Triplet Therapy, Transplantation, and Maintenance until Progression in Myeloma

Bortezomib, thalidomide, and dexamethasone versus bortezomib, lenalidomide, and dexamethasone in transplant-eligible newly diagnosed multiple myeloma: a systemic review and meta-analysis

BACKGROUND

The current study aimed to compare treatment responses, the incidence of the need for auto-HSCT, and the occurrence of specific adverse events (AEs) between VTD and velcade, VRD induction regimens in patients with transplant-eligible newly diagnosed multiple myeloma (NDMM).

METHODS

This systematic review and meta-analysis included 15 studies: six evaluating the VTD regimen and nine evaluating the VRD one. The primary endpoints were response rates after induction therapy and the incidence of a need for autologous hematopoietic stem cell transplantion (auto-HSCT) between the groups. We also examined the occurrence of grade 3 or 4 hematological, infection, and thrombotic AEs in both groups.

RESULTS

The VTD group showed an overall response rate (ORR) of 93%, while the VRD group had an ORR of 86%. The very good partial response (VGPR) rates were 61% in the VTD group and 60% in the VRD one. The auto-HSCT rate was higher in the VTD group, averaging 93% compared to 70% in the VRD one. The incidence of grade 3 or 4 hematological AEs was 31% for VTD and 33% for VRD. The rates of grade 3 or 4 infection-related AEs were 9% in the VTD group and 14% in the VRD one. The incidence of grade 3 or 4 thrombotic AEs was 4% for VTD and 3% for VRD.

CONCLUSIONS

With comparable safety profiles, VTD and VRD induction therapies are similarly effective for transplant-eligible NDMM, showing similar ORRs and VGPR rates.

Evaluation of Clinical Characteristics and Prognostic Factors of Early Progressive Disease (EPD) in Newly Diagnosed Multiple Myeloma Patients: Real-World Data of the Greek Myeloma Study Group

BACKGROUND

Despite treatment improvements a considerable proportion of newly diagnosed multiple myeloma (MM) patients experience early progressive disease (EPD) defined as progression or relapse in < 18 months following initial response to first line treatment.

METHODS

We evaluated 1436 newly diagnosed MM patients out of whom 23.3% had EPD.

RESULTS

Patients with EPD had higher median age, β2-microglobulin, LDH and lower hemoglobin and eGFR, compared to others (P < .05); EPD population presented more commonly with advanced stage (ISS3, RISS3, and R2-ISS stage III/IV). Ultra-high-risk MM (UHR-MM) i.e., detection of ≥ 2 high-risk molecular abnormalities was more frequent in EPD population (P < .001). The percentage of patients treated with lenalidomide-based regimens was not significantly different. Daratumumab-based therapies (DBT) were administered less frequently in patients with EPD (2% vs. 10%; P < .001); 11% of patients with EPD versus 33% underwent ASCT (P < .001); Complete response to induction therapy was significantly lower in EPD patients (12% vs. 27%; P < .001). Binary logistic regression analysis demonstrated that ISS, RISS, R2-ISS, UHR-MM, ASCT and DBT were significant predictors for EPD (P < .05). In multivariate analysis R2-ISS, ASCT, and DBT were independent prognosticators for EPD (P < .001). Median PFS and OS were 10 versus 40 months and 29 versus 76 months in patients with EPD versus others, respectively (P < .001).

CONCLUSION

In real-world, EPD is observed in more than one-fifth of patients, and it remains an unmet clinical need. Daratumumab-based therapies and ASCT significantly reduce the probability of EPD, while R2-ISS could serve as a useful prognostic tool for recognizing this population and guide therapeutic decisions.

Are we maintaining minimal residual disease in myeloma?

Minimal residual disease (MRD) has emerged as an important prognostic maker in patients with multiple myeloma at different stages of their treatment. Moreover, it is being increasingly incorporated as an endpoint in various clinical trials. Since maintenance therapy is an integral part of myeloma treatment, especially in the upfront setting post autologous transplantation, it is imperative to understand the role of MRD testing in the maintenance stetting. This review aims to examine the utility and dynamics of MRD testing in order to elucidate its prognostic role and possible incorporation in clinical decision making processes.

Characteristics and Clinical Outcomes of Multiple Myeloma in Adolescents and Young Adults

INTRODUCTION

Though evidence suggests that multiple myeloma (MM) in adolescents and young adults (AYA) (< 50 years) has significant biological differences from that in older individuals (≥ 50 years), the understanding of the disease in this group is limited. We examined the outcomes in AYA hospitalizations with MM.

METHODS

Using the National Inpatient Sample database, we examined sociodemographic, hospital-level, and clinical characteristics between AYA and older populations with MM.

RESULTS

Among 183 846 non-elective MM hospitalizations, 13 765 (7.5%) were AYA. There was a higher proportion of males in the AYA group compared to the older group (58.6% vs. 54.8%, p < 0.001) but a lower distribution of non-Hispanic Whites (40.6% vs. 56.7%, p < 0.001). The AYA group had lower odds of mortality (aOR: 0.59, p < 0.001) relative to the older adult group. They were more likely to receive autologous stem cell transplantation (aOR: 1.80, p < 0.001) but had similar odds of acute venous thromboembolism (aOR: 0.87; p = 0.24) and severe sepsis (aOR: 0.89; p = 0.52).

CONCLUSION

We highlight the unique characteristics and outcomes of AYA-MM, emphasizing the need for their greater representation in clinical research. Additionally, we underscore the importance of further investigation to better understand and optimize survivorship care in AYA patients with MM.

Sustained bone marrow and imaging MRD negativity for 3 years drives discontinuation of maintenance post-ASCT in myeloma

ABSTRACT

Discontinuation of lenalidomide maintenance after autologous stem cell transplantation is a burning question within the multiple myeloma (MM) community, especially after the inclusion of minimal residual disease (MRD) in the disease response criteria. In this prospective study, we evaluated the conversion to MRD positivity, the treatment-free survival (TFS), and the progression-free survival (PFS) in 52 patients with MM who discontinued lenalidomide maintenance after achieving sustained bone marrow and imaging MRD negativity for 3 years. Patients who developed MRD positivity after lenalidomide discontinuation restarted lenalidomide maintenance at the same dose. The median follow-up from lenalidomide discontinuation was 3 years. Overall, 12 (23%) patients obtained MRD positivity and restarted lenalidomide maintenance. Only 4 (7.6%) patients progressed; 3 had a biochemical progression and 1 had a clinical progression. The overall median PFS was not reached, whereas the 7-year PFS from diagnosis was 90.2%. The 1-, 2-, and 3-year TFS rates were 93.9%, 91.6%, and 75.8%, respectively, whereas the 1-, 2-, and 3-year landmark PFS rates from maintenance discontinuation (study entrance) were 96.0%, 96.0%, and 92.9%, respectively. There were no statistically significant associations among age, sex, Second Revision International Staging System, type of induction therapy, and use of consolidation therapy and the effect outcomes of PFS and TFS. We conclude that maintenance discontinuation after 3 years of sustained marrow and imaging MRD negativity is associated with low rates of MRD conversion and progressive disease. Thus, in the era of modern antimyeloma treatments, a subgroup of patients may remain treatment free while in complete remission without jeopardizing disease response.

Prognostic Value of Post-Transplant MRD Negativity in Standard Versus High- and Ultra-High-Risk Multiple Myeloma Patients

Background: Cytogenetic abnormalities and the persistence of minimal residual disease (MRD) following autologous stem cell transplantation (ASCT) are two established prognostically unfavorable biomarkers in multiple myeloma (MM). Previous studies have shown that post-transplant MRD status is a powerful predictor of progression-free survival (PFS) and overall survival (OS). However, the impact of MRD remains poorly characterized in MM patients with high- or ultra-high-risk cytogenetics. Objectives: This study investigated the prognostic value of post-transplant MRD in standard- versus high- and ultra-high-risk MM. To this aim, we performed a retrospective analysis of 137 MM patients who underwent high-dose chemotherapy (HDCT) and ASCT at our institution between January 2019 and December 2021. Cytogenetics were assessed by fluorescence in situ hybridization. High-risk genomic alterations included del(17p), t(4;14), t(14;16), t(14;20), gain(1q), and TP53 mutations, with two or more alterations defining the ultra-high-risk category. MRD was assessed in bone marrow aspirates post-ASCT using flow cytometry. Results: Eighty-two (60%) patients were categorized as being at standard risk, forty (29%) as high risk, and fifteen (11%) as ultra-high risk. Median follow-up was 47 months. MRD negativity was achieved in 76 (55%) patients. At 48 months, the overall PFS rate was 61% (72%, 50%, and 32% for the standard-, high-, and ultra-high-risk subgroups, respectively; p = 0.0004), while the OS rate was 85% (89%, 79%, and 80% in standard-, high-, and ultra-high-risk MM patients, respectively; p = 0.1494). Within the standard-risk subgroup, longer PFS was observed for patients achieving MRD negativity (p = 0.0172). High- and ultra-high-risk patients showed no significant differences in PFS when stratified by MRD status, possibly due to prompt progression to MRD positivity. Conclusions: Our results suggest that high- and ultra-high-risk MM patients might benefit from closer response monitoring, including dynamic MRD assessment. Further, high- and ultra-high-risk patients might require a more intensive peri-transplant treatment.

