Thalidomide as initial therapy for early-stage myeloma

Monoclonal Antibodies in Smoldering Multiple Myeloma and Monoclonal Gammopathy of Undetermined Significance: Current Status and Future Directions

Monoclonal antibodies (MoAbs) targeting several cellular receptors have significantly improved the prognosis of multiple myeloma (MM). Their high effectiveness and safety raise the question of whether earlier therapeutic intervention in monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM) influences the natural course of the disease. MM is preceded by clinically recognized conditions such as MGUS and SMM. Numerous studies are investigating the disease biology and immune profile of SMM and MGUS to unravel the intricate relationship between immunosurveillance and disease progression. The standard approach to MGUS and SMM remains close observation. Early studies indicate benefits in terms of progression or even survival for promptly treating high-risk SMM patients. Ongoing debates are focused on which patients with SMM and MGUS to treat, as well as on determining the optimal therapeutic approach. The first approach aims to cure by attempting to eliminate the pathological clone, while the second approach is preventive, aiming to manage disease progression to active MM and restore the immune system. In this review, we focus on the available and emerging data on early treatment, particularly with MoAbs alone or in combination with other therapies, in SMM and MGUS patients.

A review of chemotherapeutic drugs-induced arrhythmia and potential intervention with traditional Chinese medicines

Significant advances in chemotherapy drugs have reduced mortality in patients with malignant tumors. However, chemotherapy-related cardiotoxicity increases the morbidity and mortality of patients, and has become the second leading cause of death after tumor recurrence, which has received more and more attention in recent years. Arrhythmia is one of the common types of chemotherapy-induced cardiotoxicity, and has become a new risk related to chemotherapy treatment, which seriously affects the therapeutic outcome in patients. Traditional Chinese medicine has experienced thousands of years of clinical practice in China, and has accumulated a wealth of medical theories and treatment formulas, which has unique advantages in the prevention and treatment of malignant diseases. Traditional Chinese medicine may reduce the arrhythmic toxicity caused by chemotherapy without affecting the anti-cancer effect. This paper mainly discussed the types and pathogenesis of secondary chemotherapeutic drug-induced arrhythmia (CDIA), and summarized the studies on Chinese medicine compounds, Chinese medicine Combination Formula and Chinese medicine injection that may be beneficial in intervention with secondary CDIA including atrial fibrillation, ventricular arrhythmia and sinus bradycardia, in order to provide reference for clinical prevention and treatment of chemotherapy-induced arrhythmias.

Inhibition of Wnt Signaling in Colon Cancer Cells via an Oral Drug that Facilitates TNIK Degradation

We have synthesized an oxetane derivative of the benzimidazole compound mebendazole (OBD9) with enhanced solubility and strong anticancer activity in multiple types of cancer cells, especially colorectal cancer. In this report, we provide evidence that OBD9 suppresses colorectal cancer growth by interfering with the Wnt signaling pathway, a main driver of cell growth in colorectal cancer. Specifically, we find that OBD9 induces autophagic degradation of TNIK (traf2 and Nck-interacting kinase), which promotes T-cell factor-4 (TCF4)/beta-catenin-mediated gene expression. Thus, OBD9 as a TNIK inhibitor blocks Wnt/beta-catenin signaling at the final step of transcriptional activation. We suggest that OBD9 provides a potential novel autophagy-mediated, Wnt-damping therapeutic strategy for the treatment of colorectal cancer.

Mechanisms Contributing to Acquired Activated Protein C Resistance in Patients Treated with Thalidomide: A Molecular Dynamics Study

INTRODUCTION

There is a high incidence of venous thromboembolism (VTE) in patients with Multiple Myeloma (MM), however; until now, the exact mechanisms behind VTE in MM are unknown, and some of the elements that may play a significant role are the treatment with an immunomodulator (IMiD) and acquired resistance to activated protein C (APC).

OBJECTIVE

The study aims to reveal the possible mechanisms linked to the reduced antithrombotic activity of APC associated with thalidomide.

METHODS

The molecular docking approach was used to ascertain the in silico inhibitory potential of thalidomide on the APC protease domain in the architecture of the catalytic triad and its interaction with major substrate binding sites.

RESULTS

The coupling showed that the inhibitory activity of thalidomide depends on the induction of structural changes in the protease domain of APC, at the level of the Ser/His/Asp catalytic triad, as a result of a significant increase between the distances of CαAsp102 and Cα Ser195 (11.175 angstroms, increase 14.83%) and between CαSer195 and CαHis57 (9.478 angstroms, increase 13.78 %). This can result in an inefficient transfer of the proton between these residues, the other possible mechanism of inhibition, is a potential reduced binding of the substrate as a result of a direct interaction through a carbon-hydrogen bond on His57, an H-bond on Arg306, and a carbon hydrogen bond on Arg506.

CONCLUSION

We demonstrate the in silico inhibitory potential of thalidomide on APC, through two possible inhibition mechanisms, a pathophysiologically relevant finding to understand the factors that can affect the stability and functions of APC in vivo.

