IL)-5 and IL-10 levels were helpful in predicting the development of AKI. The incidence of cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome were similar between the AKI and non-AKI groups. There was also no significant difference in clinical efficacy between the two groups.

CONCLUSION

AKI is a mild severity and reversible complication. It has no impact on clinical outcomes in R/R MM patients receiving CAR-T cell therapy.

Radiomics and Artificial Intelligence Landscape for [18F]FDG PET/CT in Multiple Myeloma

[18F]FDG PET/CT is a powerful imaging modality of high performance in multiple myeloma (MM) and is considered the appropriate method for assessing treatment response in this disease. On the other hand, due to the heterogeneous and sometimes complex patterns of bone marrow infiltration in MM, the interpretation of PET/CT can be particularly challenging, hampering interobserver reproducibility and limiting the diagnostic and prognostic ability of the modality. Although many approaches have been developed to address the issue of standardization, none can yet be considered a standard method for interpretation or objective quantification of PET/CT. Therefore, advanced diagnostic quantification approaches are needed to support and potentially guide the management of MM. In recent years, radiomics has emerged as an innovative method for high-throughput mining of image-derived features for clinical decision making, which may be particularly helpful in oncology. In addition, machine learning and deep learning, both subfields of artificial intelligence (AI) closely related to the radiomics process, have been increasingly applied to automated image analysis, offering new possibilities for a standardized evaluation of imaging modalities such as CT, PET/CT and MRI in oncology. In line with this, the initial but steadily growing literature on the application of radiomics and AI-based methods in the field of [18F]FDG PET/CT in MM has already yielded encouraging results, offering a potentially reliable tool towards optimization and standardization of interpretation in this disease. The main results of these studies are presented in this review.

Consolidation With Second High Dose Therapy and Autologous Stem Cell Transplantation Is Associated With Improved Overall Survival in Patients With Multiple Myeloma in First Relapse

BACKGROUND

High dose chemotherapy and autologous stem cell transplantation (HDT/ASCT) remains the preferred first line consolidation strategy for newly diagnosed multiple myeloma (MM). However, The role of HDT/ASCT in first relapse is uncertain in the context of novel therapies. This study evaluates real-world outcomes of MM patients in first relapse, focusing on the role of consolidative HDT/ASCT.

PATIENTS AND METHODS

This retrospective cohort study was conducted at a large tertiary referral center in Northern Netherlands. MM patients who received first-line HDT/ASCT and obtained a good response were included. The time to next treatment or death (TTNT-D 2) and overall survival (OS) were evaluated, while identifying prognostic factors. A landmark analysis was performed at 6 months, including only patients with a partial response (PR) or better after re-induction.

RESULTS

This study identified 237 patients potentially eligible for repeated HDT/ASCT of whom 111 (47%) underwent a second consolidative HDT/ASCT. The median follow-up is 40 months. Baseline characteristics were largely similar, though second HDT/ASCT was applied only after achieving PR or better. In the landmark analysis, absence of high-risk cytogenetics and good performance status were associated with longer TTNT-D 2. Consolidative second HDT/ASCT, absence of high-risk cytogenetics and longer first response duration were associated with longer OS. Transplantation-related mortality rate was < 1%.

CONCLUSION

This study highlights the viability of second HDT/ASCT as treatment option for relapsed MM, particularly for patients with good responses to first-line HDT/ASCT. In the era of novel agents, second HDT/ASCT should be considered a feasible and effective consolidative strategy.

Multiple Myeloma in Italy: An Epidemiological Model by Treatment Line and Refractoriness Status

BACKGROUND

Multiple myeloma (MM) clinical management is challenging owing to its relapse and refractoriness to treatment. Understanding the treatment patterns and refractory dynamics is crucial for optimizing patient care. This study aimed to estimate the evolution of MM according to the treatment line and refractoriness status in Italy.

MATERIALS AND METHODS

A new epidemiological model was developed using epidemiological and clinical data from literature. Prevalent MM patients were characterized by calibrating the model inputs. Incident patients were included starting in 2021, when antiCD38-containing regimens were reimbursed as first-line treatments in Italy. The model employed a 1-year cycle Markov structure to simulate patient flow through the treatment lines, accounting for the development of lenalidomide and anti-CD38 monoclonal antibody (mAb) refractoriness.

RESULTS

In 2020, Italy had an estimated 33,734 prevalent MM patients. By 2027, treated patients were projected to increase from 28,499 to 35,074. The introduction of lenalidomide and mAb therapies in earlier lines has resulted in a higher accumulation of patients in the early lines, with a corresponding decrease in the proportion of patients requiring subsequent lines of therapy. Furthermore, the proportion of patients refractory to both lenalidomide and mAbs in the second to fourth lines of treatment is estimated to increase from 1.6% in 2021 to 29.7% by 2027.

CONCLUSION

Our model revealed a rising prevalence of patients receiving first-line treatment owing to more effective treatments. The marked increase in the number of refractory patients in subsequent lines underscores the urgent need for innovative therapies to address treatment resistance.

Predicting progression events in multiple myeloma from routine blood work

This study introduces a system for predicting disease progression events in multiple myeloma patients from the CoMMpass study (N = 1186). Utilizing a hybrid neural network architecture, our model predicts future blood work from historical lab results with high accuracy, significantly outperforming baseline estimators for key disease parameters. Disease progression events are annotated in the forecasted data, predicting these events with significant reliability. We externally validated our model using the GMMG-MM5 study dataset (N = 504), and could reproduce the main results of our study. Our approach enables early detection and personalized monitoring of patients at risk of impeding progression. Designed modularly, our system enhances interpretability, facilitates integration of additional modules, and uses routine blood work measurements to ensure accessibility in clinical settings. With this, we contribute to the development of a scalable, cost-effective virtual human twin system for optimized healthcare resource utilization and improved outcomes in multiple myeloma patient care.

Establishing measurable residual disease trajectories for patients on treatment for newly diagnosed multiple myeloma as benchmark for deployment of T-cell redirection therapy

Autologous stem cell transplantation (ASCT) has been the prime consolidative strategy to increase the depth and duration of response in newly diagnosed multiple myeloma (NDMM), albeit with short- and long-term toxicities. Minimal residual disease (MRD) is an important early response endpoint correlating with clinically meaningful outcomes and may be used to isolate the effect of ASCT. We report the impact of ASCT on MRD burden and generate a benchmark for evaluation of novel treatments as consolidation. We collected MRD by next generation sequencing (NGS; clonoSEQ®) post induction and post-ASCT in consecutive patients (N = 330, quadruplet, N = 279; triplet, N = 51). For patients receiving quadruplets, MRD < 10-5 post-induction was 29% (MRD < 10-6 15%) increasing to 59% post-ASCT (MRD < 10-6 45%). Among patients with MRD > 10-5 post-induction, ASCT lowered the MRD burden>1 log10 for 69% patients. The use of quadruplet induction (vs. triplet) did not reduce the effect of ASCT on MRD burden. Reduction in MRD burden with ASCT was most pronounced in patients with high-risk chromosome abnormalities.This dataset provides granular data to delineate the impact of ASCT on MRD as legacy consolidative strategy in NDMM and provides an important benchmark for evaluation of efficacy of TCRT as experimental consolidative strategy.

Efficacy and safety of isatuximab monotherapy to treat relapsed or refractory multiple myeloma: a pooled analysis of clinical trials

This pooled analysis of phase 1 and 2 clinical trials evaluated the efficacy and safety of isatuximab as monotherapy in individuals with relapsed or refractory multiple myeloma (RRMM) who had previously received a median of 4.0 lines of therapy; safety data for individuals on isatuximab plus dexamethasone has also been evaluated. The efficacy analysis (n = 167) showed that isatuximab 20 mg/kg monotherapy was effective in the treatment of individuals with RRMM, with an overall response rate (ORR) of 26.3%, a median progression-free survival (PFS) of 5.6 months and a median overall survival (OS) of 20.2 months. Isatuximab demonstrated rapid and sustained efficacy when used as monotherapy, with a median time to response of 1.0 month and a median duration of response of 10.3 months. The safety analysis, which included 477 participants from four clinical trials, showed that isatuximab had an acceptable safety profile that was consistent across all the dose groups examined. The most common treatment-emergent adverse events were infusion reactions (in 45.7% of participants), most of which were of grade 1 or 2 severity and occurred during the first infusion. Overall, no safety concerns were identified. In addition, participants aged ≥ 75 years had higher ORR and longer PFS and OS than those aged < 65 years, and since the proportions of patients with an Eastern Cooperative Oncology Group performance status of 2 did not vary significantly by age group, it appears that age does not affect the efficacy and safety of isatuximab treatment in RRMM. Further research is warranted to elaborate upon these findings.