Role of NK Cells in Progression and Treatment of Multiple Myeloma

Multiple myeloma (MM) is a haematological malignancy originating from terminally differentiated B cells, resulting in significant morbidity and mortality. Currently, MM is regarded as an incurable disease, often exhibiting a relapse-remitting pattern that necessitates multiple lines of therapy. It is now well-established that ineffective immunosurveillance plays a critical role in the progression of MM. Consequently, strategies that redirect immune effector cells against MM have emerged as effective treatment modalities, particularly in cases where standard care therapies fail. T cell-based immunotherapy has gained considerable attention in ongoing clinical trials; however, natural killer (NK) cells, known for their ability to execute cytotoxicity against infected and malignant cells with precision, may offer complementary therapeutic advantages over T cells and possess untapped therapeutic potential. This review seeks to introduce readers to the significance of NK cell-mediated immunosurveillance in the context of MM, explore the potential benefits of redirecting NK cells against MM, and illustrate how current treatment strategies are often reliant on the functionality of NK cells. Most importantly, new promising mechanisms of harnessing NK cell-based immunity against MM are reviewed and put into a clinical perspective to highlight their implications for patient treatment and outcomes.

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.

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.

Stem Cell Mobilization Yields with Daratumumab (Dara) and Lenalidomide (Len)-Containing Quadruplet Induction Therapy in Patients with Newly Diagnosed Multiple Myeloma (NDMM): A Real-World Experience at 2 Institutes

BACKGROUND

Quadruplet therapy has become standard frontline therapy in transplant eligible NDMM patients. Using data from the MASTER and GRIFFIN trials, Chhabra et al. reported that Dara-Len containing quadruplet therapies had minimal impact on stem cell harvesting and engraftment. It is unclear if this remains true in a real-world setting where heterogeneity exists among patients and in institutional practices. Herein, we describe our experience of stem cell mobilization and collection in NDMM patients receiving DRVd at Levine Cancer Institute (LCI) and Emory Winship Cancer Institute.

METHODS

In this multi-center retrospective analysis, NDMM patients were eligible if they received DRVd and pursued stem cell collection between September, 2019 and January, 2024 at LCI and January, 2019 and July, 2022 at Emory. Patients either received 10 mcg/kg of growth colony-stimulating factor (G-CSF) daily (LCI) or 7.5 mcg/kg twice daily (Emory) for 4 days prior to collection and 1 dose on the morning of apheresis. Plerixafor was provided on day -1 of apheresis as a preemptive mobilization strategy at LCI and on an as needed basis at Emory. Patients with a suboptimal stem cell yield on day 1 received additional doses of G-CSF with or without rescue plerixafor at both sites followed by a second day of stem cell collection. Stem cell yield failure was defined as the inability to achieve a minimal goal dose of 2.0 × 106 cells/kg. Categorical outcomes were summarized with frequencies and proportions while numerical outcomes were summarized with descriptive statistics. Select data elements were only available in the LCI cohort.

RESULTS

A total of 423 patients were analyzed. The median patient age was 62 years (range, 23-79), and 38.1% of the cohort was African American. Thirteen percent of the cohort had high risk cytogenetics and 19.1% had ISS stage III disease. At LCI, patients received a median of 4 (range, 1-14) cycles of induction therapy before stem cell collection. In the entire cohort, 88.8% of patients received 21-day cycles and 11.2% received 28-day cycles. Most patients achieved a VGPR or better (87.2%) after induction and, of those with MRD data available at LCI, 41.6% (37 of 89) achieved MRD negative status (at 10-5). Of those with available data (n = 92), stem cell collection occurred after a median of 4 weeks (range, 2 to 8) from induction completion. All patients at LCI and 308 of the 318 (96.9%) patients at Emory received plerixafor. Among the entire cohort, the median number of total CD34+ cells collected was 9.0 × 106 CD34+ cells/kg (range 0-24.1). By institute, the median number of CD34+ cells across all attempts at LCI was 8.5 × 106 CD34+ cells/kg (range 2.9-18.1) and the median at Emory was 9.0 × 106 CD34+ cells/kg (0-24.1) indicating that there was no significant difference between mobilization strategies (P = .088). There also was no significant difference in stem cell yield between the 21-day and 28-day cycles; median yield was 9.0 × 106 CD34+ cells/kg versus 8.6 × 106 CD34+ cells/kg, respectively (P = .246). About 94.3% (N = 397) of patients collected enough for 2 transplants. Only 2.8% (12 of 423) required an additional mobilization attempt to achieve the minimal target stem cell yield. In the entire population, there was 1 mobilization failure (0.2%) and all but 1 patient who required remobilization collected sufficient stem cells.

CONCLUSION

The addition of Dara to RVd induction therapy led to impressive hematologic responses and did not have a deleterious effect on stem cell mobilization with an upfront plerixafor strategy. The median stem cell yield in this real-world experience was slightly better than that reported in the GRIFFIN trial.

Real-World Data on the Efficacy of Daratumumab in Patients with Relapsed/Refractory Multiple Myeloma and Amplification 1q

Background: Treatment of multiple myeloma has advanced tremendously with the approval of anti-CD38 antibodies. Their efficacy is impressive but still controversial in the 1q amplification subgroup (amp1q). This retrospective study aims to provide real-world data. Methods: This trial is analyzing 74 patients with relapsed/refractory multiple myeloma treated with CD38Abs at the Medical University of Innsbruck (2016-2023). High-risk (HR) cytogenetics according to R-ISS (t(4;14), t(14;16), t(14;20), del(17p)), the presence of amp(1q21), the frequency of two HR markers (double hit), and the high-risk criteria agreed at IMS 2024 (HR-IMS24) were considered. Results: The median age of the 74 patients (62.1% male) was 62 years, with a median follow-up of six years. Most patients received third-line therapy (37.8%). R-ISS HR was documented in 39.2% of patients, double hit in 13.5% of patients, and HR-IMS24 in 32.4% of patients, while amp1q was detected in 35.1% of patients. The median OS was 66 months (35-89), and the median PFS was 17 months (6.5-26.9). While neither R-ISS HR nor isolated amp1q had an impact on progression-free survival (e.g., amp1q 7.03: 1.95-22.44; p = 0.347), the occurrence of a double-hit pattern significantly impaired PFS and OS (6.2: 1.4-16.4 months; p = 0.044; OS, 42.8: 25.9-74.6 months; p = 0.035). Patients fulfilling the HR-IMS24 criteria (32.4%, 24 patients) also exhibited an impaired PFS and OS (7: 2.7-18.1 months, p = 0.023; 40.12: 21.1-74.5 months, p = 0.01). Conclusions: This retrospective study highlights the durable effect of daratumumab on cytogenetic abnormalities, particularly amp1q. However, patients who meet the criteria for double-hit myeloma or the high-risk IMS2024 criteria remain a difficult-to-treat patient population who require early access to new treatment approaches.

Impact of induction regimens on stem cell mobilization yields in newly diagnosed multiple myeloma

Autologous stem cell transplantation (ASCT) is integral to treating newly diagnosed multiple myeloma (MM). While novel therapies improve response rates, they also hinder stem cell mobilization. This study evaluates the impacts of induction regimens on mobilization, collection, and ASCT outcomes. We analyzed 228 patients divided into three groups: bortezomib-thalidomide-dexamethasone (VTD, N = 117); bortezomib-lenalidomide-dexamethasone (VRD, N = 57); and daratumumab-VTD (DVTD, N = 54). Baseline characteristics showed no significant differences among the groups. Chemo-mobilization was most common in VTD (20.5%) compared to VRD (12.3%) and DVTD (5.6%). Total CD34 + cell yield (x10⁶/kg) was highest in VTD (7.1 ± 3.5) compared to VRD (5.8 ± 3.2) and DVTD (5.4 ± 2.4) [p = 0.0001]. Second mobilization was required most frequently in VRD (40.4%) compared to DVTD (24.1%) and VTD (16.2%) [p = 0.0010]. Plerixafor use was highest in VRD (40.4%) compared to DVTD (24.1%) and VTD (12.0%) [p = 0.0001]. Mobilization duration was longest in VRD (4.0 ± 1.9 days) and shortest in VTD (3.2 ± 1.7 days) [p = 0.0038]. Infused CD34 cells and platelet engraftment times were comparable among groups. Neutrophil engraftment was delayed in VRD (12.1 ± 0.9 days) compared to DVTD (11.8 ± 1.2) and VTD (11.6 ± 0.7) [p = 0.0014]. Prompt stem cell collection is essential in lenalidomide regimens to minimize mobilization challenges. While DVTD demonstrated comparable mobilization efficiency, it produced fewer CD34 cells than VTD, indicating potential challenges.