Early Intervention With a Curative Intent Through an Intensive Therapy Versus Immunologic Disease Control Using a Minimal Intensity Approach in the Management of High-risk Smoldering Multiple Myeloma: A Systematic Review of Evidence From Clinical Trials

A subset of individuals with smoldering myeloma (SMM) are at a high risk of progression to symptomatic myeloma. Current efforts are focused on identifying this high-risk group and intercepting the disease process before its progression. There is no consensus on what the goal of an intervention should be, whether to aim for a cure through a high-intensity intervention or pursue immunologic disease control using the least intense approach. This systematic review summarized current evidence in support of the optimum approach. A database search of Medline/PubMed, Scopus, EMBASE, Web of Science, CINAHL, Wiley Cochrane Library, clinicaltrials.gov, and conference proceedings of ASH, EHA, ASCO, ESMO was performed. Results were presented using narrative synthesis of quantitative data. Of the 2088 identified records, a total of 10 eligible studies made up of 6 minimal-intensity clinical trials, 3 moderate-intensity trials, and 1 high-intensity trial were included in this review with a total demographic population of 588 high-risk SMM patients. Minimal intensity lenalidomide-based regimen demonstrated clinical effectiveness in delaying disease progression and improving overall survival in high-risk SMM. The single-agent monoclonal antibodies did not have any major impact on improving overall survival, although the studies were not powered to do so. There is a marked increase in the depth of response as the intensity of treatment increases without a proportional improvement in overall survival. Moderate- and high-intensity interventions yielded similar minimal residual disease negativity rates and overall survival. The minimal, moderate, and high-intensity approaches all demonstrated clinical benefits in delaying disease progression and improving overall survival in patients with high-risk SMM and increasing intensity of intervention does not necessarily translate to improved overall survival.

Smoldering multiple myeloma current treatment algorithms

Smoldering multiple myeloma (SMM) is an asymptomatic condition that occupies a space between monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma (MM) along the spectrum of clonal plasma cell proliferative disorders. It is not a biologic intermediate stage between MGUS and MM, but rather represents a heterogeneous clinically defined condition in which some patients (approximately two-thirds) have MGUS (pre-malignancy), and some (approximately one-third) have MM (biologic malignancy). Unfortunately, no single pathologic or molecular feature can reliably distinguish these two groups of patients. For purposes of practice and clinical trials, specific risk factors are used to identify patients with SMM in whom malignant transformation has already likely occurred (high risk SMM). Patients with newly diagnosed high risk SMM should be offered therapy with lenalidomide or lenalidomide plus dexamethasone (Rd) for 2 years, or enrollment in clinical trials. Patients with low risk SMM should be observed without therapy every 3-4 months.

Cancer Chemotherapy-Induced Sinus Bradycardia: A Narrative Review of a Forgotten Adverse Effect of Cardiotoxicity

Cardiotoxicity is a common adverse effect of anticancer drugs (ACDs), including the so-called targeted drugs, and increases morbidity and mortality in patients with cancer. Attention has focused mainly on ACD-induced heart failure, myocardial ischemia, hypertension, thromboembolism, QT prolongation, and tachyarrhythmias. Yet, although an increasing number of ACDs can produce sinus bradycardia (SB), this proarrhythmic effect remains an underappreciated complication, probably because of its low incidence and severity since most patients are asymptomatic. However, SB merits our interest because its incidence increases with the aging of the population and cancer is an age-related disease and because SB represents a risk factor for QT prolongation. Indeed, several ACDs that produce SB also prolong the QT interval. We reviewed published reports on ACD-induced SB from January 1971 to November 2020 using the PubMed and EMBASE databases. Published reports from clinical trials, case reports, and recent reviews were considered. This review describes the associations between ACDs and SB, their clinical relevance, risk factors, and possible mechanisms of onset and treatment.

Bradyarrhythmias in Cardio-Oncology

The relationship between bradyarrhythmias and cancer therapies has not been well described but is increasingly recognized. There have been extensive advances in oncological pharmacotherapy, with several new classes of drugs available including targeted agents, immune checkpoint inhibitors and CAR T cell therapy. This increasing repertoire of available drugs has revolutionized overall prognosis and survival of cancer patients but the true extent of their cardiovascular toxicity is only beginning to be understood. Previous studies and published reviews have traditionally focused on conventional chemotherapies and in arrhythmias in general, particularly tachyarrhythmias. The number of patients with both cancer and cardiovascular problems is increasing globally and oncologists and cardiologists need to be adept at managing arrythmia based scenarios. Greater collaboration between the two specialties including studies with prospective data collection in Cardio-Oncology are much needed to fill in knowledge gaps in this arena. This case-based review summarizes current available evidence of cancer treatment-related bradyarrhythmia incidence (including its different subtypes), possible mechanisms and outcomes. Furthermore, we propose a stepwise surveillance and management protocol for patients with suspected bradyarrhythmia related to cancer treatment.

Incidence of Arrhythmias and Their Prognostic Value in Patients With Multiple Myeloma

Background: Arrhythmias are common cardiovascular complications in multiple myeloma (MM) patients and are related to a poor prognosis.

Objective: This study aimed to assess the burden of arrhythmias and their prognostic value in patients with MM.

Methods: This was a retrospective study of patients with MM between January 2015 and April 2020 at the First Affiliated Hospital of Xi'an Jiaotong University. The incidence of arrhythmia and associated risk factors were evaluated. The relationship between the type of arrhythmia and survival was analyzed.

