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Mutlu YG, Yıgıt Kaya S, Maral S, Melek E, Baslar Z, Kaynar L, Sevindik OG. Relapsed refractory multiple myeloma with CNS involvement successfully treated with Elranatamab: first reported case. Front Immunol 2023; 14:1276295. [PMID: 37901215 PMCID: PMC10611496 DOI: 10.3389/fimmu.2023.1276295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/02/2023] [Indexed: 10/31/2023] Open
Abstract
Central nervous system (CNS) involvement in multiple myeloma (MM) is a rare and challenging complication associated with poor prognosis and limited treatment options. Emerging T-cell directing therapies, such as bispecific antibodies (bsAbs) and chimeric antigen receptor T cells (CAR-T), have shown remarkable success in treating MM, but their efficacy in CNS involvement remains unclear. Elranatamab, a humanized bispecific antibody targeting B-cell maturation antigen (BCMA) and CD3-expressing T cells, has demonstrated promising results in relapsed refractory MM. However, its efficacy in treating CNS-MM has not been reported. We present a case of a 37-year-old male MM patient with CNS involvement who has been successfully treated with Elranatamab.
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Affiliation(s)
- Yasa Gul Mutlu
- Department of Hematology, Istanbul Medipol University, Istanbul, Türkiye
| | - Sureyya Yıgıt Kaya
- Department of Hematology, Istanbul Medipol University, Istanbul, Türkiye
| | - Senem Maral
- Department of Hematology, Istanbul Medipol University, Istanbul, Türkiye
| | - Elif Melek
- Department of Hematology, Istanbul Medipol University, Istanbul, Türkiye
| | - Zafer Baslar
- Department of Hematology, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Leylagul Kaynar
- Department of Hematology, Istanbul Medipol University, Istanbul, Türkiye
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Wan Z, Tao R, Hui J, Liu X, Peng X, Guo Y, Zhu X, Huang Y, Zhu B. Efficacy and safety of lenalidomide in HIV-associated cryptococcal meningitis patients with persistent intracranial inflammation: an open-label, single-arm, prospective interventional study. J Neuroinflammation 2023; 20:38. [PMID: 36793113 PMCID: PMC9933282 DOI: 10.1186/s12974-023-02717-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/01/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Patients with human immunodeficiency virus-associated cryptococcal meningitis (HIV-CM) have persistent intracranial inflammation despite negative cerebrospinal fluid (CSF) fungal cultures after optimal treatment for CM, which could be devastating for the central nervous system. However, a definitive treatment strategy for persistent intracranial inflammation despite optimal antifungal therapies is undefined. METHODS We identified 14 HIV-CM patients with persistent intracranial inflammation and conducted a 24-week, prospective, interventional study. All participants received lenalidomide (25 mg, p.o.) on days 1 to 21 of a 28-day cycle. Follow-up lasted for 24 weeks with visits at baseline and weeks 4, 8, 12, and 24. The primary endpoint was the change in clinical manifestations, routine CSF parameters, and MRI findings after lenalidomide treatment. An exploratory analysis was made on changes in cytokine levels in CSF. Safety and efficacy analyses were undertaken in patients who received at least one dose of lenalidomide. RESULTS Of 14 participants, 11 patients completed the 24 weeks of follow-up. Rapid clinical remission following lenalidomide therapy was observed. Clinical manifestations (fever, headache, altered mentation) were reversed fully by week-4 and remained stable during follow-up. A significant reduction in white blood cell (WBC) count in CSF was noted occurred at week-4 (P = 0.009). The median protein concentration in CSF decreased from 1.4 (0.7-3.2) g/L at baseline to 0.9 (0.6-1.4) at week-4 (P = 0.004). The median albumin concentration in CSF decreased from 79.2 (48.4-149.8) mg/L at baseline to 55.3 (38.3-89.0) mg/L at week-4 (P = 0.011). The WBC count, protein level, and albumin level in CSF remained stable and approached a normal range through week-24. There was no significant change in immunoglobulin-G, intracranial pressure (ICP), or chloride-ion concentration at each visit. Brain MRI demonstrated multiple lesions to be absorbed post-therapy. Levels of tumor necrosis factor-α granulocyte colony stimulating factor, interleukin (IL)-6, and IL-17A decreased significantly during 24-week follow-up. Two (14.3%) patients had mild skin rash, which resolved spontaneously. Lenalidomide-related serious adverse events were not observed. CONCLUSION Lenalidomide could improve persistent intracranial inflammation in HIV-CM patients significantly and was well tolerated without serious adverse events observed. And the additional randomized controlled study is required to further validate the finding.