Risk-adapted treatment for multiple myeloma: assessing the current potential and a roadmap for the future

Over the past two decades, new agents for multiple myeloma (MM) have significantly improved patient outcomes, particularly for those with standard-risk disease, who now have a median overall survival of over a decade. However, this benefit is less pronounced in high-risk and ultra-high-risk MM, where median survival ranges from 3 to 5 years. The definition of HRMM continues to evolve and is driven by the genomic features, disease burden, and medical comorbidities. Various risk stratification tools are available to gauge the risk status of the disease. Recently, a slew of single-arm phase 2 trials for high-risk MM have been reported with a general theme of intensification of various phases of treatment. Additionally, minimal residual disease testing in treatment escalation/de-escalation is being actively investigated. This review summarizes the existing evidence for risk-adapted treatment in patients with MM.

Novel drug combinations for newly diagnosed multiple myeloma: how can we improve on current regimens?

INTRODUCTION

Multiple myeloma (MM) therapy has greatly evolved over the last decade. Immunomodulators and anti-CD38 antibodies have reshaped the therapeutic landscape. Nevertheless, relapses occur with worsening prognosis each relapse. Achieving deep responses in first-line treatment is key to reducing future disease burden.

AREAS COVERED

To advance patient outcomes, current regimens must be continuously refined through personalization, incorporation of biomarkers to guide therapy, and novel drugs. This review aims to assess existing therapies and investigate how integrating novel drug combinations and biomarker-driven approaches can improve efficacy and tolerability for newly diagnosed multiple myeloma (NDMM) patients. Meta-analysis, systematic reviews, original articles, and real-world studies were included in this review. Databases searched included PubMed, Scopus, and Google Scholar from inception until February 2025.

EXPERT OPINION

Discerning the best therapy sequence is a challenge for NDMM individuals. Minimal residual disease assessment is becoming a pivotal tool for guiding therapeutic approaches to enhance outcomes and tolerability. Emerging evidence supports early use of potent therapies - such as next-generation anti-CD38 antibodies and CELMoDs - to achieve deeper, more durable responses and possibly delay relapses. Immunotherapies like bispecific antibodies and CAR-T cells are also being explored in front-line settings, though reducing their infectious complications is still under investigation.

Outcomes of patients with multiple myeloma undergoing autologous transplant with suboptimal pretransplant response

There are scarce data in the literature focusing on newly diagnosed multiple myeloma (NDMM) patients who undergo autologous haematopoietic cell transplantation (autoHCT) after achieving suboptimal response to induction. To address this, we performed a retrospective, single-centre analysis of patients with NDMM who underwent upfront autoHCT between 2005 and 2021 with a pretransplant response of less than very good partial response (3 years and median OS of >8 years. Post-transplant maintenance further improved survival outcomes.

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.

Health care systems as determinants of outcomes in multiple myeloma: final results from the Latin American MYLACRE study

ABSTRACT

Although systemic therapy for multiple myeloma (MM) has evolved considerably over the past 2 decades, state-of-the-art treatment is not uniformly available in Latin America. In some countries, disparities between the public and private sectors in clinical presentation, access to novel agents, and transplantation are striking, with the public sector lagging. We conducted a multicenter, observational study of patients with MM in 5 Latin American countries (Argentina, Brazil, Colombia, Mexico, and Panama). We enrolled patients aged ≥18 years diagnosed with MM between January 2016 and June 2021, using data collected between May 2019 and June 2022. We categorized institutions as "public" when primarily funded by federal or local government, and "private" when financed mostly or completely by other sources. We analyzed 1029 patients, 1021 of whom could be classified into public (n = 339) and private (n = 682) institutions. These 2 groups differed in many respects, with patients from the latter having better baseline prognostic features (including eligibility to transplantation) and receiving combinations of immunomodulatory drugs and proteasome inhibitors, as well as anti-CD38 antibodies, more frequently than patients from public institutions. Among 960 patients with complete data for this analysis, the median overall survival was 44.6 months in public institutions and 53.3 months in private institutions (hazard ratio, 0.84; 95% confidence interval, 0.67-1.04; P = .109). Our results indicate diagnostic and therapeutic shortcomings in the management of MM in Latin America, with important gaps in patient profile, treatment patterns and long-term outcomes between public and private institutions. This trial was registered at www.clinicaltrials.gov as #NCT03955900.

Daratumumab-based quadruplet versus triplet induction regimens in transplant-eligible newly diagnosed multiple myeloma: a systematic review and meta-analysis

The treatment landscape for transplant-eligible patients with newly diagnosed multiple myeloma (TE-NDMM) has evolved with the introduction of daratumumab-based quadruplet regimens. Adding daratumumab to traditional triplet regimens has demonstrated improved response rates and progression-free survival (PFS). However, the impact on long-term outcomes, particularly overall survival (OS), remains uncertain. This systematic review and meta-analysis aimed to compare the survival outcomes of these quadruplet regimens with triplets. Conducted in adherence to Cochrane Collaboration and PRISMA guidelines and registered on PROSPERO (CRD42024571946), the study involved searching PubMed, Embase, and Cochrane databases, from inception to June 2024. We included randomized clinical trials (RCT) and non-randomized controlled studies (NRCS) that compared daratumumab-based quadruplet regimens to triplets, focusing on OS and PFS, with a minimum follow-up of 18 months. The meta-analysis included 3327 TE-NDMM patients from four studies, comprising three RCT and one NRCS. Daratumumab-based regimens were administered to 1328 (40%) patients. The analysis revealed that daratumumab-based quadruplet regimens significantly improved both OS (pooled HR 0.60; 95% CI 0.48-0.75; P < 0.00001; I² = 0%) and PFS (pooled HR 0.49; 95% CI 0.37-0.65; P < 0.00001; I² = 52%). A per-protocol subgroup analysis comparing D-VRD to VRD further confirmed these benefits, with significant improvements in both OS (pooled HR 0.68; 95% CI 0.48-0.97; P = 0.03; I² = 0%) and PFS (pooled HR 0.41; 95% CI 0.31-0.54; P < 0.00001; I² = 0%). This meta-analysis consolidates evidence that daratumumab-based quadruplet regimens significantly improve OS, compared to triplet regimens for TE-NDMM patients.

Expert Perspectives on Current Challenges and Emerging Approaches for Multiple Myeloma: Narrative Review of an Inaugural Bridging the Gaps in Leukemia, Lymphoma, and Multiple Myeloma

PURPOSE

The management of multiple myeloma (MM) is becoming increasingly more complex. The approval of novel treatment approaches provides much-needed opportunities but also raises questions and controversies about how to optimally sequence therapies and select treatments for individual patients.

METHODS AND RESULTS

A panel of experts assembled to discuss current controversies in the care of patients with MM across the disease continuum. Workshop topics included: management of smoldering MM; treatment selection for transplant-eligible and transplant-ineligible patients; risk assessment and the possibility of risk-adapted treatment; use of measurable residual disease (MRD) as a clinical trial end point and to guide treatment decisions; management of early relapse; management of triple class-refractory MM; treatment sequencing; and novel therapies.

CONCLUSION

Many controversies remain regarding the management of patients with MM related to risk assessment, treatment selection and sequencing, and the optimal use of current therapies while balancing efficacy, toxicity, patient considerations, and treatment logistics. Ongoing research efforts are needed to further define the optimal use of current therapies and to develop more efficacious therapies for all patients and for particular subset populations with unmet need.