Results: A total of 319 patients with MM were identified, and 48.0% (153/319) had arrhythmias. The most common type of arrhythmia was sinus tachycardia (ST) (15.0%, 48/319), followed by sinus bradycardia (SB) (14.4%, 46/319), premature atrial contractions (PACs) (6.3%, 20/319), conduction disorders (CDs) (6.0%, 19/319), atrial fibrillation (AF) (6.0%, 19/319), premature ventricular contractions (PVCs) (4.4%, 14/319) and paroxysmal supraventricular tachycardia (PSVT) (0.6%, 2/319). The patients with arrhythmias had higher levels of log NT-proBNP and creatinine, greater bortezomib use, and a higher incidence of diabetes than those without arrhythmias (P < 0.05). The all-cause mortality rates of patients without arrhythmias and those with AF, ST, PACs, CDs, SB, and PVCs were 50.6% (84/166), 73.7% (14/19), 60.4% (29/48), 60.0% (12/20), 52.6% (10/19), 34.8% (16/46), and 28.6% (4/14), respectively. In a subgroup analysis of patients experiencing different types of arrhythmias, patients with SB had lower all-cause mortality than patients with AF (P < 0.01). Univariate and multivariate Cox analyses showed that there was a positive statistically significant association between SB and survival (HR: 0.592 [0.352–0.998], P = 0.049) in a subgroup analysis of different arrhythmias.

Conclusions: Patients with MM had a heavy arrhythmia burden, and in this study, approximately half of MM patients had arrhythmias. MM patients with SB were associated with lower all-cause mortality than those with AF. SB might be an independent positive factor for prognosis.

Chemotherapy-Induced Arrhythmia - Underrecognized and Undertreated

Cancer is one of the leading causes of death worldwide. Chemotherapy-induced arrhythmia is a potential complication of treatment that confers increased morbidity and mortality. The relationship between chemotherapeutic agents and arrhythmias is poorly established. Atrial fibrillation, ventricular ectopic beats, and prolonged QTc are the most common arrhythmias suffered by cancer patients undergoing chemotherapy. The treatment of atrial fibrillation in cancer is complicated by complex drug-drug interactions and a lack of evidence guiding practice. Furthermore, the normal risk assessment scores utilized in the decision-making for anticoagulation in the normal population are not validated in the cancer population. Multiple agents are implicated in prolonging the QTc, and this can often have adverse consequences for both the patient and the treatment of their cancer. This can manifest as torsades de pointes and sudden cardiac death. It is advised that, during treatment, oncologists should have close liaison with cardio-oncologists to ensure optimum patient management.

Co-evolution of Immune Response in Multiple Myeloma: Implications for Immune Prevention

Multiple myeloma (MM), a malignant neoplasm of plasma cells that reside in the bone marrow (BM), is universally preceded by a precursor state termed monoclonal gammopathy of undetermined significance (MGUS). Many individuals with MGUS never progress to MM or progress over many years. Therefore, MGUS provides a unique opportunity to surveil changes in the BM tumor microenvironment throughout disease progression. It is increasingly appreciated that MGUS cells carry many of the genetic changes found in MM. Prior studies have also shown that MGUS cells can be recognized by the immune system, leading to early changes in the BM immune environment compared to that of healthy individuals, including alterations in both innate and adaptive immunity. Progression to clinical MM is associated with attrition of T cells with stem memory-like features and instead accumulation of T cells with more terminally differentiated features. Recent clinical studies have suggested that early application of immune-modulatory drugs, which are known to activate both innate and adaptive immunity, can delay the progression to clinical MM. Understanding the biology of how the immune response and tumors coevolve over time is needed to develop novel immune-based approaches to achieve durable and effective prevention of clinical malignancy.

Moving From Cancer Burden to Cancer Genomics for Smoldering Myeloma: A Review

Importance

All patients who develop multiple myeloma have a preceding asymptomatic expansion of clonal plasma cells, clinically recognized as monoclonal gammopathy of undetermined significance or smoldering multiple myeloma (SMM). During the past decade, significant progress has been made in the classification and risk stratification of SMM.

Observations

This review summarizes current clinical challenges and discusses available models for risk stratification in the context of SMM. Owing to several novel, more effective, and less toxic drugs, these aspects are becoming increasingly important to identify patients eligible for early treatment. However, all proposed criteria were built around indirect markers of disease burden and therefore are generally able to identify a fraction of patients with SMM in whom transformation to multiple myeloma and genomic subclonal diversification are already happening. In contrast, next-generation sequencing approaches have the potential to identify myeloma precursor disease that will progress even before the major clonal expansion and progression, providing a potential base for more effective treatment and better precision regarding the optimal timing of treatment initiation.

Conclusions and Relevance

Owing to modern technologies, in the near future, prognostic models derived from genomic signatures independent of the disease burden will allow better identification of the optimal timing to treat a plasma cell clonal disorder at the very early stages, when the chances of eradication are higher.

International Myeloma Working Group risk stratification model for smoldering multiple myeloma (SMM)

Smoldering multiple myeloma (SMM) is an asymptomatic precursor state of multiple myeloma (MM). Recently, MM was redefined to include biomarkers predicting a high risk of progression from SMM, thus necessitating a redefinition of SMM and its risk stratification. We assembled a large cohort of SMM patients meeting the revised IMWG criteria to develop a new risk stratification system. We included 1996 patients, and using stepwise selection and multivariable analysis, we identified three independent factors predicting progression risk at 2 years: serum M-protein >2 g/dL (HR: 2.1), involved to uninvolved free light-chain ratio >20 (HR: 2.7), and marrow plasma cell infiltration >20% (HR: 2.4). This translates into 3 categories with increasing 2-year progression risk: 6% for low risk (38%; no risk factors, HR: 1); 18% for intermediate risk (33%; 1 factor; HR: 3.0), and 44% for high risk (29%; 2–3 factors). Addition of cytogenetic abnormalities (t(4;14), t(14;16), +1q, and/or del13q) allowed separation into 4 groups (low risk with 0, low intermediate risk with 1, intermediate risk with 2, and high risk with ≥3 risk factors) with 6, 23, 46, and 63% risk of progression in 2 years, respectively. The 2/20/20 risk stratification model can be easily implemented to identify high-risk SMM for clinical research and routine practice and will be widely applicable.