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Affiliation(s)
- Zhikai Wan
- grid.13402.340000 0004 1759 700XThe Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ran Tao
- grid.13402.340000 0004 1759 700XThe Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jiangjin Hui
- grid.13402.340000 0004 1759 700XThe Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiang Liu
- grid.13402.340000 0004 1759 700XThe Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaorong Peng
- grid.13402.340000 0004 1759 700XThe Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yongzheng Guo
- grid.13402.340000 0004 1759 700XThe Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xueling Zhu
- grid.13402.340000 0004 1759 700XThe Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ying Huang
- grid.13402.340000 0004 1759 700XThe Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Biao Zhu
- The Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
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3
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Sammartano V, Cerase A, Venanzi V, Mazzei MA, Vangone BE, Gentili F, Chiarotti I, Bocchia M, Gozzetti A. Central Nervous System Myeloma and Unusual Extramedullary Localizations: Real Life Practical Guidance. Front Oncol 2022; 12:934240. [PMID: 35875104 PMCID: PMC9300839 DOI: 10.3389/fonc.2022.934240] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/10/2022] [Indexed: 12/22/2022] Open
Abstract
Central nervous system localization of multiple myeloma (CNS-MM) accounts for about 1% of all MM during disease course or even rarer at diagnosis. A difference in the origin, i.e., osteodural or primary dural vs leptomeningeal/intraparenchymal, seems to define two distinct types of intracranial myeloma, with different clinical behavior. CNS-MM may occur also as a presentation of MM. Treatment is still unsatisfactory and many treatments have been reported: chemotherapy, intrathecal therapy, and radiotherapy, with dismal prognosis. Other sites of myeloma localization could be also of interest and deserve description. Because of the rarity and aggressiveness of the disease clinicians are often doubtful on how to treat it since there is no general agreement. Moreover, recent drugs such as the anti CD38 monoclonal antibody, immunomodulatory drugs, and proteasome inhibitors have changed the treatment of patients with MM with a significant improvement in overall response and survival. The role of novel agents in CNS MM management and unusual presentations will be discussed as well as the potential role of other new immunomodulatory drugs and proteasome inhibitors that seem to cross the blood-brain barrier. The purpose of this review is to increase awareness of the clinical unusual presentation and neuroradiological findings, give practical diagnostic advice and treatment options algorithm.