Outcomes of Standard-Risk Multiple Myeloma Patients Who Undergo Upfront Autologous Hematopoietic Stem Cell Transplantation

Patients with multiple myeloma (MM) without high-risk cytogenetic abnormalities are classified as having standard-risk MM (SRMM), and data focusing on their outcomes after autologous hematopoietic stem cell transplantation (autoHCT) are limited. We sought to evaluate survival outcomes for patients with SRMM receiving autoHCT, and to elucidate factors that impact these outcomes. This was a single-center retrospective analysis that included consecutive MM patients who received upfront autoHCT between 2013 and 2021, had available cytogenetic information and had no high-risk chromosomal abnormalities on fluorescence in situ hybridization, defined as t(4;14), t(14;16), del(17p) or 1q21 gain or amplification. A total of 1000 SRMM patients were included, with a median age of 61 years (range 25 to 83), and 61% were male (n = 612). The most common induction regimens were bortezomib/lenalidomide/dexamethasone (VRD; n = 398, 40%) and carfilzomib/lenalidomide/dexamethasone (KRD; n = 212, 21%), and the majority (87%) received single-agent melphalan as conditioning. After induction and before autoHCT, 16% and 57% achieved ≥complete response (CR) and ≥very good partial response (VGPR), respectively. At day 100 post autoHCT, 37% and 77% achieved ≥CR and ≥VGPR, respectively. Sixty-two percent and 89% of patients achieved ≥ CR and ≥VGPR as best response post-transplant. A minimal residual disease (MRD) negative response pre- and post-transplantation was achieved in 43% (401/936) and 64% (199/311) of patients, respectively. After a median follow-up of 42.1 months, the median progression-free survival (PFS) for the entire cohort was 68.3 months (95% CI 60.1 to 72.1), and the median overall survival (OS) was not reached (95% CI 102.3-not reached). The 5-year PFS and OS rates were 55% and 83%, respectively. In multivariable analysis, achieving MRD-negative CR prior to autoHCT (HR 0.65 [95% CI 0.44 to 0.97], P = .033) or as best response (0.52 [0.34 to 0.78], P = .002), and use of post-transplant maintenance (0.69 [0.52 to 0.93], P = .013) and lenalidomide-based combination maintenance (0.68 [0.48 to 0.96], P = .030) were associated with improved PFS, whereas use of an induction regimen other than KRD was associated with worse PFS (1.50 [1.04 to 2.17], P = .031). For OS, post-transplant maintenance (0.48 [0.32 to 0.70], P < .001) was associated with better survival in multivariable analysis, whereas R-ISS stage III, compared with stage I, (2.34 [1.01 to 5.43], P = .047) was associated with worse OS. Patients with SRMM who received upfront autoHCT had a median PFS of >5.5 years, and median OS was not reached. These results highlight the favorable outcomes with upfront autoHCT for patients with SRMM, serving as a benchmark for future therapeutic approaches in this subgroup of MM patients.

Current State of Evidence on Definitions and Management of High-Risk Multiple Myeloma

PURPOSE OF REVIEW

This review aims to address the subgroup of patients with newly diagnosed multiple myeloma (NDMM) who have high-risk multiple myeloma (HRMM) and continue to experience poor outcomes despite recent therapeutic advances. We will explore various clinical, biochemical, imaging, genetic, and dynamic features associated with high-risk status, along with the different risk stratification tools developed to identify HRMM patients.

RECENT FINDINGS

Although numerous parameters for defining HRMM have been proposed, a universally accepted definition remains absent. Studies have shown diverse treatment responses and varying outcomes in HRMM patients, prompting the development of tailored therapeutic approaches. Emerging evidence supports the need for refined definitions and more targeted strategies to improve HRMM management. HRMM patients represent an unmet need in NDMM treatment, and a standardized definition for HRMM is crucial for advancing research and clinical care. This review discusses current and future treatment options, the necessity for a consistent HRMM definition, and the importance of clinical trials focused on this high-risk group to bridge existing treatment gaps.

Evolution of frontline treatment for multiple myeloma: clinical investigation of quadruplets containing carfilzomib and anti-CD38 monoclonal antibodies

Although survival rates for patients with newly diagnosed multiple myeloma (NDMM) have improved over recent decades, multiple myeloma (MM) remains without a cure for most. There is increasing consensus that achievement of deep remissions, especially minimal residual disease negativity (MRD -), in frontline treatment is crucial and translates into improved survival. The standard of care (SOC) for NDMM consists at minimum of a triplet regimen of therapies, with or without an autologous stem cell transplant, or a doublet regimen for certain ineligible, particularly frail patients who may have specific limitations. Recently, anti-CD38 monoclonal antibodies (mAbs), such as daratumumab (Dara) or isatuximab (Isa), have been integrated into frontline SOC regimens. Seeking to further deepen and prolong responses, several clinical trials have commenced investigating the addition of anti-CD38 mAbs to carfilzomib, lenalidomide, and dexamethasone (KRd). These quadruplet regimens (Isa/Dara-KRd) are being evaluated in the context of evolving treatment considerations for the heterogeneous population of patients with NDMM. In clinical trials, the addition of Isa/Dara to KRd achieved high rates of deep responses and MRD - . Favorable outcomes were observed in patients with NDMM independent of age, transplant eligibility, and cytogenetic risk, while these treatments did not result in unexpected or emergent safety risks. The efficacy observed with intensified, yet well-tolerated therapy may offer further development of risk- and response-adapted therapy for individualized patient needs. This review summarizes the clinical outcomes of quadruplet-based therapy with Isa/Dara-KRd in NDMM.

First Line Treatment of Newly Diagnosed Transplant Eligible Multiple Myeloma Recommendations From a Canadian Consensus Guideline Consortium

The availability of effective therapies for multiple myeloma (MM) has sparked debate on the role of first line autologous stem cell transplantation (ASCT), particularly in standard-risk patients. However, treatment for individuals with high-risk disease continues to display suboptimal outcomes. With novel therapies used earlier, practice is changing rapidly in the field of MM. Presently, quadruplet induction therapy incorporating an anti-CD38 monoclonal antibody to a proteasome inhibitor and an immunomodulatory drug prior to ASCT followed by maintenance therapy stands as the foremost strategy for attaining deep and sustained responses in transplant eligible MM (TEMM). This Canadian Consensus Guideline Consortium (CGC) proposes consensus recommendations for the first line treatment of TEMM. To address the needs of physicians and people diagnosed with MM, this document focuses on ASCT eligibility, induction therapy, mobilization and collection, conditioning, consolidation, and maintenance therapy, as well as, high-risk populations, management of adverse events, assessment of treatment response, and monitoring for disease relapse. The CGC will periodically review the recommendations herein and update as necessary.

Evolving strategies in the management of transplant-eligible patients with newly diagnosed multiple myeloma

Multiple myeloma treatment has evolved significantly with the introduction of triplet and quadruplet regimens, notably incorporating anti-CD38 antibodies. While autologous stem cell transplantation remains a cornerstone of therapy, its role in the context of increasingly effective upfront treatments is debated. Current guidelines still recommend transplant for all eligible patients, especially those with high-risk features at diagnosis, despite concerns regarding the lack of overall survival benefits and the potential long-term toxicities associated with high-dose melphalan. Delaying transplantation until first relapse has been proposed, but this approach carries the risk of patients becoming ineligible for transplantation due to worsening health or disease progression. Consolidation therapy after transplant is not strongly endorsed in recent guidelines, and studies show mixed results regarding its efficacy. Some data suggests a progression-free survival advantage with post-ASCT consolidation; others found no significant differences in outcomes among various strategies. Nonetheless, tandem transplant may be beneficial for high-risk patients. Maintenance therapy, particularly with lenalidomide, has proven effective, offering substantial progression-free and overall survival benefits. While lenalidomide remains the standard, emerging data indicate that combinations with proteasome inhibitors or anti-CD38 antibodies could enhance outcomes, particularly in high-risk populations. As our understanding of myeloma biology deepens, tailoring treatment approaches based on risk profiles and response depth will be crucial for optimizing patient outcomes.

Minimal residual disease in multiple myeloma

Minimal Residual Disease (MRD) in multiple myeloma has emerged as a significant prognostic factor, guiding treatment strategies and enhancing patient outcomes. Despite advancements in therapies such as proteasome inhibitors, immunomodulatory drugs, monoclonal antibodies, CAR-T cell therapy, and bispecific antibodies, complete eradication of malignant plasma cells remains challenging. MRD refers to a small number of residual cancer cells that persist after treatment and require sensitive methods like next-generation flow cytometry (NGF) and next-generation sequencing (NGS) for detection. MRD negativity has been associated with improved progression-free survival (PFS) and overall survival (OS), making it a key marker in clinical trials. The clinical utility of MRD lies in its ability to predict outcomes, with sustained MRD negativity linked to prolonged survival. Furthermore, it will likely help in tailoring treatment approaches, such as therapy escalation for high-risk patients or de-escalation for those achieving MRD negativity. Despite its prognostic value, challenges remain in standardizing MRD testing, ensuring its widespread availability, and addressing variability in results based on different detection methods. Future research aims to refine MRD-guided treatment and explore novel detection techniques, such as liquid biopsies, to improve patient monitoring in multiple myeloma.