The impact of antibiotic use on outcomes of relapsed/refractory multiple myeloma patients treated with CAR-T therapy

Background

In recent years, chimeric antigen receptor (CAR)-T cell therapy has achieved tremendous efficacy in relapsed/refractory multiple myeloma (R/R MM). However, the impact of antibiotic (ATB) use on R/R MM patients treated with CAR-T is still not known. The aim of our study was to analyse the influence of ATB on the clinical outcomes of R/R MM patients treated with CAR-T cells.

Methods

In this retrospective study, 199 patients with R/R MM who received CAR-T cells between January 2018 and December 2023 were evaluated from two hospitals in China. They were stratified into ATB-group and No ATB-group according to whether ATB was administered in the 4 weeks before therapy. We mainly analyzed the efficacy, survival outcomes and cytotoxicity of CAR-T cell therapy in two groups of patients.

Result

In the ATB group (90 patients), the overall response rate (ORR) was 70% comparable to the No ATB group (109 patients: ORR, 81.7%; P = 0.054). The complete response rate (CRR) was 40%, which was significantly lower compared with No ATB group (CRR, 57.8%; P = 0.012). The median progression-free survival (PFS) was 6.7 months while the median overall survival (OS) was 21.9 months for the ATB group. The median PFS and OS for the No ATB group were 13.9 months and 36.1 months. There were significant differences in PFS (P = 0.007) and OS (P = 0.004) between the evaluated groups. Nonetheless, multivariate analysis found ATB use did not reduce the CRR (odds ratio [OR], 0.947; 95% confidence interval [CI], 0.251 to 3.565, P = 0.936). Besides, administration of ATB did not affect the PFS (hazard ratio [HR], 0.634; 95% CI, 0.28 to 1.436, P = 0.275) and OS (HR, 2.259; 95% CI, 0.755 to 6.762, P = 0.145) in R/R MM patients treated with CAR-T cells. Additionally, both groups of patients had similar incidences of cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS).

Conclusion

Our results point to a detrimental effect of ATB on treatment outcomes to CAR-T cell therapy. However, the use of ATB is not associated with the incidence of CRS or ICANS.

Clinical benefit loss in myeloma patients declining autologous stem cell transplantation: a real-world study

Autologous hematopoietic stem cell transplantation (ASCT) is a recommended treatment for multiple myeloma (MM). Currently, with multiple treatment alternatives, patients' prognosis has improved significantly compared to the pre-proteasome inhibitor period. However, this has raised deliberations on the value and timing of ASCT. Compared with Western countries, the proportion of Chinese patients undergoing ASCT is relatively low. Nevertheless, this situation allows us to observe the treatment outcomes of transplant-eligible (TE) patients who haven't received ASCT and explore the role of ASCT in patients with distinct clinicopathological features. This real-world analysis encompassed 1059 newly diagnosed MM patients from 2012 to 2022, among whom 480 were TE. These patients were categorized into the TE-ASCT group (158 received ASCT) and the TE-no-ASCT group (322 did not receive ASCT). Disease progression and treatment response are evaluated based on the definition of IMWG. We found that the progression-free survival (PFS) was significantly prolonged in TE-ASCT group compared to TE-no-ASCT group, but there was no significant difference in overall survival (OS). Further exploratory analyses revealed that ASCT conspicuously augmented the PFS of patients aged ≤ 60 years, featuring ISS stage II/III, 1q gain/amplification, and positive minimal residual disease (MRD). Nevertheless, for patients aged > 60 years, presenting with ISS stage I, high-risk cytogenetics, renal insufficiency, and negative MRD, ASCT did not confer PFS benefits. Our investigation furnishes evidence of the clinical superiority of ASCT for MM patients with disparate clinicopathological characteristics in the contemporary treatment era, laying a groundwork for individualized ASCT selection.

Monoclonal gammopathy of renal significance (MGRS): retrospective monocentric analysis of clinical outcomes and treatment strategies

Monoclonal Gammopathy of Renal Significance (MGRS) is a group of rare disorders in which monoclonal proteins cause kidney damage. Due to its rarity, ongoing research is vital to refine diagnostics, enhance treatment, and improve outcomes. This retrospective study analyzed 34 patients with renal biopsy-proven MGRS-defining lesions. Patients were divided into two subgroups: kidney-limited AL amyloidosis (MGRS-A, 44%, n = 15) and other MGRS (MGRS-NA, 56%, n = 19). Key outcomes included progression-free survival and overall survival. Baseline characteristics such as histopathology, plasma cell percentage, kidney function, and proteinuria were documented alongside initial treatments, and hematologic and renal response. Distinct differences were observed between the two groups: MGRS-NA was primarily associated with glomerular lesions, while MGRS-A exhibited broader kidney involvement. Treatment varied: bortezomib for plasma cell-driven cases and rituximab for B-cell-related conditions. Anemia was the most common side effect (71%), associated with treatment intensity. Despite similar overall survival outcomes, MGRS-A followed a more aggressive course, with a shorter time from diagnosis to death (206 vs. 728 days). Renal and hematologic responses were comparable between the groups, although baseline factors such as hemoglobin and CRP levels were predictive of mortality. These findings underscore the need for more precise characterization and standardized criteria to optimize the management of MGRS.

Cytogenetic risk stratification combined with minimal residual disease status influences the therapeutic outcome and prognosis of multiple myelomas

To explore the value of cytogenetic risk stratification combined with minimal residual disease (MRD) status in predicting the therapeutic efficacy and prognosis for multiple myeloma (MM). From January 2017 to December 2023, 73 cases of newly diagnosed MM were recruited. Cytogenetic risks were stratified according to the results of fluorescence in situ hybridization (FISH); MRD status and clinical data were analyzed. The progression-free survival (PFS) and overall survival (OS), and their influencing factors were evaluated. During the median follow-up period of 30 (4-65) months, the median progression-free survival (PFS) and overall survival (OS) were 38 (95% CI 29.7, 46.3) months and 55 (95% CI 45.9, 64.1) months, respectively. In our cohort, the 3-year PFS rate was 51.0% and the 3-year OS rate was 71.0%. According to the MRD status, 31 MM patients were assigned to the MRD-positivity group and 42 to the MRD-negativity group. Significant differences were detected in the median PFS (30 months vs. 45 months, χ2 = 7.747, P = 0.005) and OS (34 months vs. 59 months, χ2 = 8.683, P = 0.003) between groups. Subgroup analyses based on the cytogenetic risk stratification (standard risk [SR] and high risk [HR]) showed that MM patients in the SR/MRD-negativity subgroup did not reach the median PFS and OS, and the median PFS (42 months vs. 33 months, P = 0.093) and OS (59 months vs. 42 months, P = 0.703) were similar between the SR/MRD-positivity and HR/MRD-negativity subgroups. In comparison to the HR/MRD-negativity subgroup, the median PFS (20 months vs. 33 months, P = 0.031) and OS (33 months vs. 42 months, P = 0.032) were significantly shorter in the HR/MRD-positivity group. Multivariate analysis showed that MRD-positivity was an independent risk factor for PFS (HR 2.874, 95% CI 1.452, 5.689; P = 0.008) and OS (HR 3.504, 95% CI 1.599, 7.676; P = 0.002) of MM. MRD status is a powerful prognostic indicator of PFS and OS in MM, but its performance is inferior to cytogenetic risk stratification. More high-risk cytogenetic abnormalities (HRCAs) indicate a worse prognosis of MM, while MRD-negativity improves HRCA-associated prognosis of MM. We recommend a risk stratification by assessing MRD status combined with HRCAs in MM patients, thus favoring the design of individualized treatment.

Minimal Residual Disease-Based End Point for Accelerated Assessment of Clinical Trials in Multiple Myeloma: A Pooled Analysis of Individual Patient Data From Multiple Randomized Trials

PURPOSE

Newly approved drugs and combinations treating multiple myeloma (MM) have resulted in substantial improvements in patients' survival. To deliver rapid access to newer therapies, an earlier end point to expedite clinical trials is needed. Our objective was to evaluate the minimal residual disease-negative complete response (MRD-CR) as an intermediate end point for progression-free survival (PFS) and overall survival (OS) in newly diagnosed (ND) transplant-eligible (NDTE) patients, ND transplant-ineligible (NDTinE) patients, and patients with relapsed/refractory (RR) MM.