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Affiliation(s)
- Vincenzo Sammartano
- Hematology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Alfonso Cerase
- Neuroimaging (Diagnostic and Functional Neuroradiology) Unit, Azienda ospedaliero-universitaria Senese, Siena, Italy
| | - Valentina Venanzi
- Hematology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Maria Antonietta Mazzei
- Department of Medicine, Surgery and Neuroscience, University of Siena and Department of Radiological Sciences, Unit of Diagnostic Imaging, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Beatrice Esposito Vangone
- Hematology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Francesco Gentili
- Department of Medicine, Surgery and Neuroscience, University of Siena and Department of Radiological Sciences, Unit of Diagnostic Imaging, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Ivano Chiarotti
- Neuroimaging (Diagnostic and Functional Neuroradiology) Unit, Azienda ospedaliero-universitaria Senese, Siena, Italy
| | - Monica Bocchia
- Hematology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Alessandro Gozzetti
- Hematology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
- *Correspondence: Alessandro Gozzetti,
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Ogiya D, Murayama N, Kamiya Y, Saito R, Shiraiwa S, Suzuki R, Machida S, Tazume K, Ando K, Yamazaki H. Low cerebrospinal fluid-to-plasma ratios of orally administered lenalidomide mediated by its low cell membrane permeability in patients with hematologic malignancies. Ann Hematol 2022; 101:2013-2019. [PMID: 35732975 DOI: 10.1007/s00277-022-04893-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 06/13/2022] [Indexed: 11/01/2022]
Abstract
Lenalidomide is a synthetic analog of thalidomide formed by the removal of one keto group (plus the addition of an amino group); it has anti-tumor activities beneficial for the treatment of hematologic malignancies. However, lenalidomide distribution to brain in animal models is reportedly low compared with that of thalidomide. The aim of this study was to evaluate plasma and cerebrospinal fluid concentrations of lenalidomide in three patients with malignant hematologic malignancies. Lenalidomide was detected in plasma from the three Japanese patients 1.5 h following oral administration of 20 mg lenalidomide using liquid chromatography/mass spectrometry, despite the in vitro gastrointestinal permeability of lenalidomide being low. Clinically observed cerebrospinal fluid-to-plasma ratios of lenalidomide were low (1.3-2.4%). Observed influx permeability values for lenalidomide in monkey blood-brain barrier model and human placental cell systems were one order of magnitude lower than those of thalidomide and another second-generation drug, pomalidomide along with a positive permeability control, caffeine. Because of the low cell-barrier permeability of lenalidomide demonstrated in in vitro assays, clinically relevant pharmacokinetic profiles of lenalidomide resulted in low penetrability from plasma into cerebrospinal fluid in patients with hematologic malignancies. Lenalidomide is conclusively suggested to expert its favorable immunomodulatory effects via systemic exposures in the patients.
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Affiliation(s)
- Daisuke Ogiya
- Department of Hematology and Oncology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.,Department of Hematology, Isehara Kyodo Hospital, 345 Tanaka, Isehara, Kanagawa, 259-1187, Japan
| | - Norie Murayama
- Laboratory of Drug Metabolism and Pharmacokinetics, Showa Pharmaceutical University, 3-3165 Higashi-tamagawa Gakuen, Machida, Tokyo, 194-8543, Japan
| | - Yusuke Kamiya
- Laboratory of Drug Metabolism and Pharmacokinetics, Showa Pharmaceutical University, 3-3165 Higashi-tamagawa Gakuen, Machida, Tokyo, 194-8543, Japan
| | - Rie Saito
- Laboratory of Drug Metabolism and Pharmacokinetics, Showa Pharmaceutical University, 3-3165 Higashi-tamagawa Gakuen, Machida, Tokyo, 194-8543, Japan
| | - Sawako Shiraiwa
- Department of Hematology and Oncology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Rikio Suzuki
- Department of Hematology and Oncology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Shinichiro Machida
- Department of Hematology and Oncology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kei Tazume
- Department of Hematology, Isehara Kyodo Hospital, 345 Tanaka, Isehara, Kanagawa, 259-1187, Japan
| | - Kiyoshi Ando
- Department of Hematology and Oncology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Hiroshi Yamazaki
- Laboratory of Drug Metabolism and Pharmacokinetics, Showa Pharmaceutical University, 3-3165 Higashi-tamagawa Gakuen, Machida, Tokyo, 194-8543, Japan.