Multiple Myeloma: Improved Outcomes Resulting from a Rapidly Expanding Number of Therapeutic Options

Multiple myeloma (MM) is a bone-marrow-based cancer of plasma cells. Over the last 2 decades, marked treatment advances have led to improvements in the overall survival (OS) of patients with this disease. Key developments include the use of chemotherapy, immunomodulatory drugs, proteasome inhibitors, and monoclonal antibodies. MM remains incurable, with outcomes influenced by many factors, including age, sex, genetics, and treatment response. This review summarizes recent studies regarding monitoring and treatment of MM, emphasizing the efficacy of new therapies, the impact of maintenance treatments, and approaches for managing relapsed or refractory MM. The role of specific drug classes used to treat MM, including immunomodulatory drugs, proteasome inhibitors, monoclonal antibodies, and newer treatments such as chimeric antigen receptor T-cell therapies and bispecific antibodies are discussed. Combination therapies have significantly improved outcomes. Maintenance therapies, particularly with lenalidomide, have been effective in extending OS but lead to an increased risk of secondary cancers. Venetoclax, selinexor, and ruxolitinib have shown potential as new therapeutic options for patients with relapsed or refractory MM. Immune-based treatments, such as chimeric antigen receptor T-cell therapy and bispecific antibodies, mark a major advancement for heavily pretreated patients, although challenges remain related to cost, availability, and side effects. The treatment landscape for patients with MM has seen significant progress, with current therapies providing a longer OS and better quality of life. Future research should focus on optimizing these strategies, personalizing therapies, and exploring new therapeutic targets.

Evaluating Minimal Residual Disease Negativity as a Surrogate Endpoint for Treatment Efficacy in Multiple Myeloma: A Meta-Analysis of Randomized Controlled Trials

This meta-analysis examined the association between minimal residual disease (MRD) negativity and survival outcomes in 15 304 patients with multiple myeloma (MM) enrolled in randomized controlled trials published until June 2, 2024. Overall, there was a significant, negative and strong association between MRD negativity odds ratios and survival hazard ratios (β_PFS = -0.20, p < 0.001, β_OS = -0.12, p = 0.023). These associations remained significant for newly diagnosed patients (β_PFS = -0.35, p < 0.001), and they were consistent but not significant for relapsed/refractory patients (β_PFS = -0.06, p = 0.635). Sustained MRD negativity at 1 year was strongly correlated with prolonged PFS (β_PFS = -0.30, p < 0.001). In conclusion, this comprehensive meta-analysis supports MRD as a surrogate for survival in MM.

Application of GPRC5D Targeting Therapy in Relapsed Refractory Multiple Myeloma

BACKGROUND

As a rapidly developing therapeutic method, targeted therapy plays an important role in the treatment of multiple myeloma. In recent years, mature B cell antigen-targeting therapy has brought new hope for patients with refractory/relapsed disease. While an increasing number of patients with relapse are exposed to this type of drug, changing the therapeutic target may be an effective strategy for patients with relapse/refractory multiple myeloma.

OBJECTIVES

The expression of G protein-coupled receptor, class C Group 5 member D (GPRC5D), on the surface of myeloma tumor cells makes it a possible target for relapse/refractory multiple myeloma therapy, and relevant studies are in progress.

RESULTS & CONCLUSIONS

The review aims to systematically summarize the current advancements in GPRC5D-targeted therapies for multiple myeloma, thereby providing valuable insights and a foundation for future studies.

Treatment patterns and clinical outcomes for multiple myeloma in Korean patients: a database study

BACKGROUND

The treatment landscape for multiple myeloma (MM) has significantly progressed in recent decades.

METHODS

We analyzed the treatment patterns and clinical outcomes in Korean patients using data from the National Health Insurance Service database. Patients diagnosed with MM between 2010 and 2018 were included. Survival analysis with a Cox regression model was performed.

RESULTS

A total of 8,367 patients with MM were identified, from which 2,442 patients underwent stem cell transplantation (SCT). The mean patients' age at diagnosis was 67.1 years. Since 2011, the combination of a proteasome inhibitor (PI) and an alkylating agent has been most common, with a significant increase in the PI and immunomodulatory drug (IMiD) combination after 2015. The attrition rates after first-line therapy were 45% and 56% for the SCT and non-SCT groups, respectively. Patients on bortezomib, melphalan, and prednisolone were younger with less renal insufficiency compared to those on lenalidomide and dexamethasone. The SCT group had a median overall survival (OS) of 7.04 years, significantly higher than the non-SCT group's 2.52 years.

CONCLUSIONS

SCT eligibility and the reimbursement status of new drugs impact the treatment pattern of MM. Expanding access to new agents and identifying patients who can benefit from SCT are essential.

Incidence of engraftment syndrome with and without budesonide prophylaxis in patients with multiple myeloma undergoing autologous stem cell transplant

PURPOSE

Engraftment syndrome (ES), a rare post-transplant complication, has been defined differently across the literature. This study aims to determine if budesonide prophylaxis reduces ES after autologous hematopoietic cell transplantation (auto-HCT) for patients with multiple myeloma (MM), as defined by the published Spitzer or Maiolino criteria or by the ES definition used by Dhakal et al. METHODS: A single-center retrospective review was conducted on adult patients who received auto-HCT for MM between January 2017 and October 2023. Patients were divided into those who did not receive budesonide prophylaxis (n = 169) versus those who did (n = 144). The primary endpoint was an incidence of ES by the definition used by Spitzer, Maiolino, and Dhakal et al., respectively. Secondary endpoints included receipt of steroids to treat ES, hospital length of stay, engraftment, and 30- and 100-day mortality rates. Exploratory endpoints were antibiotics started in the peri-engraftment period and number of anti-diarrheal and anti-emetic doses.

RESULTS

No difference existed between groups in the primary outcome by the ES definition used by Spitzer, Maiolino, or Dhakal et al. (all p > 0.05). Further, no difference existed with respect to any secondary outcomes (all p > 0.05) except a lower incidence of receipt of antibiotics in the peri-engraftment period for those who received budesonide.

CONCLUSION

Our findings suggest concordance between Spitzer and Maiolino criteria with clinically documented ES, with higher incidences when the ES definition used by Dhakal et al. is utilized. Larger controlled trials need to be performed to validate these findings.

Melphalan 140 mg/m2 is Safe and Effective for Frail and Older Multiple Myeloma Patients With Comparable Rates of Minimal Residual Disease Negativity

BACKGROUND

Despite therapeutic advances, multiple myeloma (MM) remains challenging to treat effectively. High-dose melphalan (Mel200) with autologous stem cell transplantation (ASCT) is the standard treatment for transplant-eligible patients. Reduced-dose melphalan (Mel140) is an alternative for older or frail patients, yet its efficacy data remain unclear.

METHODS

We retrospectively analyzed 233 MM patients undergoing first ASCT between 2014 and 2022, comparing outcomes between Mel140 (n = 82) and Mel200 (n = 151). We assessed patient demographics, disease characteristics, progression-free survival (PFS), and overall survival (OS). In an exploratory subset analysis achievement of MRD from bone marrow samples after ASCT was compared between the 2 groups.

RESULTS

As expected, patients who received Mel 140 were significantly older with a higher KPS. Median follow-up was 47.7 months. Both groups had similar rates of readmissions and infections within the first 100 days after transplant despite Mel140 group being older with more comorbidities. No significant difference in PFS or OS was observed between Mel140 and Mel200 groups (P > .05). MRD negativity rates at sensitivity levels of 10-5 and 10-6 were comparable (64% vs. 60%, P = .7). Patients achieving sustained MRD negativity demonstrated improved PFS regardless of melphalan dose.

CONCLUSION

Our findings suggest equivalent efficacy and safety profiles between Mel140 and Mel200, supporting Mel140 as a viable option for older or frail MM patients. In a subset analysis equivalent rates of MRD were achieved between the groups and remained a highly significant predictor of PFS, highlighting its relevance regardless of dosing strategies.

Using QIP-MS to Guide the Timing of MRD Testing in Patients With Multiple Myeloma: A Budget Impact Analysis From the French Payer Perspective

Purpose

Serum or urine protein electrophoresis (SPEP or UPEP) and immunofixation electrophoresis (SIFE or UIFE) are routinely used to detect M-proteins in MM patients. However, SPEP and SIFE are not sensitive enough to measure M-protein levels that are low but still clinically significant. This study aimed to evaluate the potential cost savings associated with using the EXENT GAM Assay, a serum-based quantitative-immunoprecipitation mass spectrometry (QIP-MS) diagnostic test instead of SIFE to guide the timing of minimal residual disease (MRD) testing for patients with multiple myeloma (MM).

Patients and Methods

A simple 2-year budget impact model was created in Excel using data from MM clinical trials and fee schedules. Patients are tested with either QIP-MS or SIFE at predetermined timepoints. If patients test negative, they will receive MRD testing. The result of the MRD test will determine if the preceding serum-based test was a true negative result (MRD test is negative) or a false negative result (MRD test is positive). Patients receiving autologous stem cell transplant (henceforth referred to as transplant) and those not receiving transplant are both eligible for one MRD test per year. MRD testing for transplant-eligible patients occurs prior to transplant and one year following transplant.

Results

Across a hypothetical population of 5154 mm patients receiving 1st-line treatment in France, using QIP-MS instead of SIFE prior to MRD testing leads to 1973 fewer false negative results and 744 more false positive results (due, in part, to the detection of residual IgG). Net savings per QIP-MS test would be €260 or total savings of €2,481,832.