PATIENTS AND METHODS

Individual patient data from 20 randomized multicenter trials were collected. Eleven studies (4,773 patients) with sufficient data were analyzed to evaluate whether 9- or 12-month MRD-CR classified at a 10-5 threshold could be reasonably likely to predict the clinical benefit of new agents regarding PFS and OS. Global odds ratio (OR) was estimated using the bivariate Plackett Copula model. Supportive evaluation included correlations of the treatment effects on MRD-CR end points and PFS/OS, evaluated by both linear regression (R2weighted least squared) and Copula (R2Copula) models.

RESULTS

The analysis demonstrated that both 9- and 12-month MRD-CR strongly correlated with PFS at patient level in NDTE patients, NDTinE patients, and patients with RRMM. Global ORs ranged from 3.06 to 16.24, all with 95% CIs excluding 1.0. Encouraging trial-level correlations (R2, 0.61-0.70) were observed by pooling three populations and were stronger (R2, 0.67-0.78) in the ND population. Similar results were observed for OS.

CONCLUSION

Our findings provided the support for use of MRD-CR classified at a 10-5 threshold at either 9 or 12 months after starting of the treatment, as an intermediate end point to support accelerated approvals, in future trials in NDTE patients, NDTinE patients, and patients with RRMM.

Bortezomib, melphalan, and prednisone with or without daratumumab in transplant-ineligible patients with newly diagnosed multiple myeloma (ALCYONE): final analysis of an open-label, randomised, multicentre, phase 3 trial

BACKGROUND

In the phase 3 ALCYONE study, the addition of daratumumab to bortezomib, melphalan, and prednisone (D-VMP) significantly improved outcomes in transplant-ineligible patients with newly diagnosed multiple myeloma. Here, we present results from the final analysis of ALCYONE.

METHODS

ALCYONE was an international, multicentre, randomised, open-label, active-controlled, phase 3 trial in adults aged 18 years or older with newly diagnosed multiple myeloma who were ineligible for high-dose chemotherapy with autologous stem-cell transplantation, because of their age (≥65 years) or presence of substantial comorbidities, and had an Eastern Cooperative Oncology Group performance status of 0-2. Patients were enrolled between Feb 9, 2015, and July 14, 2016, and were randomly assigned (1:1) by randomly permuted blocks using an interactive web-based randomisation system to receive bortezomib, melphalan, and prednisone (VMP) alone or D-VMP, with randomisation stratified by International Staging System disease stage, geographical region, and age. Patients received up to nine 6-week cycles of subcutaneous bortezomib (1·3 mg/m2 of body surface area, twice per week on weeks 1, 2, 4, and 5 of cycle 1 and once weekly on weeks 1, 2, 4, and 5 of cycles 2-9), oral melphalan (9 mg/m2, once daily on days 1-4 of each cycle), and oral prednisone (60 mg/m2, once daily on days 1-4 of each cycle). Patients in the D-VMP group also received intravenous daratumumab at a dose of 16 mg/kg once weekly during cycle 1, once every 3 weeks in cycles 2-9, and once every 4 weeks thereafter until disease progression, unacceptably toxicity, or the end of study. The primary endpoint, progression-free survival, has been previously reported. The ALCYONE study has completed; presented here are final analyses for selected secondary endpoints related to overall survival, depth of response, subsequent therapy, and safety. The intention-to-treat population was the primary analysis population (including for overall survival), defined as all patients who were randomly assigned to study treatment. The safety population, consisting of patients who received any dose of study treatment, was used in safety analyses. This trial is registered with ClinicalTrials.gov, NCT02195479.

FINDINGS

In total, 706 patients were enrolled and randomly assigned to receive D-VMP (n=350) or VMP (n=356). Baseline characteristics were balanced between the two treatment groups; most participants were female (379 [54%] of 706 patients) and White (601 [85%] of 706 patients). At a median follow-up of 86·7 months (IQR 28·5-85·2), median overall survival was 83·0 months (95% CI 72·5-not estimable) with D-VMP versus 53·6 months (46·3-60·9) with VMP (hazard ratio [HR] 0·65 [95% CI 0·53-0·80]; p<0·0001). The most common grade 3 or 4 treatment-emergent adverse events were neutropenia (140 [40%] of 346 patients in the D-VMP group vs 138 [39%] of 354 patients in the VMP group), thrombocytopenia (120 [35%] vs 134 [38%]), and anaemia (63 [18%] vs 70 [20%]). Serious treatment-related adverse events occurred in 74 (21%) of 346 patients in the D-VMP group and 56 (16%) of 354 patients in the VMP group. Deaths due to treatment-related adverse events occurred in five (1%) of 346 patients in the D-VMP group (pneumonia, acute myocardial infarction, neuroendocrine tumour, tumour lysis syndrome, and acute respiratory failure) and three (1%) of 354 patients in the VMP group (acute myeloid leukaemia, pulmonary embolism, and bacterial pneumonia).

INTERPRETATION

With more than 7 years of follow-up, D-VMP continued to elicit clinical benefits in transplant-ineligible patients with newly diagnosed multiple myeloma, supporting the efficacy and safety of frontline daratumumab-based therapy in this patient population.

FUNDING

Janssen Research & Development.

Opportunities and challenges for MRD assessment in the clinical management of multiple myeloma

Measurable residual disease (MRD) assessment is, from the methodological point of view, ready for prime time in multiple myeloma (MM). Abundant evidence underscores the value of MRD status determined using highly sensitive next-generation flow cytometry and next-generation sequencing tests in evaluating response to treatment and, therefore, prognosis in patients with this disease. MRD response assessment and monitoring might present a range of opportunities for individualized patient management. Moreover, the considerable amounts of high-quality and standardized MRD data generated in clinical trials have led to the acceptance of MRD negativity as an early end point for accelerated regulatory approval of treatments for MM. The data leave no doubt that the efficacy of new regimens in inducing deeper and durable MRD-negative responses is connected with prolonged survival. Yet, several evidential, technical and practical challenges continue to limit the implementation of MRD-guided treatment strategies in routine practice, and the use of MRD as a surrogate end point remains controversial to some. In this Review, we draw on past and present research to propose opportunities for overcoming some of these challenges, and to accelerate the use of MRD assessment for improved clinical management of patients with MM.

Dynamic monitoring of M-protein quantification by immunotyping using capillary zone electrophoresis during the chemotherapy of patients with multiple myeloma

Dynamic quantification of monoclonal immunoglobulin proteins (M-proteins) by immunotyping using immunosubtraction (ISUB) through capillary zone electrophoresis (CZE) was performed to examine the efficacy of chemotherapy drugs in patients with multiple myeloma (MM). Twenty-one patients with eight different types of M-protein were analyzed, and M-protein quantification during chemotherapy regimens was dynamically monitored. For patients with M-protein identified by CZE, immunotyping by ISUB can accurately determine the percentage of M-protein. In this study, 15 of the 16 included patients with a definite diagnosis of MM were initially treated with bortezomib chemotherapy, and the treatment efficacy differed significantly among individuals. Three patients showed M-protein clearance, with the M-protein decreasing by more than 50% after the first course of treatment. Capillary-based immunotyping accurately determined the percentage of M-proteins. Dynamic monitoring of M-protein through immunotyping using ISUB can objectively and effectively aid in evaluating treatment efficacy. Clinically, chemotherapeutic drugs that reduce M-protein levels by more than 50% after a treatment course should be selected. The early detection of trace changes in M-protein levels is crucial for disease monitoring and medication guidance. Quantification of M-protein should be regularly undertaken in patients with MM.

Venetoclax-based treatment combinations in relapsed/refractory multiple myeloma: practice patterns and impact of secondary cytogenetic abnormalities on outcomes

Venetoclax (Ven), a BCL-2 inhibitor, has demonstrated efficacy in patients with relapsed/refractory multiple myeloma (RRMM) harboring a t(11;14) and/or elevated BCL-2 expression. However, data from clinical trial remain inconclusive. This retrospective study evaluated the efficacy and safety of Ven-based therapies in 232 MM patients without concurrent AL amyloidosis treated at Mayo Clinic sites between Jan 2015 and Dec 2023. The median age was 62 years, with a median of 3 prior lines of therapy. Among the cohort, 82% had t(11;14), and elevated BCL-2 expression was identified in 17 of 18 non-t(11;14) patients tested. Ven combinations included Ven-Dex (VenD; 48.3%), Proteasome Inhibitor-Ven (30.2%), and Daratumumab-Ven (19%) with other combinations making up the rest. The overall response rate was 57%; 64% for t(11;14) patients and 26% for non-t(11;14) patients. Median progression-free survival (PFS) was 9.4 months overall; 11.8 months for t(11;14) patients and 2.9 months for those without (p < 0.001). Among t(11;14) patients, the presence of del(17p) or 1q gain/amplification significantly reduced PFS to 7.7 months. Venetoclax-based regimens remain an important option for t(11;14) patients, but efficacy is limited in patients without a t(11;14). The presence of secondary high-risk cytogenetics imparts an inferior PFS.