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Fernandez LG, Oyon DE, Gondi V, Grimm S, Khan OH. Secondary CNS myeloma with remission after systemic CNS-penetrating agents. Neurooncol Adv 2022; 4:vdac106. [PMID: 35892045 PMCID: PMC9307102 DOI: 10.1093/noajnl/vdac106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background CNS myeloma is a rare manifestation of multiple myeloma and is often associated with a dismal prognosis; however, cases are increasing in frequency as overall survival improves for MM. There is currently no standardized treatment for CNS myeloma; however, different chemotherapy and radiotherapy regimens have been described. Methods We had previously reported on the efficacy of proton-based craniospinal irradiation in a patient with CNS myeloma; here we present a patient with a history of extramedullary plasmacytoma, 10 years in remission status post standard systemic chemotherapy, with biopsy-proven CNS myeloma successfully treated with systemic chemotherapy as a first-line treatment. Results The patient achieved clinical and radiographic remission on 2 separate occasions with systemic chemotherapy alone. Conclusions This case demonstrates that systemically administered agents may have activity in CNS myeloma. Further investigations are necessary to establish the optimal combination of agents and treatment schedules.
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Affiliation(s)
- Luis G Fernandez
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University , Chicago, Illinois , USA
| | - Daniel Eduardo Oyon
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University , Chicago, Illinois , USA
| | - Vinai Gondi
- Northwestern Medicine Proton Center , Warrenville, Illinois , USA
| | - Sean Grimm
- Rush University Medical Center, Department of Neurological Sciences, Section of Neuro-Oncology, Rush Medical College , Chicago, Illinois , USA
| | - Osaama H Khan
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University , Chicago, Illinois , USA
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6
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Yamashita T, Takamatsu H, Kawamura K, Sunami K, Hagiwara S, Itagaki M, Takahashi T, Kondo T, Ikeda T, Watakabe-Inamoto K, Handa H, Imaizumi Y, Kuroda J, Murakami J, Nakamura Y, Nakazawa H, Ozaki S, Okura M, Takeuchi M, Nagai H, Hanamura I, Nakao S, Iida S. A nationwide survey on central nervous system multiple myeloma in Japan: analysis of prognostic and treatment factors that impact survival. Br J Haematol 2021; 195:217-229. [PMID: 34318926 DOI: 10.1111/bjh.17717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022]
Abstract
This nationwide multicentre retrospective study was performed to analyze clinical features that predict the prognosis of central nervous system invasion in multiple myeloma (CNS-MM, approximately 1% of MM). Overall, of the 77 adult patients with CNS-MM identified between 2005 and 2016, those diagnosed at MM diagnosis (n = 3) had longer overall survival (OS) than those diagnosed at relapse (n = 74; median: 48·5 vs 2·7 months). Therefore, we compared the relapsed MM with CNS-MM in patients with any treatment (n = 60). Multivariate analyses revealed that lenalidomide treatment [hazard ratio (HR) 0·27, P = 0·003], intrathecal chemotherapy (IT; HR 0·54, P = 0·05), and radiation therapy (RTx; HR 0·33, P < 0·001) for CNS-MM had a positive effect on longer OS. These factors were used to develop a scoring system combining the number of treatments with lenalidomide, IT, and RTx (0, 1, 2, 3). The OS of CNS-MM patients was stratified based on these factors, with a median OS of 1·1, 4·5, and 7·5 months for patients with zero, one, two to three favourable features, respectively (0 vs 1, P = 0·0002; 1 vs 2-3, P = 0·08). Multimodal treatment including lenalidomide in addition to conventional IT and RTx can improve OS.
