Lenalidomide-induced upregulation of CXCR4 in CD34+ hematopoietic cells, a potential mechanism of decreased hematopoietic progenitor mobilization

Effect of prior lenalidomide or daratumumab exposure on hematopoietic stem cell collection and reconstitution in multiple myeloma

BACKGROUND

The roles of Lenalidomide (Len) and Daratumumab (Dara) in multiple myeloma treatment are well-established, yet their influences on hematopoietic stem cell harvesting and reconstitution remain disputed.

METHODS

We conducted a systematic database review to identify cohort studies or RCTs evaluating the effect of the use of Len or Dara on hematopoietic stem cell collection and peripheral blood count recovery in multiple myeloma patients. Effects on hematopoietic collection or reconstitution were estimated by comparing standardized mean differences (SMD) and mean differences (MD), or median differences.

RESULTS

Eighteen relevant studies were identified, summarizing mobilization results. For Len, data from 13 studies were summarized, including total CD34+ cell yield, collection failure rate, and time to neutrophil and platelet engraftment. Results indicated that Len exposure led to decreased stem cell collection [SMD=-0.23, 95% CI (-0.34, -0.12)]. However, collection failure (<2×106) could be mitigated by plerixafor [OR=2.14, 95% CI (0.96, 4.77)]. For Dara, two RCTs and three cohort studies were included, showing that Dara exposure resulted in a reduction in total stem cells even with optimized plerixafor mobilization [SMD=-0.75, 95% CI (-1.26, -0.23)], and delayed platelet engraftment recovery [MD=1.20, 95% CI (0.73, 1.66)].

CONCLUSIONS

Our meta-analysis offers a comprehensive view of Len and Dara's impacts on hematopoietic stem cell collection and reconstitution in multiple myeloma. Len usage could lead to reduced stem cell collection, counteracted by plerixafor mobilization. Dara usage could result in diminished stem cell collection and delayed platelet engraftment.

Comprehensive analysis of serum cytokines in patients with multiple myeloma before and after lenalidomide and dexamethasone

Multiple myeloma (MM) is an incurable B-cell malignancy often accompanied by profound immunodeficiency. Lenalidomide (Len) is an immunomodulatory drug that exerts promising therapeutic effects on MM through the immune system. However, predictive markers related to the effects of Len treatment are not fully understood. This study aimed to identify candidate biomarkers for predicting the clinical efficacy of Len and dexamethasone (Ld) therapy through a comprehensive analysis of serum cytokines. The levels of 48 cytokines in the serum of patients with MM just before Ld therapy (n = 77), at the time of best response (n = 56), and at disease progression (n = 49) were measured and evaluated. Patients with high IL-18 and M-CSF levels showed significantly shorter progression-free survival and overall survival (OS). In contrast, patients with high PDGF-BB levels had longer survival. Moreover, low levels of G-CSF, IL-7, IL-8, and SDF-1α were associated with shorter OS after Ld therapy. During Ld therapy, pro-inflammatory cytokines such as IL-2Rα, IL-18, and TNF-α were decreased, while IFN-γ was increased. IL-4 and IL-6 levels increased during disease progression. In conclusion, this study provides a better understanding of the association between cytokines and the efficacy of Ld therapy as well as the unique changes in cytokines related to inflammatory and immune responses during Ld therapy.

Stem cell mobilization in multiple myeloma: challenges, strategies, and current developments

Among hematological malignancies, multiple myeloma (MM) represents the leading indication of autologous hematopoietic stem cell transplantation (auto-HCT). Auto-HCT is predominantly performed with peripheral blood stem cells (PBSCs), and the mobilization and collection of PBSCs are essential steps for auto-HCT. Despite the improved success of conventional methods with the incorporation of novel agents for PBSC mobilization in MM, mobilization failure is still a concern. The current review comprehensively summarizes various mobilization strategies for mobilizing PBSCs in MM patients and the evolution of these strategies over time. Moreover, existing evidence substantiates that the mobilization regimen used may be an important determinant of graft content. However, limited data are available on the effects of graft characteristics in patient outcomes other than hematopoietic engraftment. In this review, we discussed the effect of graft characteristics on clinical outcomes, mobilization failure, factors predictive of poor mobilization, and potential mobilization regimens for such patients.

Initial Therapeutic Approaches to Patients with Multiple Myeloma

Multiple Myeloma (MM) is part of a spectrum of plasma cell disorders that may result in end organ damage. MM is subclassified into high and standard risk based on cytogenetic and laboratory markers. The treatment of newly diagnosed multiple myeloma is constantly changing with the advent of novel therapies. Recent advances in therapies have resulted in longer time to remission and overall survival. the introduction of targeted therapy with monoclonal antibodies such as Daratumumab has improved stringent complete response to 39%. In this review, we outline the current approach to diagnosis, prognosis, and management of newly diagnosed multiple myeloma in both transplant eligible and ineligible patients.