Prognostic value of [18F]fluorodeoxyglucose-PET/MRI(CT) novel interpretation criteria (IMPeTUs) in multiple myeloma

PURPOSE

[18F]fluorodeoxyglucose (FDG)-PET is a powerful tool to evaluate prognosis in multiple myeloma (MM). The development of systematic and reproducible standard interpretation criteria is crucial for the effective application of FDG-PET in MM. A new set of criteria-Italian Myeloma criteria for PET Use (IMPeTUs)-has standardized PET evaluation in MM. However, the prognostic value of IMPeTUs score remains unknown.

METHODS

A total of 58 patients with newly diagnosed multiple myeloma (NDMM) who underwent both [18F]FDG-PET/MRI and PET/CT examinations at diagnosis were enrolled (ChiCTR1900022597). All patients completed a 42-month follow-up. The prognostic value of the PET/MRI (or PET/CT) IMPeTUs score in predicting progression-free (PFS) and overall (OS) survival was compared with that of individual laboratory parameters and the maximum standardized uptake value (SUVmax). Kaplan-Meier method was used for survival analysis. Univariate and multivariate analyses of prognostic factors were conducted using Cox regression.

RESULTS

ROC curves demonstrated that the area under the curve for the PET/MRI IMPeTUs score was 0.760, exceeding that of the PET/CT IMPeTUs score (0.711), PET/CT BM SUVmax (0.649), PET/MRI BM SUVmax (0.575), bone marrow plasma cells (0.500), and β2-microglobulin (0.501). Univariate analysis and Kaplan-Meier analysis showed that a PET/MRI IMPeTUs score ≥ 13 and PET/CT IMPeTUs score ≥ 10 were significantly associated with worse PFS. Cox multivariate analysis showed that a PET/MRI IMPeTUs score ≥ 13 was an independent risk factor for PFS.

CONCLUSION

IMPeTUs standardized [18F]FDG-PET/MRI and PET/CT readings in MM. The IMPeTUs score is crucial for predicting MM prognosis, performing better than SUVmax and clinical indicators.

CLINICAL TRIAL REGISTRATION

ChiCTR1900022597, Registered on 18 April 2019.

Real-world evaluation of teclistamab for the treatment of relapsed/refractory multiple myeloma (RRMM): an International Myeloma Working Group Study

Teclistamab, a BCMAxCD3-directed bispecific antibody, has shown high response rates and durable remissions in triple-class-exposed patients with relapsed/refractory multiple myeloma. We performed a retrospective study evaluating the efficacy and safety of teclistamab in 210 patients treated at 9 academic centers from five countries within the IMWG Immunotherapy Working Group Committee. Patients were heavily pretreated, with 83% having triple-class refractory disease and 44% with prior BCMA-targeted therapy. With a median follow-up of 5.3 months, the overall response rate (ORR) was 67% in 188 response-evaluable patients, including 55% with a very good partial response or better. The 6-month progression-free survival (PFS) and overall survival rates were 53% (95% CI, 46-61%) and 73% (67-80%), respectively. Patients who received prior BCMA-directed therapy compared to BCMA-treatment-naïve patients had a lower ORR (58.3 vs 74.0%; P = 0.03) and PFS (6-month PFS 43% [95% CI, 33-55%] vs 63% [54-73%]; logrank P = 0.004). Step-up dosing occurred in an outpatient setting for 23% of patients. CRS occurred in 54% of patients, and infections were reported in 56.2% of patients, with 22% having grade ≥3 infections. In this multicenter real-world study, we found that teclistamab can lead to rapid responses in heavily pretreated myeloma patients with comparable efficacy and safety profiles, as demonstrated in MajesTEC-1.

Phase 1 clinical trial of B-Cell Maturation Antigen (BCMA) NEX-T® Chimeric Antigen Receptor (CAR) T cell therapy CC-98633/BMS-986354 in participants with triple-class exposed multiple myeloma

BCMA-targeted CAR T-cells transformed the treatment of relapsed and refractory multiple myeloma (RRMM), yet improvements are needed in manufacturing, toxicity and efficacy. We conducted a phase 1 clinical trial of BMS-986354, an autologous BCMA CAR T manufactured using an optimized NEX-T® process, in participants with triple-class exposed, RRMM. The 65 participants had a median of 5 (range 3-13) prior regimens, 39% had cytogenetic high-risk, 91% triple-class refractory, and 43% extra-medullar disease. Part A (dose-escalation) of the study enrolled participants in cohorts receiving 20 (N = 7), 40 (N = 24), or 80 (N = 11)x 106 CAR + T-cells. In part B (expansion), an additional 23 participants were treated at the recommended phase 2 dose, 40 ×106 CAR + T cells. Across dose levels, cytokine release syndrome (CRS) occurred in 82% (2% grade ≥3), neurotoxicity in 8% (2% grade ≥3), and infections in 32% of participants (5% grade ≥ 3). The response rate was 95%, with 46% achieving complete responses. Median progression-free survival was 12.3 months (95% CI 11.3-16). Compared to orvacabtagene autoleucel (same CAR construct, conventional manufacturing), BMS-986354 had higher proportion of T central memory cells, were less differentiated and had enhanced potency and proliferative capacity, supporting the use of NEX-T® in future CAR T development.

Early versus late infectious complications following chimeric antigen receptor-modified T-cell therapy

Despite increasing utilization of CAR T-cell therapy, data are lacking regarding long term follow up and risk of infectious complications after the early period following CAR T-cell infusion. In this study, we sought to compare epidemiology and risk factors for early (≤ 3 months) and late (3 months to 1 year) infections. Data were retrospectively collected at six time points: pre-CAR T, day of infusion, and at 3, 6, 9, and 12 months post CAR-T infusion for all consecutive adult patients treated at our institution. In this cohort, the cumulative incidence of any infection was 73.2% in the first year. Bridging therapy, CRS, neurotoxicity and steroid use were identified as contributing risk factors for early bacterial infections. After 3 months, community acquired respiratory infections were common. We characterize bacterial, viral and fungal pathogens based on time elapsed after CAR T-cell infusion.

Treatment adherence and effectiveness in patients treated with carfilzomib-based therapy combinations for relapsed/refractory multiple myeloma in Germany: interim results from the non-interventional CARO study

Therapy adherence can significantly influence the outcome of cancer patients. The prospective, non-interventional CARO study (NCT02970747) investigated adherence, effectiveness, and safety of carfilzomib in patients with relapsed/refractory multiple myeloma (RRMM) in the German real-world setting. In total, 359 patients were included at 69 sites. Data on carfilzomib combination regimens were evaluated for three treatment cohorts: carfilzomib with lenalidomide and dexamethasone (KRd), with dexamethasone only (Kd) or with daratumumab and dexamethasone (KdD). Encouragingly, patients maintained levels of treatment adherence ≥95% to carfilzomib across cohorts. The effectiveness outcomes of CARO were in line with previous data. Median PFS (95% CI) was 17.5 months (14.5, 24.7 [KRd]), 13.4 months (7.0, 18.1 [Kd]), and 15.6 months (9.9, NA [KdD]), respectively. Median OS was 38.9 months (31.5, 53.9 [KRd]), 24.2 months (17.3, 36.8 [Kd]), and not reached (KdD). Overall, the CARO study impressively demonstrates efficacy and safety of KRd, Kd, and KdD regimen in real-world.