Treatment of Smoldering Multiple Myeloma: Ready for Prime Time?

The current standard of care for smoldering multiple myeloma (SMM) is observation until there is end-organ involvement. With newer and more effective treatments available, a question that is increasingly asked is whether early intervention in patients with SMM will alter the natural history of their disease. Herein, we review the evolving definition of SMM and risk stratification models. We discuss evidence supporting early intervention for SMM-both as a preventative strategy to delay progression and as an intensive treatment strategy with a goal of potential cure. We highlight ongoing trials and focus on better defining who may require early intervention.

Effect of thalidomide on bone marrow angiogenesis in multiple myeloma patients

BACKGROUND

Bone marrow angiogenesis is increased in multiple myeloma (MM) patients, prompting the rationale for using antiangiogenic drugs in the treatment of these patients.

OBJECTIVE

To assess angiogenesis in patients with MM at diagnosis and following treatment with an antiangiogenic drug.

PATIENTS AND METHODS

Twenty-three patients with newly diagnosed MM were treated with thalidomide-based regimens. Bone marrow evaluation was made before and following treatment and included angiogenesis assessment, which was quantified through microvessel density (MVD) determination, by means of anti-CD34 immunohistochemical labeling, and classified either as high MVD or low MVD, according to the mean CD34 count: above or below the median of 12.6.

RESULTS

The pre-therapy median MVD was 12 (7.5-18.3) versus 8.7 (5.35-18.5) post-therapy, p=0.2114.

CONCLUSIONS

Our study found no reduction in MVD before and following treatment and, accordingly, we could establish no relationship between MVD and response to therapy in the sample we studied.

A case report: high dose melphalan as a conditioning regimen for multiple myeloma induces sinus arrest

High dose melphalan is commonly used as a conditioning regimen for autologous stem cell transplantation in multiple myeloma. There are reports of adverse cardiac events with melphalan manifested by supraventricular tachycardia and atrial fibrillation. Here, we report a rare case of a 58 year old female with multiple myeloma, who developed sinus arrest after autologous stem cell transplantation using high dose melphalan as a conditioning regimen. It was severe and rare, therefore, monitoring for cardiac toxicity in patients receiving high-dose melphalan is mandatory.

Smoldering Multiple Myeloma: To Treat or Not to Treat

Smoldering multiple myeloma (SMM) is an asymptomatic, intermediate stage positioned between the plasma cell disorders of monoclonal gammopathy of undermined significance and overt multiple myeloma (MM). Although the patients with SMM have a higher risk of progression to MM in comparison to their counterparts with monoclonal gammopathy of undermined significance, their clinical course can be highly variable. The standard of care for SMM, irrespective of the risk status, continues to be observation due to paucity of high-level evidence demonstrating survival or quality-of-life benefit with early intervention. With the expanded 2014 criteria for MM utilizing biomarkers, the subset of SMM patients with 70% to 80% risk of progression at 2 years (ultra-high risk SMM) is now categorized as active MM and treated prior to the development of end-organ damage. After exclusion of this group, patients with approximately 50% risk of progression in 2 years are now considered high-risk SMM, and the value of early treatment in this subset can be established only through clinical trials. Despite its limitations, a recent phase III trial (QuiRedex) has shown survival advantage to using lenalidomide and dexamethasone doublet over observation in high-risk SMM. In this article, we review the evolving concepts in the diagnosis, risk stratification, and management of SMM.

How We Approach Smoldering Multiple Myeloma

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors’ suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

State of the science in smoldering myeloma: Should we be treating in the clinic?

Currently the standard of care for smoldering multiple myeloma (SMM) is "watch and wait." However, in recent years the treatment for multiple myeloma (MM) has shifted from cytotoxic chemotherapy with poor efficacy to less toxic, more effective treatments. Therefore, the standard for SMM is coming into question, especially for patients at the highest risk of developing MM. There are currently multiple active clinical trials investigating earlier intervention in patients with SMM. This article will review the history of SMM and how the current standard of care came to be. We will define prognostic factors of SMM and how to identify patients at highest risk of developing MM. Next we will review previous clinical trials examining treatment of SMM and finally discuss active clinical trials. While there are clear guidelines outlining management of high-risk SMM patients, they are mostly based on expert opinion and therefore it is an active area of research. Accordingly, patients should be encouraged to participate in clinical trials to better understand the benefit versus risk of early treatment.

Smoldering multiple myeloma: prevalence and current evidence guiding treatment decisions

Smoldering multiple myeloma (SMM) is an asymptomatic plasma cell proliferative disorder associated with risk of progression to symptomatic multiple myeloma (MM) or amyloidosis. In comparison to monoclonal gammopathy of undetermined significance (MGUS), SMM has a much higher risk of progression to MM. Thanks to advances in our understanding of the risk factors, the subset of patients with ultra-high risk of progression to MM (80%-90% at 2 years) has been identified. The revision of the diagnostic criteria resulted in changes in the management of this cohort of patients. In contrast to the management guidelines for MGUS patients, SMM patients need to be studied more intensively in order to identify biomarkers necessary for accurate risk stratification. In this review, we focus on the risk of progression from SMM to MM, as well as the influence of early treatment on overall survival, time to progression and quality of life.

