Randomised phase II study to optimise melphalan, prednisolone, and bortezomib in untreated multiple myeloma (JCOG1105)

Structural variety and pharmacological potential of naphthylisoquinoline alkaloids

Naphthylisoquinoline alkaloids are a fascinating class of natural biaryl compounds. They show characteristic mono- and dimeric scaffolds, with chiral axes and stereogenic centers. Since the appearance of the last comprehensive overview on these secondary plant metabolites in this series in 1995, the number of discovered representatives has tremendously increased to more than 280 examples known today. Many novel-type compounds have meanwhile been discovered, among them naphthylisoquinoline-related follow-up products like e.g., the first seco-type (i.e., ring-opened) and ring-contracted analogues. As highlighted in this review, the knowledge on the broad structural chemodiversity of naphthylisoquinoline alkaloids has been decisively driven forward by extensive phytochemical studies on the metabolite pattern of Ancistrocladus abbreviatus from Coastal West Africa, which is a particularly "creative" plant. These investigations furnished a considerable number of more than 80-mostly new-natural products from this single species, with promising antiplasmodial activities and with pronounced cytotoxic effects against human leukemia, pancreatic, cervical, and breast cancer cells. Another unique feature of naphthylisoquinoline alkaloids is their unprecedented biosynthetic origin from polyketidic precursors and not, as usual for isoquinoline alkaloids, from aromatic amino acids-a striking example of biosynthetic convergence in nature. Furthermore, remarkable botanical results are presented on the natural producers of naphthylisoquinoline alkaloids, the paleotropical Dioncophyllaceae and Ancistrocladaceae lianas, including first investigations on the chemoecological role of these plant metabolites and their storage and accumulation in particular plant organs.

Adverse cognitive effects of glucocorticoids: A systematic review of the literature

OBJECTIVES

Glucocorticoids as a drug class are widely used in the treatment of many conditions including more recently as one of the mainstay treatments for the SARS-CoV-2 infection. The physiological adverse effects are well described. However, less is known and understood about the potentially deleterious neuro-cognitive effects of this class of medication.

METHODS

We carried out a systematic review of the literature using two separate search strategies. The first focussed on the rates of reporting of adverse cognitive effects of glucocorticoid use in randomised controlled trials. The second looked at those studies focussing directly on adverse cognitive effects associated with the use of glucocorticoids. MEDLINE, Embase and Cochrane Library was searched for randomised controlled trials utilising glucocorticoids as a part of a treatment regimen. Additionally, these databases were also used to search for articles looking directly at the adverse cognitive effects of glucocorticoids.

RESULTS

Of the forty-three RCTs included as a part of the first search strategy, only one (2.3%) included specific documentation pertaining to cognitive side effects. As a part of the twenty studies included in the second search strategy, eleven of the included studies (55%) were able to demonstrate a correlation between glucocorticoid use and decreased cognition. Most studies within this strategy showed that GCs predominately affected hippocampus-dependent functions such as memory, while sparing executive function and attention.

CONCLUSIONS

Overall, the data reporting of adverse clinical effects of glucocorticoid use is poor in recent RCTs. Given the demonstrable effect on predominately hippocampal-dependent cognitive functions evident within the literature, more thorough documentation is needed within clinical research to fully appreciate the potentially widespread nature of these effects.

Asian Ancistrocladus Lianas as Creative Producers of Naphthylisoquinoline Alkaloids

This book describes a unique class of secondary metabolites, the mono- and dimeric naphthylisoquinoline alkaloids. They occur in lianas of the paleotropical Ancistrocladaceae and Dioncophyllaceae families, exclusively. Their unprecedented structures include stereogenic centers and rotationally hindered, and thus likewise stereogenic, axes. Extended recent investigations on six Ancistrocladus species from Asia, as reported in this review, shed light on their fascinating phytochemical productivity, with over 100 such intriguing natural products. This high chemodiversity arises from a likewise unique biosynthesis from acetate-malonate units, following a novel polyketidic pathway to plant-derived isoquinoline alkaloids. Some of the compounds show most promising antiparasitic activities. Likewise presented are strategies for the regio- and stereoselective total synthesis of the alkaloids, including the directed construction of the chiral axis.