Diagnostic Innovations: Advances in imaging techniques for diagnosis and follow-up of multiple myeloma

Introduction

The International Myeloma Working Group (IMWG) defines myeloma related bone disease (MBD) as a diagnostic criterion for symptomatic multiple myeloma (MM) as the presence of osteolytic lesions ≥ 5 mm or more than one focal lesion (FL) ≥ 5 mm by magnetic resonance imaging (MRI). Whole-body low-dose CT (WBLDCT) is recommended as the first-choice imaging technique for the diagnosis of MBD with 18F-fluorodeoxyglucose-positron emission tomography/CT (18F-FDG-PET/CT) being considered a possible alternative at staging, whereas use of MRI studies is recommended in cases without myeloma-defining events (MDEs) in order to exclude the presence of FLs. Furthermore, use of 18F-FDG-PET/CT is recommended in response assessment, to be integrated with hematologic response and bone marrow minimal residual disease (MRD).

Areas covered

In this paper, we review novel functional imaging techniques in MM, particularly focusing on their advantages, limits, applications and comparisons with 18F-FDG-PET/CT or other standardized imaging techniques.

Conclusions

Combining both morphological and functional imaging, 18F-FDG-PET/CT is currently considered a standard imaging technique in MM for staging (despite false positive or negative results) and response assessment. The introduction of novel functional imaging techniques, as whole-body diffusion-weighted magnetic resonance imaging (WB-DWI-MRI), or novel PET tracers might be useful in overcoming these limits. Future studies will give more information on the complementarity of these imaging techniques or whether one of them might become a new gold standard in MM.

Long-Term Cognitive Outcomes in Adult Patients Receiving Chimeric Antigen Receptor T-Cell Therapies

BACKGROUND

CAR T-cell therapy (CAR-T) is leading to durable responses in patients with cancer but there is concern that cytokine release syndrome (CRS) and neurotoxicity may impact survivors' cognitive function. We assessed long-term cognitive function in CAR-T recipients and examine factors associated with change in cognition over time.

METHODS

We assessed perceived cognition (Functional Assessment of Cancer Therapy-Cognition) and neurocognitive performance (standardized neuropsychological battery) in adult patients prior to receiving CAR-T and at 6 month follow-up. We examined changes in cognitive outcomes using paired T-tests. We used univariate and multivariate linear regression models to explore whether patient-, disease-, or CAR-T specific factors were associated with change in cognition over time.

RESULTS

We included 106 participants (mean age = 62.7 years, 60.4% male, 56.6% diagnosed with non-Hodgkin´s lymphoma), of whom 70 reported perceived cognition data and 26 underwent neurocognitive performance assessments at both timepoints. There were no changes in perceived cognition (P = .560), overall neurocognitive performance (P = .924), or neurocognitive domains (P´s > .05) from baseline to 6 months post CAR-T. At 6 months, 32.9% reported improved, 47.1% stable, and 20.0% declined perceived cognition relative to baseline. In unadjusted analyses, progressive disease (β = -8.86, P = .012), baseline elevated C-reactive protein (β = -5.60, P = .076) and baseline neurologic comorbidity (β = -11.4, P = .052) were numerically associated with worse perceived cognition over time. In multivariate analyses, only progressive disease was statistically significantly associated with worse perceived cognition (β = -7.32, P = .032) over time.

CONCLUSIONS

We found stable cognition among CAR-T recipients and identified an association of therapy response with change in perceived cognition over time.

Safety and activity of talquetamab in patients with relapsed or refractory multiple myeloma (MonumenTAL-1): a multicentre, open-label, phase 1-2 study

BACKGROUND

Talquetamab is the first GPRC5D × CD3 bispecific antibody approved for relapsed or refractory multiple myeloma. In phase 1 of the MonumenTAL-1 study, initial results of subcutaneous talquetamab 0·4 mg/kg once a week and 0·8 mg/kg every 2 weeks showed preliminary clinical activity. We describe safety and activity results in patients treated with talquetamab, including patients who had received previous T-cell redirection therapy (TCR). This post-hoc analysis was done with more mature median follow-up to evaluate duration of response in patients treated with talquetamab 0·8 mg/kg every 2 weeks.

METHODS

MonumenTAL-1 is a multicentre, open-label, phase 1-2 study of talquetamab, phase 1 of which has previously been published. The 0·4 mg/kg once a week and 0·8 mg/kg every 2 weeks recommended subcutaneous doses identified in phase 1 were evaluated in phase 2 in patients who were 18 years of age or older, had at least three previous lines of therapy, had an Eastern Cooperative Oncology Group performance status of 0 to 2, and were naive or exposed to previous TCR. The primary endpoint was overall response rate assessed by independent review committee in all patients who received at least one dose of talquetamab. Safety was assessed in all patients who received at least one dose of talquetamab. This study was registered with ClinicalTrials.gov, NCT03399799 (phase 1) and NCT04634552 (phase 2).

FINDINGS

Between Jan 3, 2018, and Feb 20, 2023, 735 patients were screened across all phase 1-2 cohorts. Of these, 537 patients screened for inclusion were treated across phase 1 and 2 cohorts, of whom 198 (27%) patients were excluded from the study, most commonly due to not meeting eligibility criteria or not having measurable disease. As of Oct 11, 2023, 375 patients had received recommended talquetamab doses across three groups: 143 (0·4 mg/kg once a week group) and 154 (0·8 mg/kg every 2 weeks group) TCR-naive patients and 78 with previous TCR who received either recommended dose (previous TCR group). 217 (58%) of 375 patients were male and 158 (42%) were female. 325 (87%) of 375 patients were White and 32 (9%) patients were Black. Median follow-up was 25·6 months (IQR 8·5-25·9) in the 0·4 mg/kg once a week group, 19·4 months (9·2-20·7) in the 0·8 mg/kg every 2 weeks group, and 16·8 months (7·6-18·7) in the previous TCR group. Overall response rate was 74% (106 of 143 patients, 95% CI 66-81) in the 0·4 mg/kg once a week group, 69% (107 of 154 patients, 62-77) in the 0·8 mg/kg every 2 weeks group, and 67% (52 of 78 patients, 55-77) in the previous TCR group. Most common adverse events in the 0·4 mg/kg once a week, 0·8 mg/kg every 2 weeks, and previous TCR groups were cytokine release syndrome (113 [79%] of 143 patients, 115 [75%] of 154 patients, and 57 [73%] of 78 patients), taste changes (103 [72%], 110 [71%], and 59 [76%]), and infections (85 [59%], 105 [68%], and 59 [76%]). Most common grade 3-4 adverse events were neutropenia (44 [31%], 33 [21%], and 37 [47%]), anaemia (45 [31%], 40 [26%], and 21 [27%]), and lymphopenia (37 [26%], 40 [26%], and 13 [17%]). Fatal adverse events occurred in five patients in the 0·4 mg/kg once a week group, seven patients in the 0·8 mg/kg every 2 weeks group, and no patients in the previous TCR group; none were related to treatment.

INTERPRETATION

Talquetamab continued to demonstrate high overall response rates in heavily pretreated patients with relapsed or refractory multiple myeloma with longer follow-up in this post-hoc analysis. Overall response rate was promising in patients with previous TCR, including therapies targeting BCMA. On-target, off-tumour adverse events were common but led to few treatment discontinuations.

FUNDING

Janssen.

European Myeloma Network Group review and consensus statement on primary plasma cell leukemia

BACKGROUND

Primary plasma cell leukemia (PPCL) is the most aggressive disorder among plasma cell malignancies, with new diagnostic criteria recently established by the International Myeloma Working Group. Studies have shown that PPCL patients receiving a combination of novel agents, but not eligible for transplantation, may have a median survival up to 2 years, extended to 3 years or more in those undergoing transplant procedures. These findings remain unsatisfactory, particularly if compared with progresses obtained in multiple myeloma.

DESIGN

A European Myeloma Network (EMN) expert panel reviewed the most recent literature and selected the areas of major concern in the management of PPCL by generating and rank ordering key questions using the criterion of clinical relevance. Multistep procedures were utilized to achieve a consensus on recommendations. The Delphi questionnaire method was used and a consensus of at least 80% was reached for all final statements.

RESULTS

An extended overview of current biological, clinical, prognostic, and therapeutic aspects of PPCL, including ongoing and close to start clinical trials, is presented. Furthermore, updated guidelines for the management of PPCL and practical recommendations are provided, in the context of current knowledge about this disease, also looking at possible future perspectives to ameliorate the outcome of these patients.

CONCLUSIONS

PPCL still remains an unmet clinical need. Notwithstanding, some not negligible progresses have been recently achieved. The European Myeloma Network panel strongly support ongoing and planned clinical trials, as well as biological studies based on novel technologies, strategies, and treatment options that could represent breakthroughs we have been waiting for too long.