Using Genome Sequence to Enable the Design of Medicines and Chemical Probes

Rapid progress in genome sequencing technology has put us firmly into a postgenomic era. A key challenge in biomedical research is harnessing genome sequence to fulfill the promise of personalized medicine. This Review describes how genome sequencing has enabled the identification of disease-causing biomolecules and how these data have been converted into chemical probes of function, preclinical lead modalities, and ultimately U.S. Food and Drug Administration (FDA)-approved drugs. In particular, we focus on the use of oligonucleotide-based modalities to target disease-causing RNAs; small molecules that target DNA, RNA, or protein; the rational repurposing of known therapeutic modalities; and the advantages of pharmacogenetics. Lastly, we discuss the remaining challenges and opportunities in the direct utilization of genome sequence to enable design of medicines.

Stem Cell Transplantation for Multiple Myeloma

BACKGROUND

Multiple myeloma (MM) is the second most common hematologic malignancy, affecting approximately 14,000 new patients in the United State per year. The median overall survival is 5 years, and cure is a realistic goal for only a small minority of patients.

METHODS

A review of the literature was conducted that focused on treatment strategies for MM involving administration of high doses of chemotherapy followed by autologous or allogeneic hematopoietic stem cell transplant.

RESULTS

For over three decades, the standard treatment for MM has been a regimen of melphalan and prednisone (MP). Complete responses (CRs) have been rare, and 50% of patients have had disease that was resistant to treatment with MP. Attempts have been made to improve the outcome of MM by administering other combinations of standard doses of chemotherapy, but these treatments are equivalent in terms of overall survival. For patients who are candidates, high-dose therapy followed by autologous stem cell transplantation results in higher CR rates and improved long-term survival compared to treatment with standard doses of chemotherapy alone. While this strategy represents an advance in the treatment of MM, evidence-based reviews indicate that there are a number of issues to consider regarding the induction therapy, the collection of stem cells, and the timing, type, and number of high-dose therapies to use in this type of treatment strategy.

CONCLUSIONS

Advances have been made in autologous transplantation, allogeneic transplantation, anti-MM agents, and immunotherapy for MM. Combining these different strategies to achieve synergistic responses is an exciting possibility.

Diagnosis and management of smoldering multiple myeloma: the razor's edge between clonality and cancer

Smoldering multiple myeloma (SMM) is a rare plasma cell disorder, and as the disease is asymptomatic, diagnosis is often incidental. SMM is characterized by increased marrow infiltration by clonal plasma cells and/or elevated serum M-protein in the absence of a myeloma-defining event (MDE). In recent years, SMM has gained increased attention owing to a broadening of the criteria for MDE, which include apart from the CRAB criteria, three additional parameters. Survival advantage may be offered by early treatment in the high-risk subset, based on a single trial. In this review, we assess the risk factors and models for progression to multiple myeloma. A review of our diagnostic and management approaches to SMM is presented.

Asymptomatic monoclonal gammopathies

Monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM) represent the earlier phases of plasma cell dyscrasias. Their definition is based on absence of end-organ damage with presence of a malignant clone that grows in the bone marrow. They share, as a common feature, the risk of progression to a symptomatic disease. MGUS progression risk is approximately 1% per year, and SMM has a risk of progression of 10% for the first 5 years which tapers off over time. The main purpose of identification of these earlier phases of the plasma cell dyscrasia was to identify patients who do not warrant treatment with chemotherapy, in whom the risk of treatment outweighs the benefit. Over the years, the definitions have not been modified to incorporate developments in imaging (magnetic resonance or positron emission and computed tomography), or genomics to identify patients at highest risk of progression within 2 years, where wait and watch might not be an appropriate option. In the absence of such definition, patients who have only a 50% chance of progression within 2 years are being offered therapy, which might also not be an optimal approach. In this review, we provide an overview of the definition, current prognostic factors, and risk stratifications in asymptomatic gammopathies, and discuss clinical trial outcomes in high-risk SMM.

Anticancer Properties of a Novel Class of Tetrafluorinated Thalidomide Analogues

Thalidomide has demonstrated clinical activity in various malignancies affecting immunomodulatory and angiogenic pathways. The development of novel thalidomide analogs with improved efficacy and decreased toxicity is an ongoing research effort. We recently designed and synthesized a new class of compounds, consisting of both tetrafluorinated thalidomide analogues (Gu973 and Gu998) and tetrafluorobenzamides (Gu1029 and Gu992). In this study, we demonstrate the antiangiogenic properties of these newly synthesized compounds. We examined the specific antiangiogenic characteristics in vitro using rat aortic rings with carboxyamidotriazole as a positive control. In addition, further in vitro efficacy was evaluated using human umbilical vein endothelial cells (HUVEC) and PC3 cells treated with 5 and 10 μmol/L doses of each compound. All compounds were seen to reduce microvessel outgrowth in rat aortic rings as well as to inhibit HUVECs to a greater extent, at lower concentrations than previously tested thalidomide analogs. The antiangiogenic properties of the compounds were also examined in vivo in fli1:EGFP zebrafish embryos, where all compounds were seen to inhibit the extent of outgrowth of newly developing blood vessels. In addition, Gu1029 and Gu973 reduced the anti-inflammatory response in mpo:GFP zebrafish embryos, whereas Gu998 and Gu992 showed no difference. The compounds' antitumor effects were also explored in vivo using the human prostate cancer PC3 xenograft model. All four compounds were also screened in vivo in chicken embryos to investigate their teratogenic potential. This study establishes these novel thalidomide analogues as a promising immunomodulatory class with anticancer effects that warrant further development to characterize their mechanisms of action.