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Affiliation(s)
- Takeshi Yamashita
- Department of Hematology, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan.,Division of Internal Medicine, Keiju Kanazawa Hospital, Ishikawa, Japan
| | - Hiroyuki Takamatsu
- Department of Hematology, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Koji Kawamura
- Division of Clinical Laboratory Medicine, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Kazutaka Sunami
- Department of Hematology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Shotaro Hagiwara
- Division of Hematology, Internal Medicine, National Center for Global Health and Medicine/Department of Hematology, Tsukuba University, Faculty of Medicine, Ibaraki, Japan
| | - Mitsuhiro Itagaki
- Department of Hematology, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Tsutomu Takahashi
- Department of Hematology, Shimane University Hospital, Shimane, Japan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Ikeda
- Division of Hematology and Stem Cell Transplantation, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kyoko Watakabe-Inamoto
- Hematology Division, Tokyo Metropolitan Center and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Hiroshi Handa
- Department of Hematology, Gunma University Hospital, Gunma, Japan
| | | | - Junya Kuroda
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Jun Murakami
- Department of Clinical Laboratory and Transfusion Medicine & Cell therapy, Toyama University Hospital, Toyama, Japan
| | - Yuichi Nakamura
- Department of Hematology, Saitama Medical University Hospital, Saitama, Japan
| | - Hideyuki Nakazawa
- Division of Hematology, Internal Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Shuji Ozaki
- Department of Hematology, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Miyuki Okura
- Department of Hematology and Oncology, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Masami Takeuchi
- Division of Hematology/Oncology, Department of Medicine, Kameda Medical Center, Chiba, Japan
| | - Hirokazu Nagai
- Department of Hematology, National Hospital Organization Nagoya Medical Center, Aichi, Japan
| | - Ichiro Hanamura
- Division of Hematology, Department of Internal Medicine, Aichi Medical University School of Medicine, Aichi, Japan
| | - Shinji Nakao
- Department of Hematology, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Shinsuke Iida
- Department of Hematology and Oncology, Nagoya City University Institute of Medical and Pharmaceutical Sciences, Aichi, Japan
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Hotta M, Ito T, Konishi A, Yoshimura H, Nakanishi T, Fujita S, Satake A, Nomura S. Multiple Myeloma with Central Nervous System Relapse Early after Autologous Stem Cell Transplantation: A Case Report and Literature Review. Intern Med 2021; 60:463-468. [PMID: 33518613 PMCID: PMC7925288 DOI: 10.2169/internalmedicine.5646-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Few reports have so far described central nervous system (CNS) involvement in multiple myeloma (MM), which shows a poor prognosis owing to its resistance to several treatments. We herein describe a 45-year-old woman who had MM (diagnosed with IgA-κ type) with CNS relapse early after undergoing autologous hematopoietic stem cell transplantation. Because no standard treatment for CNS lesions of MM has been established, we conducted a literature review on the cerebrospinal fluid (CSF) transferability of drugs for MM, since it was considered to be a useful tool for CNS involvement. Immunomodulatory-drugs including pomalidomide exhibit a good CSF transfer ability, and, therefore, may be beneficial against the CNS involvement of MM.
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Affiliation(s)
- Masaaki Hotta
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Tomoki Ito
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Akiko Konishi
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Hideaki Yoshimura
- First Department of Internal Medicine, Kansai Medical University, Japan
| | | | - Shinya Fujita
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Atsushi Satake
- First Department of Internal Medicine, Kansai Medical University, Japan
| | - Shosaku Nomura
- First Department of Internal Medicine, Kansai Medical University, Japan
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8
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Aggressive Central Nervous System Relapse after Autologous Stem Cell Transplant in Multiple Myeloma: Case Reports and Literature Review. Case Rep Hematol 2020; 2020:8563098. [PMID: 31984141 PMCID: PMC6964715 DOI: 10.1155/2020/8563098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 12/16/2019] [Indexed: 12/18/2022] Open
Abstract
Extramedullary disease is an aggressive presentation at diagnosis and relapse for multiple myeloma (MM) patients. Central nervous system (CNS) is a very rare manifestation of the extramedullary disease, accounting for less than 1% of MM on diagnosis and relapse. Neurological symptoms are unspecific and usually attributed to other causes. We present two patients with CNS-MM at relapse after autologous stem cell transplant highlighting the importance of clinical suspicion and interdisciplinarity at diagnostic workup as well as the need for intensive therapeutic options on such rare and aggressive cases. The presence of neurological abnormalities in anamnesis and physical examination on a patient with MM should always prompt to suspect of a CNS involvement, and active investigation must be undertaken. MRI is the standard radiological method to detect CNS-MM, with histopathological corroboration by stereotactic biopsy and CSF evaluation alongside. Treatment of CNS-MM should include two essential approaches—be able to cross the BBB and treat the systemic disease. There is no standard therapy for this extramedullary relapse, and a tailored and multiple therapy should be promptly started—intrathecal therapy, radiotherapy, and systemic therapy, including an immunomodulator.