A German multicenter real-world analysis of talquetamab in 138 patients with relapsed/refractory multiple myeloma

Bispecific T-cell engagers (BTCEs) represent a paradigm shift in the treatment of relapsed/refractory multiple myeloma (RRMM). Talquetamab, a GPRC5DxCD3 BTCE, has shown promising results in the MonumenTAL-1 trial and was recently approved by the Food and Drug Administration and the European Medicines Agency. However, treatment under real-world conditions may not represent patient characteristics in clinical trials with restricted enrollment criteria. We performed a retrospective real-world analysis including 138 RRMM patients treated with talquetamab at 21 German centers. Of evaluable patients, 43% had ISS stage III, 37% had extraosseous disease, and 48% had high-risk cytogenetics. After a median of six prior therapy lines, 58% of patients would not have been eligible for MonumenTAL-1. With a median follow-up of 8.2 months, we observed an overall response rate of 65% and a median progression-free survival of 6.4 months (95% confidence interval 5.1-9.0). Prior BTCE exposure, ISS stage III, extraosseous disease, and penta-drug refractory disease were associated with unfavorable outcomes. Grade ≥ 3 cytokine release syndrome and neurotoxicity occurred in 5.1% and 1.5% of patients, respectively. In summary, our real-world study confirms the efficacy and safety of talquetamab, despite a high proportion of patient- and disease-related risk factors. These results support its use as bridging or long-term treatment, even in advanced stages.

High-risk features of early relapse in newly-diagnosed multiple myeloma: The impact of cytogenetics and response to initial therapy

Patients with newly-diagnosed multiple myeloma (MM) who experience early relapse (ER) have dismal overall survival (OS). Their prospective identification, either before or soon after treatment initiation, is paramount to use alternative approaches and prevent ER. In this study, we investigated the frequency and disease characteristics of ER during the first 18 months after treatment initiation (ER18), in a series of 1215 newly-diagnosed MM patients enrolled in four PETHEMA/GEM clinical trials for the transplant-eligible and transplant-ineligible populations. ER18 was observed in 266 of the 1215 patients (22%) and resulted in a median OS of 19 versus 114 months in cases without ER18. When compared to the ISS and the presence of ≥2 high-risk cytogenetic abnormalities, a modified version of the new high-risk definition from the International Myeloma Society (mHR-IMS) showed the most balanced negative and positive predictive values of ER18 (83.5% and 40%, respectively). In addition to the mHR-IMS, an ECOG = 2, ISS 3, and calcium levels ≥ 11 mg/dL were independently associated with ER18. These variables were modeled into a predictive score in which the rates of ER18 were 2%, 24.5%, and 59% in patients with low-, intermediate-, and high-risk score. The risk of ER18 and OS were modulated by the VGPR status at 6-9 months after treatment initiation. In conclusion, we present a risk model that predicts ER18 and can be readily applied in clinical trials and routine practice to identify treatment strategies empowered to prevent ER18 and improve survival outcomes of newly-diagnosed patients with functional high-risk MM.

Expert Opinion on Multiple Myeloma Treatment in Brazil in the Bispecific Antibody Era

Multiple myeloma treatment has evolved rapidly with the development of novel targeted therapies. The paper outlines multiple myeloma epidemiology, current treatments, and recent advances, highlighting the role of bispecific antibodies. Brazilian authorities have approved 3 bispecific antibodies (teclistamab, elranatamab, and talquetamab) for relapsed/refractory multiple myeloma patients who have received at least three prior therapies. These therapies have shown promising efficacy in clinical trials, with 61%-74% overall response rates. However, access to these treatments varies significantly between Brazil's private and public healthcare systems. A panel of 6 Brazilian experts in multiple myeloma and bispecific antibody therapy convened for a three-day virtual conference organized and moderated by Americas Health Foundation. They addressed key questions regarding bispecific antibody therapy in multiple myeloma and developed consensus recommendations. While bispecific antibodies offer new hope for multiple myeloma patients, challenges remain in ensuring equitable access to these therapies. The paper discusses the sequencing of bispecific antibodies with other treatments, the management of adverse events, and the need for real-world data. It also highlights the disparities in multiple myeloma treatment between Brazil's public and private healthcare systems, emphasizing the need for targeted efforts to bridge this gap and improve outcomes for all multiple myeloma patients.

Daratumumab plus bortezomib, lenalidomide and dexamethasone for transplant-ineligible or transplant-deferred newly diagnosed multiple myeloma: the randomized phase 3 CEPHEUS trial

Frontline daratumumab-based triplet and quadruplet standard-of-care regimens have demonstrated improved survival outcomes in newly diagnosed multiple myeloma (NDMM). For patients with transplant-ineligible NDMM, triplet therapy with either daratumumab plus lenalidomide and dexamethasone (D-Rd) or bortezomib, lenalidomide and dexamethasone (VRd) is the current standard of care. This phase 3 trial evaluated subcutaneous daratumumab plus VRd (D-VRd) in patients with transplant-ineligible NDMM or for whom transplant was not planned as the initial therapy (transplant deferred). Some 395 patients with transplant-ineligible or transplant-deferred NDMM were randomly assigned to eight cycles of D-VRd or VRd followed by D-Rd or Rd until progression. The primary endpoint was overall minimal residual disease (MRD)-negativity rate at 10-5 by next-generation sequencing. Major secondary endpoints included complete response (CR) or better (≥CR) rate, progression-free survival and sustained MRD-negativity rate at 10-5. At a median follow-up of 58.7 months, the MRD-negativity rate was 60.9% with D-VRd versus 39.4% with VRd (odds ratio, 2.37; 95% confidence interval (CI), 1.58-3.55; P < 0.0001). Rates of ≥CR (81.2% versus 61.6%; P < 0.0001) and sustained MRD negativity (≥12 months; 48.7% versus 26.3%; P < 0.0001) were significantly higher with D-VRd versus VRd. Risk of progression or death was 43% lower for D-VRd versus VRd (hazard ratio, 0.57; 95% CI, 0.41-0.79; P = 0.0005). Adverse events were consistent with the known safety profiles for daratumumab and VRd. Combining daratumumab with VRd produced deeper and more durable MRD responses versus VRd alone. The present study supports D-VRd quadruplet therapy as a new standard of care for transplant-ineligible or transplant-deferred NDMM. ClinicalTrials.gov registration: NCT03652064 .

Incidence of herpes zoster in transplant-ineligible patients with newly diagnosed multiple myeloma treated with daratumumab, lenalidomide, and dexamethasone

Combination therapy with daratumumab, lenalidomide, and dexamethasone (D-Rd) has greatly improved outcomes for transplant-ineligible newly diagnosed multiple myeloma (TIE-NDMM). Effective management of herpes zoster (HZ) and other infections is critical to maximize therapeutic benefit and to maintain treatment continuity. However, antiviral prophylaxis for HZ in TIE-NDMM patients receiving D-Rd has unclear efficacy, and is currently not covered by health insurance in Japan. In this study, we retrospectively analyzed the incidence of HZ in 40 TIE-NDMM patients treated with D-Rd. Nine patients (22.5%) developed HZ at a median period of 10.7 months (range, 0.4-34.2 months) after starting D-Rd. The cumulative HZ incidence at 12, 24, and 36 months was 13.3%, 19.5%, and 28.6%, respectively. Development of HZ was not associated with patient characteristics, disease characteristics, or hematologic response. Our data indicate a high incidence of HZ in TIE-NDMM patients receiving D-Rd, and we anticipate that Japanese health insurance should soon cover prophylactic treatment of HZ in D-Rd.

Forcing Ahead: Second-Line Treatment Options for Lenalidomide-Refractory Multiple Myeloma

The therapeutic landscape for multiple myeloma has gradually expanded in recent decades, leading to unprecedented deep and sustained responses as well as remarkable improvements in patient survival. Nonetheless, changes in treatment algorithms have raised new demands for patients with relapsed/refractory disease, as prior exposure and refractoriness to prior therapies impact the choice of subsequent treatments. In particular, refractoriness to lenalidomide-an established backbone of treatment in both front-line and maintenance settings and a key component of many approved regimens used in relapsed disease-is associated with suboptimal clinical outcomes. Therefore, identifying the most appropriate management in lenalidomide-refractory patients, and even more so in patients who are refractory to more than one agent, is critical. At present, treatment options for this growing subgroup of patients are still limited; however, recent data from clinical research are promising. Herein, we summarized the currently available treatment options and discuss future directions based on the latest results from ongoing clinical trials.