Time to redefine Myeloma

In November 2014 the International Myeloma Working Group (IMWG) revised the definition of multiple myeloma, such that asymptomatic patients with newly diagnosed multiple myeloma without any of the traditional 'CRAB' (hypercalcaemia, renal impairment, anaemia, bone disease) end organ damage criteria but with one of three new criteria would be recommended to start treatment. Previously, the standard of care for such patients was expectant management. These three new criteria are: greater than 60% clonal plasma cells on bone marrow biopsy, a serum free light chain (sFLC) ratio of >100 (the involved sFLC must be >100 mg/l) and greater than one unequivocal focal lesion on advanced imaging (low dose whole body computerized tomography, magnetic resonance imaging, (18) F fluorodeoxyglucose positron emission tomography). Although this would appear to affect a small number of patients, the impact of these changes are broad, leading to an increased use of advanced imaging, a debate around the management of patients previously diagnosed with smouldering myeloma, changed terminology and clinical trial design and an extension of the use of biomarkers. For the first time the philosophy of treatment in myeloma will change from treatment initiation only being triggered by overt end organ damage to an era where sub clinical risk factors will also be taken into account.

Smoldering multiple myeloma

Smoldering multiple myeloma (SMM) is an asymptomatic precursor stage of multiple myeloma (MM) characterized by clonal bone marrow plasma cells (BMPC) ≥ 10% and/or M protein level ≥ 30 g/L in the absence of end organ damage. It represents an intermediate stage between monoclonal gammopathy of undetermined significance (MGUS) and symptomatic MM. The risk of progression to symptomatic MM is not uniform, and several parameters have been reported to predict the risk of progression. These include the level of M protein and the percentage of BMPC, the proportion of immunophenotypically aberrant plasma cells, and the presence of immunoparesis, free light-chain (FLC) ratio, peripheral blood plasma cells (PBPC), pattern of serum M protein evolution, abnormal magnetic resonance imaging (MRI), cytogenetic abnormalities, IgA isotype, and Bence Jones proteinuria. So far treatment is still not recommended for SMM, because several trials suggested that patients with SMM do not benefit from early treatment. However, the Mateos et al. trial showed a survival benefit after early treatment with lenalidomide plus dexamethasone in patients with high-risk SMM. This trial has prompted a reevaluation of early treatment in an asymptomatic patient population.

Smoldering multiple myeloma

Smoldering multiple myeloma (SMM) is an asymptomatic clonal plasma cell disorder. SMM is distinguished from monoclonal gammopathy of undetermined significance by a much higher risk of progression to multiple myeloma (MM). There have been major advances in the diagnosis, prognosis, and management of SMM in the last few years. These include a revised disease definition, identification of several new prognostic factors, a classification based on underlying cytogenetic changes, and new treatment options. Importantly, a subset of patients previously considered SMM is now reclassified as MM on the basis of biomarkers identifying patients with an ≥80% risk of progression within 2 years. SMM has assumed greater significance on the basis of recent trials showing that early therapy can be potentially beneficial to patients. As a result, there is a need to accurately diagnose and risk-stratify patients with SMM, including routine incorporation of modern imaging and laboratory techniques. In this review, we outline current concepts in diagnosis and risk stratification of SMM, and provide specific recommendations on the management of SMM.

Cereblon binding molecules in multiple myeloma

Immunomodulation is an established treatment strategy in multiple myeloma with thalidomide and its derivatives lenalidomide and pomalidomide as its FDA approved representatives. Just recently the method of action of these cereblon binding molecules was deciphered and results from large phase 3 trials confirmed the backbone function of this drug family in various combination therapies. This review details the to-date knowledge concerning mechanism of IMiD action, clinical applications and plausible escape mechanisms in which cells may become resistant/refractory to cereblon binding molecule based treatment.

Iterative decomposition of water and fat with echo asymmetry and least-squares estimation (IDEAL) magnetic resonance imaging as a biomarker for symptomatic multiple myeloma

Introduction

To evaluate the effectiveness of iterative decomposition of water and fat with echo asymmetry and least-squares estimation (IDEAL) magnetic resonance imaging (MRI) to discriminate between symptomatic and asymptomatic myeloma in lumbar bone marrow without visible focal lesions.

Materials and Methods

The lumbar spine was examined with 3-T MRI in 11 patients with asymptomatic myeloma and 24 patients with symptomatic myeloma. The fat-signal fraction was calculated from the ratio of the signal intensity in the fat image divided by the signal intensity of the corresponding ROI in the in-phase IDEAL image. The t test was used to compare the asymptomatic and symptomatic groups. ROC curves were constructed to determine the ability of variables to discriminate between symptomatic and asymptomatic myeloma.

Results

Univariate analysis showed that β2-microglobulin and bone marrow plasma cell percent (BMPC%) were significantly higher and fat-signal fraction was significantly lower with symptomatic myeloma than with asymptomatic myeloma. Areas under the curve were 0.847 for β₂;-microglobulin, 0.834 for fat-signal fraction, and 0.759 for BMPC%.

Conclusion

The fat-signal fraction as a biomarker for multiple myeloma enables discrimination of symptomatic myeloma from asymptomatic myeloma. The fat-signal fraction offers superior sensitivity and specificity to BMPC% of biopsy specimens.