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9
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Development of a physiologically based pharmacokinetic model for intravenous lenalidomide in mice. Cancer Chemother Pharmacol 2019; 84:1073-1087. [PMID: 31493176 DOI: 10.1007/s00280-019-03941-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 08/23/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE Lenalidomide is used widely in B-cell malignancies for its immunomodulatory activity. It is primarily eliminated via the kidneys, with a significant proportion of renal elimination attributed to active processes. Lenalidomide is a weak substrate of P-glycoprotein (P-gp), though it is unclear whether P-gp is solely responsible for lenalidomide transport. This study aimed to determine whether the current knowledge of lenalidomide was sufficient to describe the pharmacokinetics of lenalidomide in multiple tissues. METHODS A physiologically based pharmacokinetic model was developed using the Open Systems Pharmacology Suite to explore the pharmacokinetics of lenalidomide in a variety of tissues. Data were available for mice dosed intravenously at 0.5, 1.5, 5, and 10 mg/kg, with concentrations measured in plasma, brain, heart, kidney, liver, lung, muscle, and spleen. P-gp expression and activity were sourced from the literature. RESULTS The model predictions in plasma, liver, and lung were representative of the observed data (median prediction error 13%, - 10%, and 30%, respectively, with 90% confidence intervals including zero), while other tissue predictions showed sufficient similarity to the observed data. Contrary to the data, model predictions for the brain showed no drug reaching brain tissue when P-gp was expressed at the blood-brain barrier. The data were better described by basolateral transporters at the intracellular wall. Local sensitivity analysis showed that transporter activity was the most sensitive parameter in these models for exposure. CONCLUSION As P-gp transport at the blood-brain barrier did not explain the observed brain concentrations alone, there may be other transporters involved in lenalidomide disposition.
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10
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Bohn JP, Willenbacher W, Peschel I, Oberacher H, Steurer M. Second-generation immunomodulatory drugs in leptomeningeal myeloma. Leuk Lymphoma 2018; 60:550-552. [PMID: 30032690 DOI: 10.1080/10428194.2018.1492125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Jan-Paul Bohn
- a Department of Internal Medicine V , Medical University of Innsbruck , Innsbruck , Austria
| | - Wolfgang Willenbacher
- a Department of Internal Medicine V , Medical University of Innsbruck , Innsbruck , Austria.,b Oncotyrol , Center for Personalized Cancer Medicine , Innsbruck , Austria
| | - Ines Peschel
- c Central Institute for Medical and Chemical Laboratory Diagnostics , Medical University Innsbruck , Innsbruck , Austria
| | - Herbert Oberacher
- d Institute of Legal Medicine and Core Facility Metabolomics , Medical University of Innsbruck , Innsbruck , Austria
| | - Michael Steurer
- a Department of Internal Medicine V , Medical University of Innsbruck , Innsbruck , Austria
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11
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Bairey O, Siegal T. The possible role of maintenance treatment for primary central nervous system lymphoma. Blood Rev 2018; 32:378-386. [PMID: 29551465 DOI: 10.1016/j.blre.2018.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 02/27/2018] [Accepted: 03/09/2018] [Indexed: 12/22/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare and aggressive brain tumor. The prognosis is poor, with high rates of relapse and disease progression after treatment. In addition, PCNSL affects a largely older population, so that a significant proportion of patients are ineligible for intensive therapies and high-dose chemotherapy. The elderly patients are also susceptible to the accelerated and detrimental cognitive side effects of whole-brain irradiation which is an alternative consolidation to high-dose chemotherapy. Maintenance therapy has been shown to be a promising strategy to prolong remission time in other hematopoietic malignancies. Herein, we discuss the place of maintenance treatment in PCNSL in view of perspective obtained from hematological malignancies and non-Hodgkin's lymphoma.