Long-term follow-up of BCMA CAR-T cell therapy in patients with relapsed/refractory multiple myeloma

BACKGROUND

B-cell maturation antigen (BCMA)-targeting chimeric antigen receptor (CAR) T-cell immunotherapy has shown promising results in the treatment of relapsed or refractory multiple myeloma (R/RMM). This study presents the updated long-term outcomes from our center.

METHODS

Between July 30, 2018, and September 27, 2023, 141 patients with R/RMM who received BCMA CAR-T therapy were enrolled. Patients underwent conditioning chemotherapy with cyclophosphamide and fludarabine, followed by BCMA CAR-T cell infusion at a median dose of 2.36×106 cells/kg. The study evaluated overall response rates, long-term efficacy, safety profiles, and their associations with clinical and disease characteristics.

RESULTS

At a median follow-up of 20.2 months, the safety profile of the therapy was manageable. Grade 3/4 cytokine release syndrome occurred in 36.2% of patients, with no cases of severe neurotoxicity reported. 1-month post-infusion, grade ≥3 anemia persisted in 39.6% of patients, while neutropenia (43.3%) and thrombocytopenia (52.2%) were observed. The objective response rate (ORR) among evaluable patients was 94.8%, with 50.7% achieving a complete response (CR). The 4-year progression-free survival and overall survival rates were 37.4% (95% CI, 29.1% to 48.1%) and 63.2% (95% CI, 54.8% to 72.8%), respectively, with survival curves showing gradual flattening over time. Patients with a history of autologous stem cell transplantation (ASCT) and those with extramedullary disease demonstrated significantly inferior efficacy and survival outcomes. Peak CAR-T cell expansion was positively correlated with ORR (p<0.001) and CR (p<0.001). Notably, patients with prior ASCT exhibited significantly lower CAR-T cell expansion compared with those without prior ASCT (p<0.001). Immunophenotypic analysis of infused CAR-T cells demonstrated impaired fitness in patients who received ASCT in the past year.

CONCLUSIONS

BCMA CAR-T therapy in patients with R/RMM results in significant and sustained responses, with a manageable safety profile on a large scale. Prior ASCT and extramedullary disease represent adverse prognostic factors. Patients with a history of ASCT demonstrate limited peak CAR-T cell expansion.

Carfilzomib prescribing patterns and outcomes for relapsed or refractory multiple myeloma: a real-world analysis

Despite the widespread use of carfilzomib (K) in relapsed/refractory multiple myeloma (RRMM), there is no consensus on optimal K dose in milligrams per square meter (mg/m2) or dosing schedule. We assessed three modern K prescribing patterns in RRMM using a large United States electronic health record-derived database. Our final cohort (n = 486) included 136 patients (28.0%) who received K 56 mg/m2 once weekly (K56-1x), 86 (17.7%) who received 56 mg/m2 twice weekly (K56-2x), and 264 (54.3%) who received 70 mg/m2 once weekly (K70-1x). Between 2016 and 2023, once-weekly dosing became more common: K70-1x proportions changed from 21.1% in 2016 to 50.6% in 2023, K56-1x from 15.8% to 37.0%, and K56-2x from 63.2% to 12.3%. Median progression-free survival was 13.0 months [95% confidence interval (CI) 11.2-20.7] for K56-1x, 13.2 months (95% CI 9.0-28.1 months) for K56-2x, and 10.9 months (95% CI 9.9-15.3 months) for K70-1x; these differences were not statistically significant (log-rank p = 0.46). Rates of heart failure was comparable (<5% in all cohorts). In summary, our findings do not support improved outcomes with twice-weekly carfilzomib in RRMM. K56-1x may provide the best balance of efficacy, safety, and avoidance of time toxicity from frequent infusions.

Outcomes of Patients With Extramedullary Disease in Triple-Class Exposed Relapsed/Refractory Multiple Myeloma From the Pooled LocoMMotion and MoMMent Studies

BACKGROUND

Patients with relapsed/refractory multiple myeloma (RRMM) who develop extramedullary disease (EMD) generally have a poor prognosis, highlighting the urgent need for new therapies. We report effectiveness outcomes and safety in patients with and without EMD from the pooled analysis of LocoMMotion and MoMMent.

METHODS

LocoMMotion and MoMMent-1 are prospective, noninterventional, consecutive studies assessing the evolving standard of care from 20192022 in patients with triple-class exposed RRMM.

RESULTS

Of 302 patients, 29 had EMD per investigator discretion and only 15 patients were assessed as having true extramedullary plasmacytoma (EMP; defined as patients with ≥1 EMP lesion) by the response review committee. The 29 EMD patients received 21 unique regimens (most commonly chemotherapy-based regimens). Of the 29 patients with EMD, overall response rate (ORR) was 24.1%, median progression-free survival (PFS) was 2.66 months, median overall survival (OS) was 7.16 months, and median time to next treatment (TTNT) was 3.09 months. All responses were lower (ORR) and shorter (median PFS, OS, and TTNT) in patients with EMD vs patients without EMD. Nineteen (65.5%) patients with EMD received ≥1 subsequent lines of therapy. Of those, two (10.5%) patients received bispecific antibodies and achieved a partial response or better; three (15.8%) patients received antibody-drug conjugates (responses were unknown or not determined at data cut-off), and no patients received chimeric antigen receptorT cell therapy.

CONCLUSIONS

These results demonstrate the urgent need for more effective novel therapies for patients with EMD and highlight the need to use clear definitions of EMD and EMD response criteria for clinical trials.

β-Arrestin 2 as a Prognostic Indicator and Immunomodulatory Factor in Multiple Myeloma

β-arrestin 2 (ARRB2) is involved in the desensitization and trafficking of G protein-coupled receptors (GPCRs) and plays a critical role in cell proliferation, apoptosis, chemotaxis, and immune response modulation. The role of ARRB2 in the pathogenesis of multiple myeloma (MM) has not been elucidated. This study addressed this question by evaluating the expression of ARRB2 in bone marrow (BM) samples from newly diagnosed MM patients and deriving correlations with key clinical outcomes. In light of recent trends towards the use of immune checkpoint inhibitors across malignancies, the effect of ARRB2 in the regulation of the PD-1/PD-L1 axis was also investigated. The expression of ARRB2 was significantly higher in MM patients resistant to proteosome inhibitor (bortezomib) treatment compared to those who responded. Higher ARRB2 expression in the BM of newly diagnosed MM patients was associated with inferior progression-free survival and overall survival. PD-1 expression was downregulated in CD3 T cells isolated from ARRB2 knockout (KO) mice. Furthermore, knockdown of ARRB2 with siRNA reduced PD-1 expression in murine CD3 T cells and PD-L1 expression in murine myeloid-derived suppressor cells. These findings suggest an important role of ARRB2 in MM pathogenesis, potentially mediated via modulation of immune checkpoints in the tumor microenvironment. Our study provides new evidence that ARRB2 may have non-canonical functions independent of GPCRs with relevance to the understanding of MM pathobiology as well as immunotherapy and checkpoint inhibitor escape/resistance more broadly.

Extraosseous Plasmacytoma Confers Poor Outcomes in Primary Plasma Cell Leukemia

BACKGROUND

Primary plasma cell leukemia (PPCL) is one of the most aggressive diseases in oncohematology. Due to its low incidence, there is no established standard treatment, and it is considered an incurable disease.

AIMS

This study presents our experience and outcomes of 92 cases of PPCL between January 2011 and December 2020.

METHODS

Fat pad biopsy was positive for Congo red in six (35 %) of 17 patients, solitary extraosseous plasmacytoma was observed in 30 (32.5 %), and bone marrow fibrosis was identified in 81 (88 %) patients.

RESULTS

While most patients (69.5 %) received conventional chemotherapy combinations, 30.5 % underwent proteasome inhibitor-based treatment and/or autologous stem cell transplantation (auto-SCT). In this series, we report that the presence of extraosseous plasmacytoma, treatment failure, and therapy with classic chemotherapy agents were independent covariates associated with poor survival.

CONCLUSIONS

In PPCL, extraosseous plasmacytoma, treatment failure, and treatment with conventional chemotherapy were associated with poor outcomes.