Feasibility of six cycles of lenalidomide-based triplet induction before stem cell collection for newly diagnosed transplant-eligible multiple myeloma

OBJECTIVES

Achieving a deep response with induction therapy has a major impact on outcomes following autologous stem cell transplantation. Although longer and intensified induction therapy may provide better disease control, longer exposure to lenalidomide negatively affects stem cell yield. We examined the feasibility of 6 cycles of lenalidomide-based triplet induction therapy before stem cell collection in transplant-eligible multiple myeloma patients.

METHODS

In this prospective study, patients received a combination of bortezomib, lenalidomide, and dexamethasone for 6 cycles. For patients who did not achieve a deep response after 3 cycles, bortezomib was substituted with carfilzomib for the last 2 cycles (5th and 6th courses).

RESULTS

Although only half of the patients achieved a deep response after 3 cycles, all but 1 patient achieved a very good partial response (n = 4) or complete response (n = 5) after completing 6 cycles. Among 9 patients who received cyclophosphamide-based stem cell mobilization, 1 patient required a second mobilization that was successfully performed using plerixafor. After autologous transplantation, 7 patients showed complete response, including 5 with minimal residual disease-negative status.

CONCLUSION

This study demonstrates that 6 cycles of lenalidomide-based induction therapy before stem cell collection are a feasible and promising approach for transplant-eligible newly diagnosed multiple myeloma patients.The study is registered at UMIN Clinical Trials Registry as UMIN000026936.Trial registration: UMIN Japan identifier: UMIN000026936.

Successful hematopoietic stem-cell mobilization with plerixafor plus granulocyte-colony stimulating factor in multiple myeloma patients treated with pomalidomide

Autologous stem-cell transplantation is an effective procedure for the treatment of multiple myeloma, and involves the collection of hematopoietic stem cells (HSCs). However, in some patients, HSCs in the bone marrow fail to mobilize. Pomalidomide upregulates CXCR4 in hematopoietic stem cells, in a manner similar to that of lenalidomide, and is, thus, likely to have a negative impact on hematopoietic stem-cell mobilization in multiple myeloma patients. Here, we report the two cases in which hematopoietic stem cells were mobilized using plerixafor plus granulocyte-colony stimulating factor after exposure to lenalidomide and pomalidomide. Use of plerixafor with a sufficient washout period may lead to successful mobilization following pomalidomide use, although further study of this potential use is needed.

Current status of autologous stem cell transplantation for multiple myeloma

More than 30 years after its introduction, autologous stem cell transplantation (ASCT) remains the standard of care for young patients with newly diagnosed multiple myeloma. Not only did the arrival of novel agents such as immunomodulatory drugs (IMiDs), proteasome inhibitors (PI) and monoclonal antibodies not replace ASCT, instead they solidified its central role as standard of care. Novel agent use is now inarguably essential in induction, maintenance, and possibly consolidation. In light of these new advancements, new challenges arise in deciding on optimal practice. Who is most suited to undergo ASCT? Is there an age threshold that should not be surpassed? Should transplantation be embarked on early or is it reasonable to delay it? What are the optimal induction, consolidation, and maintenance therapies? What is the role of tandem transplantation in the era of novel agents and where do patient-specific cytogenetics come into the equation when deciding on treatment? These are some of the questions addressed in this review which we will attempt to answer with the latest currently available data.

Impact of lenalidomide exposure on blood cell collection for autotransplants in persons with POEMS syndrome

INTRODUCTION

Lenalidomide is an effective therapy of POEMS syndrome. However, there is concern that exposure to lenalidomide may reduce the efficiency of blood cell collection in persons who may eventually receive an autotransplant. We studied the impact of lenalidomide therapy on subsequent blood cell mobilization and collection including frequency of blood CD34+ cells and CXCR4 expression before and after mobilization with cyclophosphamide and granulocyte-colony stimulating factor (G-CSF).

MATERIAL AND METHODS

Forty-three subjects with POEMS were assigned to receive lenalidomide and dexamethasone for 2-4 28 d cycles (n = 19) or no therapy (n = 24). All subjects then received cyclophosphamide and G-CSF. Neither cohort had substantial numbers of blood CD34+ cells before mobilization.

RESULTS

Mobilization increased blood CD34+ frequency in lenalidomide-treated subjects and controls similarly (0.25% (95% confidence interval (CI): 0.03-1.39% vs. 0.32%, 0.04-1.47%), p = 0.472). Increases in blood CD34+ numbers were also similar (10 × 10⁶/l) (5-77 × 10⁶/l) vs. 14 × 10⁶/l (6-101 × 10⁶/l), p = 0.312). Mean CXCR4 fluorescence intensity on bone marrow cells from controls decreased from 58 ±34 (mean ± SD) to 31 ±16 after mobilization (p = NS). In contrast, mean CXCR4 intensity on bone marrow cells in lenalidomide-treated subjects increased from 55 ±43 to 89 ±40 (p = 0.017, comparing the deviation between two groups). Median numbers of CD34+ cells collected in lenalidomide-treated subjects and controls were 2.3 × 10⁶/kg (0.6-6.8 × 10⁶/kg) and 2.810⁶/kg (1.0-8.9 × 10⁶/kg; p = 0.521).

CONCLUSIONS

Brief lenalidomide treatment for POEMS did not reduce numbers of CD34+ blood cells collected but increased CXCR4 expression on bone marrow CD34+ cells.