Conclusion

This study suggests that the use of QIP-MS prior to MRD testing may be cost-saving for testing French patients with MM.

Retrospective Study to Compare Outcomes in 159 Patients Undergoing First Autologous Stem Cell Transplantation for Myeloma Treated with Melphalan 140 mg/m² or 200 mg/m²

BACKGROUND The standard conditioning regimen for autologous stem cell transplantation (ASCT) in multiple myeloma (MM) is 200 mg/m² of melphalan (Mel200). Dosing is reduced by 30% (Mel140) in frail patients. Studies comparing the performance of these regimens report inconsistent findings, mainly confounded by non-consecutive patient inclusion, missing data, and heterogenous practices. The largest study reported an increased risk of death with Mel200 among patients with very good partial remission, or better, before ASCT. This retrospective study from a single center compared outcomes of patients with a first ASCT for myeloma treated with melphalan 140 mg/m² or 200 mg/m². MATERIAL AND METHODS This was a retrospective real-world analysis from a single center. Data from 159 consecutive, first, single ASCTs for MM between 2012 and 2021 were included. Mel200 and Mel140 were administered to 131 and 28 patients, respectively. Primary and secondary objectives were overall survival (OS) and progression-free survival (PFS), respectively. RESULTS Median follow-up was 5.8 years. Over 90% received bortezomib-based induction, and over 76% achieved at least very good partial remission (VGPR) before ASCT in either group. PFS estimates were similar between groups (P=0.49). OS was longer with Mel200 (HR=0.42, P=0.002). Mel200 maintained OS superiority in all relevant subgroups. CONCLUSIONS In a homogenous population of patients with MM, Mel200 was associated with longer OS, likely reflecting the physiological state of patients and tolerance to subsequent treatments. Concerns reported from EBMT data regarding the association of Mel200 with mortality among patients with VGPR or better before ASCT are not supported by this study's findings.

The Evolving Landscape in Multiple Myeloma: From Risk Stratification to T Cell-Directed Advanced Therapies

Multiple myeloma is biologically and clinically a complex and heterogeneous disease which develops late in life, with the median age at the time of initial diagnosis being 66 years. In 1975, Durie and Salmon developed the first broadly adopted staging system in multiple myeloma, and in the ensuing decades, the risk stratification tools have improved and now incorporate different parameters to better predict the prognosis and to guide the treatment decisions. The International Staging System (ISS) was initially developed in 2005, revised in 2015 (R-ISS), and again in 2022 (R2-ISS). Tremendous progress has been achieved in multiple myeloma therapy over the past 25 years with the approval of immunomodulatory drugs, proteasome inhibitors, and anti-CD38 monoclonal antibodies, resulting in a major paradigm shift. The dysfunction of the innate and adaptive immune system, especially in the T cell repertoire, represents a hallmark of multiple myeloma evolution over time, supporting the need for additional therapeutic approaches to activate the host's immune system and to overcome the immunosuppressive tumor microenvironment. Novel T cell-directed therapies include chimeric antigen receptor (CAR) T cell therapies and bispecific antibodies that leverage the immune system's T cells to recognize and attack the tumor cells. Second-generation anti-BCMA CAR T cell therapies and bispecific antibodies that bind the tumor antigen BCMA or GPRC5D onto myeloma cells and CD3 on the T cell's surface are currently available for the treatment of relapsed/refractory multiple myeloma. Despite impressive results obtained with currently approved treatments, multiple myeloma remains incurable, and almost all patients eventually relapse. Moreover, patients with extramedullary disease and plasma cell leukemia represent an unmet medical need that require additional strategies to improve the outcome. In this review, we provide an overview of the evolution of risk stratification and the treatment of multiple myeloma.

Autologous stem-cell transplantation and maintenance therapy for transplant-eligible multiple myeloma patients: cost-effectiveness analysis based on a network meta-analysis

BACKGROUND

This study aimed to evaluate the cost-effectiveness of ASCT and maintenance therapy strategies for transplant-eligible patients with newly diagnosed multiple myeloma from a Chinese healthcare perspective.

RESEARCH DESIGN AND METHODS

A short-run decision tree and a long-run Markov model were created to assess the mean costs and quality-adjusted life-years (QALYs) of ASCT plus maintenance therapy over a lifetime horizon. Utility values were sourced from published literature, while healthcare costs were based on a single-center retrospective analysis and national drug bidding data.

RESULTS

The ASCT strategy with two-year daratumumab maintenance had the lowest discounted costs (1,394,183 CNY). Compared to no ASCT with continuous lenalidomide maintenance, ASCT had an ICER of 90,997 CNY/QALY. With one-year lenalidomide maintenance, ASCT provided more QALYs at lower costs. One-year lenalidomide maintenance after ASCT also resulted in higher QALYs and lower costs than no maintenance, while continuous lenalidomide had an ICER of 396,731 CNY/QALY.

CONCLUSIONS

Under the WTP threshold of CNY 268,074 per QALY, ASCT strategies were more cost-effective than non-ASCT approaches. One-year lenalidomide therapy after ASCT was more cost-effective than no maintenance or continuous therapy. Among all strategies, ASCT followed by two years of daratumumab maintenance was the most cost-effective option.

Allogeneic hematopoietic cell transplantation for therapy-related myeloid neoplasms arising following treatment for multiple myeloma: a retrospective study on behalf of the Chronic Malignancies Working Party of the EBMT

Therapy-related myeloid neoplasms (t-MN) are a complication of multiple myeloma (MM) treatment. Our retrospective, EBMT registry study included 157 such patients allografted (allo-HCT) between 2006 and 2018. Most patients (130) had a prior autologous HCT. Fifty-seven (36.4%) were transplanted for t-AML and 100 (63.6%) for t-MDS. Median times from MM and t-MN diagnoses to allo-HCT were 72.6 (interquartile range (IQR), 46.1-102.9) and 6.4 (IQR, 3.9-9.4) months. Fifty-eight (38.4%) t-MN patients were in complete remission (CR) at allo-HCT predominantly conditioned with reduced intensity (70.3%). With a median follow-up of 64.9 (95% CI: 39-76) months, relapse incidence (RI) from MM at 1 and 5 years was 4% (0-10%) and 12% (2-22%), respectively, with few deaths (n = 3) only due to MM disease progression, whereas t-MN RI and non-relapse mortality (NRM) at 1 and 5 years were 35% (95% CI 28-43%) and 45% (95% CI: 36-53%) and 20% (95% CI 13-26%) and 31% (95% CI: 23-39%). Overall survival (OS) and progression-free survival (PFS) estimates at 1 and 5 years were 55% (95% CI: 47-63%) and 27% (95% CI: 19-35%) and 45% (95% CI 36-53%) and 24% (95% CI 16-32%). Older (>65 years) t-MN patients with high-risk cytogenetics do not benefit from allo-HCT.

VCd versus VRd in Newly Diagnosed Multiple Myeloma: Matched Real-World Analysis from the Balkan Myeloma Study Group (BMSG)

BACKGROUND

Bortezomib, dexamethasone and cyclophosphamide (VCd) remains a popular regimen, due to its activity and low toxicity, while bortezomib, lenalidomide and dexamethasone (VRd) is widely used in US and Europe; both are combined with anti-CD38 monoclonal antibodies but VCd and VRd have not been compared directly in adequately powered prospective trials.

AIM

We compared the outcomes of 1216 patients treated with VCd (N = 690) or VRd (N = 526) in a real-world setting.

RESULTS

Patients treated with VCd had more often severe renal dysfunction, ISS-3 disease, hypercalcemia, elevated LDH, anemia, thrombocytopenia, poor performance while VRd-treated were older and received less often autologous transplant but more frequently maintenance but the duration of induction was similar. VRd was associated with substantially higher overall response and CR/VGPR rates to induction(P < .001) and improved PFS and OS in univariate analysis, especially among patients with standard risk disease, without renal dysfunction and in the elderly; however, in multivariate analysis there was no significant difference in either PFS or OS. In patients strictly matched 1:1 for major prognostic variables (188 in each group, total N = 376), the superiority of VRd in terms of responses rates and depth of response was confirmed, but without significant PFS or OS difference.

CONCLUSION

VRd is a more active induction regimen than VCd, although use of maintenance with lenalidomide may dilute the PFS or OS benefit. VCd induction remains an option in special circumstances. With the implementation of monoclonal antibodies, VCd backbone can be considered for patients without access to or who do not tolerate VRd.