VRd vs. VPd as induction therapy in high risk newly diagnosed multiple myeloma

In high-risk newly diagnosed multiple myeloma (HRNDMM), two different induction regimens were evaluated for safety and efficacy: Bortezomib-Pomalidomide-Dexamethasone (VPd) and Bortezomib-Lenalidomide-Dexamethasone (VRd). Newly diagnosed high-risk MM patients(age > 18) were included in this retrospective study, who received VRd and VPd induction therapy between January 2021 and November 2023. All methods of this experiment were performed in accordance with relevant guidelines and regulations. Informed consent has been obtained from all subjects and/or their legal guardians. The Ethics Association of Anqing City Hospital has approved the study on pomadomide in this experiment (Medical Review (2021) No. 27). The evaluation of OS (overall survival), PFS (progression free survival), AE (adverse event) was the secondary endpoints, while the primary endpoint of the study was the overall response rate (ORR) after four cycles of VRd and VPd. Ultimately, 25 patients with VRd and 21 patients with VPd were enrolled. After four cycles of induction, stringent complete, complete, very good partial, partial and overall response rates were 16%/24%/12%/40%/92% with VRd, and 23.81%/33.33%/33.33%/9.52%/100% with VPd. VGPR or better was achieved in 52% of patients receiving VRd compared to 90.47% in those receiving VPd, with a p-value of 0.003. VPd was linked to more cases of skin rash (p = 0.02). For VRd and VPd, the average overall survival time was 27-months and 21-months, respectively (p = 0.801). The PFS was 27-months for VRd and 20-months for VPd (p = 0.116). Median OS and PFS were not defined in both groups. According to our research, the induction of VPd has been found to elicit more profound and superior responses in HRNDMM compared to VRd, thereby establishing its safety. Our results underscore the potential clinical advantage of pomalidomide as first-line therapy and offer more proof of the beneficial efficacy of VPd in the treating of HRNDMM patients.

BCMA-directed CAR T-cell therapy in patients with multiple myeloma and CNS involvement

ABSTRACT

We investigated B-cell maturation antigen-directed chimeric antigen receptor T-cell (CAR-T) therapy in patients with relapsed or refractory multiple myeloma (MM) and central nervous system (CNS) involvement. Ten patients received either idecabtagene vicleucel (n = 6) or ciltacabtagene autoleucel (n = 4), where brain/cranial nerve and/or spinal cord involvement/leptomeningeal disease were evident on either magnetic resonance imaging (100%) and/or cerebrospinal fluid (40%). Eight patients had their CNS diagnosis before CAR-T therapy, and two were diagnosed within 14 days post-infusion. Seven received CNS-directed therapy during bridging before CAR-T therapy. There were no excess toxicities: no cytokine release syndrome grade ≥3; 10% immune effector cell-associated neurotoxicity syndrome (ICANS) grade 3; and no ICANS grade 4. Two patients experienced delayed but treatable neurotoxicity, with no reported parkinsonian side effects. The best overall response rate was 80% (≥70% very good partial response) and a 100% CNS response. With a median follow-up of 381 days, patients with CNS myeloma diagnosed before CAR-T therapy (n = 8) had a median overall survival and progression-free survival (PFS) of 13.3 and 6.3 months, respectively. Best outcomes were observed in 4 patients who had a response to bridging therapy, suggesting that optimizing pre-CAR-T therapy may be key for improved outcomes. Our study suggests that CAR-T therapy in patients with CNS MM is safe and feasible, and screening for CNS involvement before CAR-T therapy could be warranted in high-risk patients. The excellent initial response but relatively short PFS suggests consideration for post-CAR-T maintenance. Larger studies are needed to confirm these findings.

Cumulative deficits frailty index and relationship status predict survival in multiple myeloma

ABSTRACT

Several tools have been proposed for assessing frailty in multiple myeloma (MM), but most are based on clinical trial data sets. There are also limited data on the association between frailty and patient-reported outcomes and on the prognostic value of social determinants of health. This study evaluates the prognostic impact of frailty, based on the cumulative deficit frailty index (FI), and relationship and socioeconomic status (SES) in patients with newly diagnosed MM. This retrospective study included 515 patients with MM seen at Mayo Clinic (Rochester, MN) at diagnosis between 2005 and 2018. The FI was calculated using patient-reported data on activities of daily living and comorbidity data, with items scored as 0, 0.5, or 1, in which 1 indicated a deficit. The FI was calculated by dividing the total score by the number of nonmissing items. Frailty was defined as FI ≥0.15; 61% were nonfrail, and 39% were frail. Frailty and nonmarried/relationship status were associated with higher disease stage, decreased the likelihood of early transplantation, and independently associated with decreased survival. SES was not independently associated with survival. Frail patients reported worse scores for fatigue, pain, and quality of life. Approximately a quarter of patients had a deterioration in frailty status at 3 to 12 months, and <10% had improvement. In conclusion, a cumulative deficit FI was associated with higher symptom burden and decreased survival in a real-world cohort of patients with newly diagnosed MM. Frailty status is dynamic and should be reassessed during treatment. Social support has prognostic value and should be evaluated in clinical practice.

Effect of metachronous primary and secondary solid cancers in patients with multiple myeloma: a retrospective study from a single-center

Statement of translational relevance

Effects of metachronous primary malignant solid tumor (MPMST) on survival risk and prognosis of multiple myeloma (MM) and differences between MPMST occurring before and after MM remains unclear. Use of well-characterized clinical information of individual patient, we found that older patients with MM (≥ 65 years) had a higher risk of developing MPMST. Patients with MM and MPMST including male patients, aged ≥ 65 years and those with ISS stage III had a worse prognosis. The top three solid cancers occurred before and after MM were the lung, thyroid, and breast cancer. These findings provide detailed information for the precise treatment of patients with MM and MPMST.

Objective

To analyze the effects of MPMST on MM and the risk difference of MPMSTs occurring before and after MM.

Methods

Retrospective data from patients with MM and MPMST, including sex, age, immunoglobulin isotype, ISS stage, and therapy, were collected from 2015 to 2023. Differences in variables, risk, and survival were compared using the χ² test, logistic regression analysis and the Cox model, respectively.

Results

The 34 (1.57%) patients with MM and MPMST identified from a total of 2167 MM patients had a shorter overall survival. The survival risk was higher in male patients with MM and MPMST (HR: 3.96, 95% CI: 1.05 -14.96), in those aged ≥ 65 years (HR: 3.30, 95% CI: 1.41 -7.71), and with ISS stage III (HR: 4.08, 95% CI: 0.81-20.65). Patients with MM subsequent to CAR-T cell therapy had neither enhanced incidence rates of second solid cancers nor had longer overall survival time. Furthermore, the top three solid cancers occurred before or after MM were lung, thyroid, and breast cancer.

Conclusion

Male patients, aged ≥ 65 years and MM patients with ISS stage III and MPMST had a worse prognosis.

Outcomes of Newly Diagnosed Multiple Myeloma Patients Requiring Dialysis

INTRODUCTION

Renal impairment (RI) is a common complication in newly diagnosed multiple myeloma (NDMM), with 1-5% of patients presenting with severe RI requiring dialysis, which is associated with significant morbidity and early mortality. Limited real-world data exist on outcomes for these patients.

AIM/METHODS

We assessed renal response patterns and outcome determinants in 73 consecutive NDMM patients requiring dialysis, treated in a single centre (2010 to 2023).

RESULTS

Median age was 69 years; 52% had high-risk cytogenetics. All patients received bortezomib-based induction therapy (19% doublets, 71% triplets, 10% quadruplets; 12% anti-CD38 antibodies). Median follow-up was 37.2 months. Dialysis independence was achieved by 31 patients (42.5%) after a median of 52 days (range 3-247). Dialysis independence was associated with improved survival (median 36 vs. 13.3 months, P = .085) and lower early mortality (3.2% vs. 14.3%, P = .15). Factors associated with independence from dialysis were younger age) OR 0.92, P = .003), hypercalcemia (OR 1.43, P = .013) and hematologic response (≥ PR) at 1 month (OR 3.7, P = .015). In multivariate analysis, younger age (P = .012, OR 0.93) and hematologic response (≥ PR) at 1 month (P = .014, OR 4.94) were independent predictors of dialysis independence. Depth of hematologic response (≥ VGPR) significantly impacted renal recovery (OR 4.0, P = .020). High-risk cytogenetics independently predicted poor outcomes (HR 3.67, P = .003).

CONCLUSION

Dialysis independence is achievable in 42.5% of NDMM patients without special filters in the era of bortezomib-based regimens, with significant impact on outcome. Outcomes remain poor overall for patients who are dialysis-dependent at diagnosis and further evaluation of quadruplet regimens with anti-CD38 antibodies is needed.