Impact of lenalidomide-based induction therapy on the mobilization of CD34+ cells, blood graft cellular composition, and post-transplant recovery in myeloma patients: a prospective multicenter study

BACKGROUND

Lenalidomide is an immunomodulatory drug that is also currently used in transplant-eligible patients with multiple myeloma. Previous studies have suggested a negative impact of lenalidomide on the mobilization of CD34⁺ cells. No data are available regarding the more detailed composition of blood grafts after lenalidomide.

STUDY DESIGN AND METHODS

In a multicenter, prospective study, we analyzed the mobilization of CD34⁺ cells, graft cellular composition, and post-transplant hematologic recovery in 26 patients with multiple myeloma after lenalidomide-based induction and in 34 lenalidomide-naive controls with multiple myeloma. All patients were mobilized with low-dose cyclophosphamide plus granulocyte-colony-stimulating factor. The cellular composition of the grafts was analyzed from thawed, cryopreserved samples with flow cytometry. Graft function was evaluated by engraftment data and by complete blood counts until 12 months after the graft infusion.

RESULTS

Patients in the lenalidomide arm had lower median peak CD34⁺ counts and approximately 40% lower CD34⁺ cell yields from the first apheresis session, but these differences were not significant. The median total number of CD34⁺ cells collected was comparable (6.4 vs. 7.5 × 10⁶ /kg). The number of apheresis sessions was higher in the lenalidomide group (2 vs. 1; p = 0.039). The blood graft composition was comparable between the groups. Hematologic recovery within 12 months post-transplant did not differ between the groups.

CONCLUSION

Lenalidomide-based induction seems to have an impact on the number of aphereses performed, but not on the total yields of the CD34⁺ cells in the graft. Neither cellular composition of the grafts nor post-transplant recovery was affected by the limited pre-transplant exposure to lenalidomide.

Multiple myeloma-derived MMP-13 mediates osteoclast fusogenesis and osteolytic disease

Multiple myeloma (MM) cells secrete osteoclastogenic factors that promote osteolytic lesions; however, the identity of these factors is largely unknown. Here, we performed a screen of human myeloma cells to identify pro-osteoclastogenic agents that could potentially serve as therapeutic targets for ameliorating MM-associated bone disease. We found that myeloma cells express high levels of the matrix metalloproteinase MMP-13 and determined that MMP-13 directly enhances osteoclast multinucleation and bone-resorptive activity by triggering upregulation of the cell fusogen DC-STAMP. Moreover, this effect was independent of the proteolytic activity of the enzyme. Further, in mouse xenograft models, silencing MMP-13 expression in myeloma cells inhibited the development of osteolytic lesions. In patient cohorts, MMP-13 expression was localized to BM-associated myeloma cells, while elevated MMP-13 serum levels were able to correctly predict the presence of active bone disease. Together, these data demonstrate that MMP-13 is critical for the development of osteolytic lesions in MM and that targeting the MMP-13 protein - rather than its catalytic activity - constitutes a potential approach to mitigating bone disease in affected patients.

A randomized phase II study of stem cell mobilization with cyclophosphamide+G-CSF or G-CSF alone after lenalidomide-based induction in multiple myeloma

The most common means of mobilizing autologous stem cells is G-CSF alone or combined with cyclophosphamide (CY) to obtain sufficient CD34⁺ cells for one to two transplants. There are few prospective, randomized studies investigating mobilization regimens in multiple myeloma (MM), especially after lenalidomide-based induction. We designed this prospective, randomized study to compare low-dose CY 2 g/m²+G-CSF (arm A) and G-CSF alone (arm B) after lenalidomide-based up-front induction in MM. Of the 80 initially randomized patients, 69 patients were evaluable, 34 and 35 patients in arms A and B, respectively. The primary end point was the proportion of patients achieving a yield of ⩾3 × 10⁶/kg CD34⁺ cells with 1−2 aphereses, which was achieved in 94% and 77% in arms A and B, respectively (P=0.084). The median number of aphereses needed to reach the yield of ⩾3 × 10⁶/kg was lower in arm A than in arm B (1 vs 2, P=0.035). Two patients needed plerixafor in arm A and five patients in arm B (P=0.428). Although CY-based mobilization was more effective, G-CSF alone was successful in a great majority of patients to reach the defined collection target after three cycles of lenalidomide-based induction.

Overview of therapy and strategies for optimizing outcomes in de novo pediatric acute myeloid leukemia

Although acute myelogenous leukemia (AML) accounts for <20 % of leukemia in children, it is responsible for over half of all pediatric leukemia deaths. Improvement in event-free survival rates, now over 50 %, are due largely to intensification of chemotherapy, aggressive supportive care, development of risk stratification based on cytogenetic and molecular markers, and improved salvage regimens. Despite this improvement over the past few decades, the survival rates have recently plateaued, and further improvement will need to take into account advances in molecular characterization of AML, development of novel agents, and better understanding of host factors influencing toxicity and response to chemotherapy. This article reviews the epidemiology and biology trends in diagnosis and treatment of pediatric acute myelogenous leukemia.