The tumor microenvironment shapes hallmarks of mature B-cell malignancies

B-cell tumorigenesis results from a host of known and unknown genetic anomalies, including non-random translocations of genes that normally function as determinants of cell proliferation or cell survival to regions juxtaposed to active immunoglobulin heavy chain enhancer elements, chromosomal aneuploidy, somatic mutations that further affect oncogenic signaling and loss of heterozygosity of tumor-suppressor genes. However, it is critical to recognize that even in the setting of a genetic disease, the B-cell/plasma cell tumor microenvironment (TME) contributes significantly to malignant transformation and pathogenesis. Over a decade ago, we proposed the concept of cell adhesion-mediated drug resistance to delineate a form of TME-mediated drug resistance that protects hematopoietic tumor cells from the initial effect of diverse therapies. In the interim, it has been increasingly appreciated that TME also contributes to tumor initiation and progression through sustained growth/proliferation, self-renewal capacity, immune evasion, migration and invasion as well as resistance to cell death in a host of B-cell malignancies, including mantle cell lymphoma, diffuse large B-cell lymphoma, Waldenstroms macroglobulinemia, chronic lymphocytic leukemia and multiple myeloma. Within this review, we propose that TME and the tumor co-evolve as a consequence of bidirectional signaling networks. As such, TME represents an important target and should be considered integral to tumor progression and drug response.

Smoldering multiple myeloma: when to observe and when to treat?

Smoldering multiple myeloma (SMM) is an asymptomatic disorder characterized by the presence of at least 3 g/dL of serum M-protein and/or 10% to 60% bone marrow plasma cell infiltration with no myeloma-defining event. The risk of progression to active multiple myeloma (MM) is not uniform and several markers are useful for identifying patients at high risk of progression. The definition of the disease has recently been revisited and patients with asymptomatic MM at 80% to 90% of progression risk at 2 years are now considered to have MM. Although the current standard of care is not to treat, a randomized trial in patients with high-risk SMM that compared early treatment versus observation demonstrated that early intervention resulted in substantial benefits in terms of time to progression and overall survival (OS). These findings highlight the need to follow a correct diagnosis by an accurate risk stratification to plan an optimized follow-up according to the risk of disease progression.

Dilemmas in treating smoldering multiple myeloma

Novel therapies hold promise for high-risk smoldering multiple myeloma (SMM). Recent studies suggest that modern combination approaches can be options for high-risk SMM to obtain deep molecular responses with favorable toxicity profiles. Although pioneering treatment trials based on small numbers of patients suggest progression-free and overall survival benefits, application of the data to real-life practice remains to be validated. Therapeutic modulation of disease tempo, disease burden, clonal evolution, and tumor microenvironment in SMM remains to be understood and calls for reliable biomarkers reflective of disease biology. Here, we review studies that open a new management platform for SMM, address ongoing dilemmas in practice and under investigation, and highlight emerging scientific questions in the era of SMM treatment.

Management of asymptomatic myeloma patients

Smoldering multiple myeloma is an asymptomatic disorder characterized by the presence of ≥30 g/l serum M-protein and/or ≥10% bone marrow plasma cell infiltration. The risk of progression to active multiple myeloma is not uniform, and several markers are useful for identifying patients at high risk of this. Although the current standard of care is not to treat, a randomized trial in high-risk smoldering multiple myeloma patients comparing those allocated to receive early treatment with lenalidomide plus dexamethasone with those under observation reported a significant benefit with respect to time to progression and overall survival. We conclude that efforts should be made to identify high-risk patients who are candidates for receiving early treatment before they develop myeloma-related symptomatology.

Early versus deferred treatment for smoldering multiple myeloma: a meta-analysis of randomized, controlled trials

Purpose

Whether patients with smoldering multiple myeloma (SMM) needed to receive early interventional treatment remains controversial. Herein, we conducted a meta-analysis comparing the efficacy and safety of early treatment over deferred treatment for patients with SMM.

Methods

MEDLINE and Cochrane Library were searched to May 2014 for randomized controlled trials (RCTs) that assessed the effect of early treatment over deferred treatment. Primary outcome measure was mortality, and secondary outcome measures were progression, response rate, and adverse events.

Results

Overall, 5 trials including 449 patients were identified. There was a markedly reduced risk of disease progression with early treatment (Odds Ratio [OR] = 0.13, 95% confidence interval [CI] = 0.07 to 0.24). There were no significant differences in mortality and response rate (OR = 0.85, 95% CI = 0.45 to 1.60, and OR = 0.63, 95% CI = 0.32 to 1.23, respectively). More patients in the early treatment arm experienced gastrointestinal toxicities (OR = 10.02, 95%CI = 4.32 to 23.23), constipation (OR = 8.58, 95%CI = 3.20 to 23.00) and fatigue or asthenia (OR = 2.72, 95%CI = 1.30 to 5.67). No significant differences were seen with the development of acute leukemia (OR = 2.80, 95%CI = 0.42 to 18.81), hematologic cancer (OR = 2.07, 95%CI = 0.43 to 10.01), second primary tumors (OR = 3.45, 95%CI = 0.81 to 14.68), nor vertebral compression (OR = 0.18, 95%CI = 0.02 to 1.59).

Conclusions

Early treatment delayed disease progression but increased the risk of gastrointestinal toxicities, constipation and fatigue or asthenia. The differences on vertebral compression, acute leukemia, hematological cancer and second primary tumors were not statistically significant. Based on the current evidence, early treatment didn’t significantly affect mortality and response rate. However, further much larger trials were needed to provide more evidence.