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Affiliation(s)
- Osnat Bairey
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Tali Siegal
- Neuro-Oncology Center, Davidoff Cancer Center, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.
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12
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Abstract
Lenalidomide is a lead therapeutic in multiple myeloma and deletion 5q myelodysplastic syndromes and shows promising activities in other hematologic malignancies. This article presents a comprehensive review of the clinical pharmacokinetics and pharmacodynamics of lenalidomide. Oral lenalidomide is rapidly and highly absorbed (>90 % of dose) under fasting conditions. Food affects oral absorption, reducing area under the concentration-time curve (AUC) by 20 % and maximum concentration (C max) by 50 %. The increase in AUC and C max is dose proportional, and interindividual variability in plasma exposure is low to moderate. Lenalidomide distributes into semen but is undetectable 3 days after stopping treatment. Biotransformation of lenalidomide in humans includes chiral inversion, trivial hydroxylation, and slow non-enzymatic hydrolysis. Approximately 82 % of an oral dose is excreted as lenalidomide in urine within 24 h. Lenalidomide has a short half-life (3-4 h) and does not accumulate in plasma upon repeated dosing. Its pharmacokinetics are consistent across patient populations, regardless of the type of hematologic malignancy. Renal function is the only important factor affecting lenalidomide plasma exposure. Lenalidomide has no QT prolongation risk at approved doses, and higher plasma exposure to lenalidomide is associated with increased risk of neutropenia and thrombocytopenia. Despite being a weak substrate of P-glycoprotein (P-gp) in vitro, lenalidomide does not have clinically significant pharmacokinetic interactions with P-gp substrates/inhibitors in controlled studies. The AUC-matched dose adjustment is recommended for patients with renal impairment at the start of therapy. No dose adjustment for lenalidomide is needed on the basis of age, ethnicity, mild hepatic impairment, or drug-drug interactions.
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Affiliation(s)
- Nianhang Chen
- Department of Clinical Pharmacology, Celgene Corporation, 86 Morris Avenue, Summit, NJ, 07901, USA.
| | - Simon Zhou
- Department of Clinical Pharmacology, Celgene Corporation, 86 Morris Avenue, Summit, NJ, 07901, USA
| | - Maria Palmisano
- Department of Clinical Pharmacology, Celgene Corporation, 86 Morris Avenue, Summit, NJ, 07901, USA
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13
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Marini A, Carulli G, Lari T, Buda G, Lambelet P, Ciancia EM, Benedetti E, Caracciolo F, Ferreri MI, Pesaresi I, Rousseau M, Ottaviano V, Azzar^|^agrave; A, Petrini M. Myelomatous Meningitis Evaluated by Multiparameter Flow Cytometry : Report of a Case and Review of the Literature. J Clin Exp Hematop 2014; 54:129-36. [DOI: 10.3960/jslrt.54.129] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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14
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Ise M, Sakai C, Kumagai K. Meningeal myelomatosis developed after treatment with novel agents. Int J Hematol 2013; 98:271-2. [PMID: 23955113 DOI: 10.1007/s12185-013-1415-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 07/29/2013] [Accepted: 08/06/2013] [Indexed: 11/24/2022]
Affiliation(s)
- Mikiko Ise
- Department of Hematology-Oncology, Chiba Cancer Center, 666-2 Nitona-cho, Chuo-ku, Chiba, Chiba, 260-8717, Japan,
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