Modernizing multiple myeloma clinical trial eligibility to improve equity and inclusivity by hematological parameters

In the United States, Black people experience multiple myeloma (MM) at a frequency that is more than double that of White people and experience much higher rates of mortality. Despite bearing a disproportionate impact of both MM incidence and mortality, Black patients are significantly underrepresented in most MM clinical trials. This is in part because Black patients experience a higher prevalence of hemoglobinopathies and Duffy-null phenotype, which affect hemoglobin and neutrophil levels, respectively, potentially excluding patients from clinical trials. The Multiple Myeloma Research Foundation (MMRF) has convened a series of Health Equity Summits that include a focus on creating inclusive clinical trials for MM. The present paper, an output of the most recent workshop, focuses on the role of laboratory reference ranges as a barrier to clinical trial participation and offers tangible steps to improve the enrollment of a diverse and representative population.

Satisfactory outcomes following a second autologous hematopoietic cell transplantation for multiple myeloma in poor stem cell mobilizers: a retrospective study on behalf of the Chronic Malignancies Working Party of the EBMT

Autologous hematopoietic cell transplants (auto-HCTs) remain the standard of care for transplant-eligible MM patients. The general practice has been to undergo upfront apheresis following induction to collect sufficient number of CD34+ cells to facilitate two auto-HCTs. However, 5-30% of MM patients do not initially mobilise a sufficient number of hematopoietic stem cells and are classified as poor mobilizers (PM). We compared the baseline characteristics and outcomes of 61 PMs and 816 non-PM patients who underwent a second auto-HCT and who were enrolled in the non-interventional CALM study (NCT01362972). Only patients who collected CD34+ prior to auto-HCT1 were included. Auto-HCT2 comprised both tandem and salvage transplants. PMs were re-mobilized with plerixafor (n = 24, 39.3%) or non-plerixafor-based regimens (n = 37, 60.7%). There were no significant differences in engraftment, progression-free survival (PFS) or overall survival (OS) after the second auto-HCT between PM and non-PM patients. There was a trend to shorter PFS in PM patients undergoing salvage auto-HCT (median 9.6 vs. 12.9 months; p = 0.08) but no significant difference in OS. The median OS was 41.1 months for PM and 41.2 months for non-PM patients (p = 0.86). These data suggest that salvage mobilization is effective and does not affect overall outcomes after a second auto-HCT.

Patient and caregiver perspectives on treatment decision-making for stem cell transplantation in multiple myeloma

PURPOSE

Stem cell transplantation (SCT) is considered standard of care for patients with newly diagnosed multiple myeloma (MM) but is still associated with substantial challenges for patients and caregivers. Given the challenging treatment process and availability of other treatment options, it is important to engage patients in treatment decision-making, particularly patients with MM who may have unique goals and preferences.

METHODS

We conducted an exploratory focus-group study to evaluate how patients and caregivers make treatment decisions related to SCT. Fourteen patients who underwent SCT and 3 caregivers participated in three 2-h focus-group sessions. All 17 patients were selected from Janssen's Patient Engagement Research Council. Discussions focused on conversations about SCT, considerations for decision-making, and reflections about the decision to undergo SCT. This study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ).

RESULTS

Participants initially had limited knowledge about SCT but received information from their doctors and sought information from various sources. Key considerations during decision-making included long-term health impacts, side effects, and logistical and financial concerns. Most participants reported that they never considered or were never offered other treatment options, highlighting a need for improved education on available treatments for MM. Some participants also shared a desire for more information about the SCT process, particularly the recovery period, which they found more difficult than expected.

CONCLUSION

These findings highlight potential opportunities for improved education to enhance shared decision-making in patients undergoing SCT and their caregivers.

Association of age, race, and ethnicity with access, response, and toxicities from CAR-T therapy in children and adults with B-cell malignancies: a review

Chimeric antigen receptor T cell (CAR-T) therapies are now standard-of-care for several B-cell malignancies, and additional indications are being evaluated. In this review, we survey data on how outcomes after CAR-T therapies vary according to age, race, and ethnicity. We also review the representation of age, racial, and ethnic groups in key CAR-T clinical trials. We focus on B-cell acute lymphoblastic leukemia, B-cell non-Hodgkin's lymphoma, and multiple myeloma.

Minimal Residual Disease as an Early Endpoint for Accelerated Drug Approval in Myeloma: A Roadmap

SIGNIFICANCE

The acceptance of MRD-negative complete response as an endpoint that is reasonably likely to predict clinical benefit will allow for the design of streamlined clinical trials for accelerated approval, enabling significantly faster patient access to novel therapies. Cooperative efforts were required to obtain and analyze clinical trial data from multiple sponsors and to determine the best approach to analysis with a relatively limited number of available datasets. The process to evaluate MRD as an intermediate endpoint, undertaken jointly by myeloma researchers and industry, with feedback from the FDA, serves as a roadmap for other areas of oncology to develop intermediate endpoints.

Autologous Hematopoietic Cell Transplant as an Effective Treatment Modality for Systemic Sclerosis and Multiple Myeloma

Systemic sclerosis (SSc) is a multi-system disease characterized by a dysregulated immune system. Autologous hematopoietic cell transplantation (AHCT) is the only treatment that has been shown to confer significant benefit in controlling disease and improving survival for patients with SSc. A diagnosis of multiple myeloma (MM) after the diagnosis of SSc is rare and optimal treatment in such cases remains unclear. We here report a case of a female patient who was diagnosed with MM while she was undergoing evaluation for AHCT due to SSc. A novel conditioning regimen for AHCT, with therapeutic efficacy in SSc and MM was offered to the patient, resulting in long term remission of both diseases.

Dexamethasone dose intensity does not impact outcomes in newly diagnosed multiple myeloma: a secondary SWOG analysis

ABSTRACT

Dexamethasone is a key component of induction for newly diagnosed multiple myeloma (NDMM), despite common toxicities, including hyperglycemia and insomnia. In the randomized ECOG E4A03 trial, dexamethasone 40 mg once weekly was associated with lower mortality than higher doses. However, the performance of dexamethasone dose reductions below this threshold with regard to progression-free survival (PFS) and overall survival (OS) in NDMM has not been fully characterized. We conducted a secondary pooled analysis of the SWOG 0777 and SWOG 1211 studies of NDMM, which used lenalidomide and dexamethasone (Rd) alone, with or without bortezomib, and with or without elotuzumab. The planned dexamethasone intensity was 40 to 60 mg weekly in all arms. Patients were categorized into FD-DEX (full-dose dexamethasone maintained throughout induction) or LD-DEX (lowered-dose dexamethasone or discontinuation; only permitted for grade 3+ toxicities per both study protocols). Of the 541 evaluated patients, the LD-DEX group comprised 373 patients (69%). There were no differences in PFS or OS between the FD-DEX and LD-DEX groups, which were balanced in terms of age, stage, and performance status. Predictors of PFS and OS in the multivariate models were treatment arm, age ≥70 years, and thrombocytopenia. FD-DEX did not significantly improve either outcome. Our study suggests that dexamethasone dose reductions are common in multiple myeloma, even within clinical trials. Given the many toxicities and unclear benefits of dexamethasone in the era of modern treatment regimens, dexamethasone dose reduction during NDMM induction warrants further prospective studies. These trials were registered at www.clinicaltrials.gov as #NCT00644228 and NCT01668719.

Brazilian Real-Life Experience of Multiple Myeloma (MMyBRAve): Improvement in Outcomes, But Remaining Diagnostic and Therapeutic Gaps

BACKGROUND

This study aimed at describing the demographic and clinical characteristics, treatment patterns and overall survival of patients with MM in Brazil to identify gaps in the disease diagnosis and treatment.

METHODS

MMyBRAve (NCT03506386) was a multicenter, observational study of patients diagnosed with MM in Brazil between January 2008 and December 2016, with data collection between August 2018 and September 2019 at 17 participating centers.

RESULTS

Of 943 patients included, 914 had complete data for overall survival (OS) analysis. The most used frontline regimens were cyclophosphamide, thalidomide and dexamethasone; bortezomib, cyclophosphamide and dexamethasone; and thalidomide and dexamethasone. After a median follow-up of 63 months, the median OS from diagnosis was 70 months. These results indicate continuous improvements in comparison with previous observational studies from Brazil. The median OS in transplantation-ineligible (N = 491) and eligible (N = 452) patients were 49 and 93 months, respectively (hazard ratio [HR] = 0.52; 95% confidence interval [CI], 0.43 to 0.63; P < .001). The median OS also differed between patients with and without known prognostic factors.

CONCLUSION

Despite the improvements, our results suggest that access to novel agents and transplantation continue to hinder further progress in patient outcomes in Brazil and countries with similar health-care constraints.