Venous and arterial thrombotic risks with thalidomide: evidence and practical guidance

Oral immunomodulatory drugs (IMiDs), namely thalidomide, lenalidomide and pomalidomide, interfere with several pathways important for disease progression. Today they play a crucial role in the treatment of multiple myeloma patients, and have considerably improved myeloma outcomes. These agents, and thalidomide in particular, are associated with higher rates of thromboembolic events, both venous and arterial. Individual risk factors for thromboembolic events include advanced age, previous history of thromboembolism, an indwelling central venous catheter, comorbid conditions (e.g. infections, diabetes, cardiac disease, obesity), current or recent immobilization, recent surgery and inherited thrombophilic abnormalities. Cancer therapy and cancer itself also increase the risk of thromboembolic events. The aim of this review is to help clinicians to define the risk of thrombotic events in patients treated with thalidomide and thus to provide practical recommendations to manage thromboprophylaxis in these patients.

Pomalidomide in the treatment of multiple myeloma and perspectives in other hematological malignancies

SUMMARY 

Pomalidomide is an immunomodulatory drug recently approved by the US FDA and EMA for the treatment of refractory and relapsed multiple myeloma. Pomalidomide appears to be more potent and less toxic than thalidomide and lenalidomide and has proven to be effective in a proportion of patients already exposed and refractory to these agents. The approved combination of pomalidomide and weekly dexamethasone offers clinical benefit to at least one-third of patients with multiple myeloma that have failed both bortezomib and lenolidomide treatment. This review will focus on the preclinical data and clinical experience in this setting. Off-label use of pomalidomide, mainly its combination with other active drugs for multiple myeloma and the role of pomalidomide in other hematologic malignancies still remain to be explored in depth and are discussed briefly.

Synthesis and antiangiogenic activity of 6-amido-2,4,5-trimethylpyridin-3-ols

We recently reported that 6-aminoalkyl-2,4,5-trimethylpyridin-3-ols, novel series of 6-aminopyridin-3-ol-based antioxidants, have high antiangiogenic activities. In pursuit of wider variety in the analogues, we here report the synthesis and antiangiogenic activities of 6-amidoalkyl-2,4,5-trimethylpyridin-3-ols, which would not be considered excellent antioxidants because of the poorer electron-donating effect of the C(6)-amido group than the corresponding C(6)-amino group. The selected 6-amido compounds showed up to several fold-higher antiangiogenic activities and up to an order of magnitude better antitumor activities in the chick embryo chorioallantoic membrane (CAM) assay than SU4312, a positive control. We also found that paracetamol, as a direct phenolic analogue of our simplest 6-amidopyridin-3-ol, showed a moderate level of antiangiogenic activity. We propose this study will offer a basis for a scaffold of novel angiogenesis inhibitors that can perturb angiogenesis-related pathologies.

Is it time for preemptive drug treatment of asymptomatic (smoldering) multiple myeloma?

Asymptomatic (smoldering) multiple myeloma is a heterogeneous plasma cell proliferative disorder with a variable rate of progression to active multiple myeloma or related disorders. Hypercalcemia, renal insufficiency, anemia, bone lesions or recurrent bacterial infections characterize active multiple myeloma. Some patients with asymptomatic myeloma develop active disease rapidly, and others can stay asymptomatic for many years. Those who are likely to progress within the first 2 years of diagnosis have been categorized as having high-risk disease. The availability of novel agents in the treatment of active multiple myeloma and our better understanding of the heterogeneity of asymptomatic multiple myeloma have spurred interest in the early treatment of these patients. We have reviewed the current proposed definitions of high-risk asymptomatic multiple myeloma, the concerns about future therapy in view of the transient nature, remissions and toxicities of the therapies, and the eventual relapses that characterize this incurable disease.

Thalidomide-induced angiopoietin 2, Notch1 and Dll4 downregulation under hypoxic condition in tissues with gastrointestinal vascular malformation and human umbilical vein endothelial cells

OBJECTIVE

To determine the pathogenesis of gastrointestinal vascular malformation (GIVM) and the mechanism of thalidomide in treating GIVM by evaluating the expression of angiopoietin 2 (Ang2), Notch1, delta-like ligand 4 (Dll4) and hypoxia inducible factor 1α (Hif-1α).

METHODS

Data of 10 patients with histology-confirmed GIVM were reviewed. Immunohistochemistry of surgically resected GIVM tissues and the adjacent mucosa of the patients and normal tissues from those who had undergone colonoscopy for health examination was performed to examine the expressions of Ang2, Notch1, Dll4 and Hif-1α. In addition, in vitro effect of thalidomide on Ang2, Notch1 and Dll4 in human umbilical vein endothelial cells (HUVEC) and on HUVEC proliferation was also investigated during normoxic and hypoxic conditions.

RESULTS

GIVM lesions presented as tortuous, dilated arterioles, venules and capillaries. Ang2, Notch1 and Dll4 showed strong immunoreactivity in the cytoplasm and nuclei of GIVM lesions but negative or weak positivity in the intestinal mucosa of the adjacent tissues and normal mucosa. Under hypoxic condition the expressions of Hif-1α, Ang2, Notch1 and Dll4 were upregulated and the tube formation was more abundant with a greater diameter of tubes. Moreover, thalidomide downregulated their expression in HUVEC and HUVEC proliferation decreased in a concentration-dependent manner under both hypoxic and normoxic conditions.

CONCLUSION

Ang2, Notch1, Dll4 and Hif-1α may play an important role in the pathogenesis of GIVM and may be potential targets of thalidomide in the treatment of the disease.