Optimizing multiple Myeloma clinical trials: research direction, addressing limitations, and strategies for improvement

Despite significant advancements in multiple myeloma (MM) treatment, including novel therapies and combination strategies, the translation of findings from randomized controlled trials (RCTs) into real-world clinical practice has been associated with several challenges. Specifically, the principles and criterion that shape the current design of MM RCTs have left out a sizable portion of patients that would particularly benefit from trial inclusion. In addition, RCTs may use primary outcomes which only partially cover patient-relevant endpoints important for evaluating treatment efficacy and quality of life. In this review, we explore the current MM RCT landscape and suggest possible solutions to improve generalizability of trial results, mitigate logistical pitfalls, and integrate real-world evidence into trials. Together, these strategies are designed to refine MM treatment guidelines and improve outcomes for all patient populations.

Outcomes of Patients with Heavily Pretreated Relapsed/Refractory Multiple Myeloma Receiving Salvage Cytotoxic Therapy with Supportive Stem Cell Boost

BACKGROUND

Multiple myeloma (MM) is an incurable hematologic malignancy characterized by the neoplastic proliferation of plasma cells, which produce monoclonal immunoglobulin that can cause vital organ damage, subsequently leading to significant morbidity and mortality. Autologous hematopoietic stem cell transplant (ASCT) is the standard-of-care management of eligible patients with newly diagnosed MM. Experts recommend collecting enough stem cells upfront to support a possible tandem transplant, salvage ASCT, or a stem cell "boost" to allow for the administration of multiagent cytotoxic chemotherapy in patients with relapsed/refractory disease.

OBJECTIVE

There is currently a paucity of data on the response rates and outcomes of patients with relapsed MM who undergo cytotoxic chemotherapy followed by a stem cell boost; this study examines the outcomes of patients treated with this approach.

METHODS

We conducted a retrospective chart review from two oncologic treatment centers in the United States of adult patients who underwent a first ASCT between 1999 and 2021 and subsequently received cytotoxic chemotherapy followed by stem cell boost further on in their disease course. Survival analysis was carried out using the Kaplan-Meier method, and the log-rank test was used to compare survival curves.

RESULTS

We found that the majority (56.6%) of these patients responded to therapy and that 60.6% of these patients were able to receive at least one subsequent line of therapy post-boost. Furthermore, patients who responded to therapy had significantly longer median overall survival compared to those who did not respond (323 days vs 93 days, p=0.0045), and age did not affect response to therapy.

CONCLUSION

This data allow clinicians to appropriately implement and inform patients of the therapeutic uses and clinical outcomes of stem cell boost in patients with multiply relapsed/refractory MM.

Tandem Versus Single Autologous Stem Cell Transplantation for High-Risk Multiple Myeloma in the Era of Novel Agents: A Real-World Study of China

BACKGROUND

This study compares the efficacy and safety of single autologous stem cell transplantation (ASCT) versus tandem ASCT for multiple myeloma (MM) patients in the era of novel agents.

METHODS

A total of 112 high-risk MM patients were included (single ASCT, (n = 57) or tandem ASCT(n = 55) in this retrospective multicenter study. Responses and outcomes were evaluated.

RESULTS

At 100 days after ASCT1 and ASCT2, 36 (63.2%) versus 45 (81.8%) patients achieved sCR/CR, 16 (28.1%) versus 7 (12.7%) patients achieved VGPR, and 5 (8.8%) versus 1 (1.8%) patient achieved PR, respectively, in the single and tandem ASCT cohorts. The 3-year cumulative incidence of non-relapse mortality and disease progression was 0% versus 7.3% (p = 0.083), and 45.8% versus 25.8% (p = 0.039), respectively, for the single and tandem ASCT cohort. The tandem ASCT cohort showed a trend of better 3-year probability of PFS (58.1% vs. 64.7%, p = 0.064) compared with the single ASCT cohort. In multivariate analysis, ultra high-risk and achieving

CONCLUSIONS

Tandem ASCT demonstrated improved outcomes compared to single ASCT in high-risk MM patients receiving triplet or quadruplet induction and maintenance therapy. However, patients with ultra high-risk cytogenetics may require innovative therapeutic approaches, as tendem ASCT does not overcome their adverse prognosis.

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Key Words

• autologous stem cell transplant
• multiple myeloma
• tandem

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MESH Headings

• Humans
• Multiple Myeloma/therapy
• Multiple Myeloma/mortality
• Male
• Female
• Middle Aged
• Retrospective Studies
• Transplantation, Autologous
• Hematopoietic Stem Cell Transplantation/methods
• Hematopoietic Stem Cell Transplantation/adverse effects
• China/epidemiology
• Adult
• Aged
• Treatment Outcome
• Antineoplastic Combined Chemotherapy Protocols/therapeutic use
• Antineoplastic Combined Chemotherapy Protocols/adverse effects

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Grants

• KJ2024CX045 Plan Project of Tongzhou Municipal Science and Technology
• 82170208 the National Natural Science Foundation of China
• 71003Y3035 Peking University Medicine Fund for world's leading discipline or discipline cluster development
• 2022YFC2502606 National Key Research and Development Program of China
• 82293630 Major Program of the National Natural Science Foundation of China
• 2020-2-4082 Capital Health Development Research Project
• The Natural Science Foundation of Beijing : Z230016

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Affiliation(s)

Xuelin Dou Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
Juan Ren Department of Hematology, The First Affiliated Hospital of Xi'an Jiao Tong University, Shanxi, China
Jiangtao Li Department of Hematology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
Xiaodan Liu Department of Hematology, The Affiliated Hospital of Qingdao University, Shandong, China
Li Bao Department of Hematology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
Yuan Chen Department of Hematology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
Peng Zhao Department of Hematology, The Affiliated Hospital of Guizhou Medical University, Guizhou, China
Yuping Zhong Department of Hematology, Qingdao Municipal Hospital, Qingdao, China
Nan Peng Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
Lei Wen Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
Leqing Cao Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
Yang Liu Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
Daoxing Deng Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
Fengrong Wang Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
Liru Wang Department of Hematology, Fu Xing Hospital, Capital Medical University, Beijing, China
Hui Liu Department of Hematology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
Xiaojun Huang Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
Xiaodong Mo Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
Jin Lu Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China

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Collaborators Collapse

Optimizing individualized therapy decision-making in multiple myeloma (MM): integration and impact of the Revised Myeloma Comorbidity Index in the MM-tumor board

Multiple Myeloma (MM) is a hematological disease predominantly affecting elderly patients. The complexity of current treatment necessitates individualized approaches. Therein, functional assessment (FA) tools, such as the Revised Comorbidity Index (R-MCI) at our University- and Comprehensive Cancer Center Freiburg, play a crucial role. This study aimed to determine (a) the implementation of the R-MCI in our MM-tumor board (MM-TB), (b) its impact on treatment guidance at baseline and (c) potential changes during follow-up. This exploratory study investigated R-MCI coverage and distribution in a cohort of patients with multiple TB presentations. Among them, a follow-up patient cohort undergoing subsequent MM-therapy was analyzed to determine treatment adjustments and changes in patients' condition measured by R-MCI alterations. During our 3-year assessment period, 565 patients were presented in our MM-TB, totaling 1256 TB-presentations. In the multiple TB presentation cohort, the median number of TB presentations was 3 (range: 2-12). R-MCI scores within the MM-TB were available in 94%, whereas in 6%, the R-MCI had not been integrated. Among these, potential failure to identify the need for treatment modifications was determined. In the follow-up cohort, patient characteristics were typical for referral/university centers. Dose reductions were performed in 55% and were more prevalent among patients with ≥ 4 vs. lesser TB presentations. Most patients (55%) showed a fitness stabilization or improvement via follow-up R-MCI. R-MCI integration in MM-TB exceeded > 90%, indicating its successful integration for treatment support. Our results underscore its value in guiding therapy decisions, providing a comprehensive assessment beyond age considerations.

Characteristics and outcomes of therapy-related acute leukemia following autologous transplant (Auto-HCT) for multiple myeloma

With a prolonging duration of survivorship, patients with multiple myeloma (MM) who receive high-dose chemotherapy and autologous hematopoietic stem cell transplantation (auto-HCT) have an increased risk of secondary malignancy, most concerning acute leukemia. We retrospectively reviewed the records of all patients with MM who underwent auto-HCT between January 1, 2010, and January 1, 2023, who later developed therapy-related acute leukemia (t-AL). Of 1770 patients with MM who underwent auto-HCT, 18 (1.01%) developed t-AL at a mean interval of 60.0 ± 41.3 months after auto-HCT. The patients with t-AL consisted of 9 (50%) with B-cell acute lymphoblastic leukemia (B-ALL), 8 (44.4%) with acute myeloid leukemia (AML), and 1 (5.6%) with acute promyelocytic leukemia (APML). All patients had received an alkylating agent as part of induction, and the majority received lenalidomide as maintenance therapy. Genetic abnormalities of t-AL were consistent with prior reports. Median overall survival from diagnosis of t-AL was 19.5 months. In patients with t-AL who entered CR, long term survival was common. Further research on predisposing conditions to developing t-AL in patients with MM undergoing auto-HCT is warranted.