Randomized phase III study of daratumumab versus bortezomib plus daratumumab as maintenance therapy after D-MPB for transplant-ineligible patients with untreated multiple myeloma (JCOG1911, B-DASH study)

Daratumumab, melphalan, prednisolone and bortezomib followed by daratumumab maintenance is a standard regimen for transplant-ineligible newly diagnosed multiple myeloma. A large-scale clinical trial demonstrated that progression-free survival declined more sharply during the maintenance phase than during the daratumumab, melphalan, prednisolone and bortezomib induction phase, which suggests the necessity of reinforcing maintenance therapy. This randomized phase III trial aims to confirm the superiority of daratumumab plus bortezomib to daratumumab as maintenance therapy in terms of progression-free survival for transplant-ineligible newly diagnosed multiple myeloma (JCOG1911, B-DASH). First registration (222 patients, within 5 years) was before daratumumab, melphalan, prednisolone and bortezomib administration; those who responded to daratumumab, melphalan, prednisolone and bortezomib were included in the second registration. They were randomized to the daratumumab or daratumumab plus bortezomib maintenance arm. This trial is registered in the Japan Registry for Clinical Trials as jRCT031200320 (https://jrct.niph.go.jp/). An ancillary study examining the association of genetic alterations in myeloma cells with prognosis and drug resistance, using next-generation sequencing, is ongoing.

Recent advances in the management of older adults with newly diagnosed multiple myeloma in Japan

Multiple myeloma is a cancer of plasma cells; the incidence rate of multiple myeloma is high among older adults. Although significant advances have been made in the clinical management of multiple myeloma driven by the introduction of novel drugs, such as proteasome inhibitors, immuno- modulators and antibodies, multiple myeloma remains incurable. Hence, the current therapeutic goal for multiple myeloma is to achieve long-term survival while maintaining a good quality of life. In this context, personalized treatment to balance the efficacy and safety of therapies is important, especially for older adults as they display diverse physical, cognitive or organ functioning. Furthermore, old age is also often associated with frailty. Several tools for evaluating frailty in older adults with multiple myeloma are now available, and frail patients defined by these tools have shown a poor prognosis and more treatment-related toxicities. In addition, it is important to evaluate other factors, such as the International Staging System, high-risk chromosomal abnormalities and treatment response, to predict the clinical course of patients. Further investigations are required to determine how these factors can optimize the treatment for multiple myeloma. In this review, we present a detailed account on the developments and issues related to the current treatment approaches for older adults with newly diagnosed multiple myeloma. We also discuss the ongoing phase III clinical study conducted by the lymphoma study group of the Japan Clinical Oncology Group, which targeted older adults with newly diagnosed multiple myeloma.

HLA genotyping in Japanese patients with multiple myeloma receiving bortezomib: An exploratory biomarker study of JCOG1105 (JCOG1105A1)

Bortezomib (Btz) shows robust efficacy in patients with multiple myeloma (MM); however, some patients experience suboptimal responses and show specific toxicities. Therefore, we attempted to identify specific HLA alleles associated with Btz-related toxicities and response to treatment. Eighty-two transplant-ineligible patients with newly diagnosed MM enrolled in a phase II study (JCOG1105) comparing two less intensive melphalan, prednisolone, plus Btz (MPB) regimens were subjected to HLA typing. The frequency of each allele was compared between the groups, categorized based on toxicity grades and responses to MPB therapy. Among 82 patients, the numbers of patients with severe peripheral neuropathy (PN; grade 2 or higher), skin disorders (SD; grade 2 or higher), and pneumonitis were 16 (19.5%), 15 (18.3%), and 6 (7.3%), respectively. Complete response was achieved in 10 (12.2%) patients. Although no significant HLA allele was identified by multiple comparisons, several candidates were identified. HLA-B*40:06 was more prevalent in patients with severe PN than in those with less severe PN (odds ratio [OR] = 6.76). HLA-B*40:06 and HLA-DRB1*12:01 were more prevalent in patients with SD than in those with less severe SD (OR = 7.47 and OR = 5.55, respectively). HLA-DRB1*08:02 clustered in the group of patients with pneumonitis (OR = 11.34). Complete response was achieved in patients carrying HLA-DQB1*03:02, HLA-DQB1*05:01, and HLA-DRB1*01:01 class II alleles. HLA genotyping could help predict Btz-induced toxicity and treatment efficacy in patients with MM, although this needs further validation.

Efficacy of first-line treatment options in transplant-ineligible multiple myeloma: A network meta-analysis

BACKGROUND

Despite major therapeutic advances, the rational choice of the most appropriate first-line regimen in newly diagnosed transplant-ineligible multiple myeloma (TIE-MM) is currently undefined.

AIM

We aimed to identify the most effective first-line treatment for TIE-MM patients.

METHODS

A total of 37 articles, including 34 treatments and 16,681 patients, were included in this Bayesian network meta-analysis. The outcomes of interest were risk ratios (RR) for progression-free survival (PFS) and overall survival (OS).

RESULTS

Based on surface under cumulative ranking curve values, daratumumab-bortezomib-melphalan-prednisone (Dara-VMP) and daratumumab-lenalidomide-dexamethasone (Dara-Rd28) showed superiority compared to other combinations regarding 12-, 24-, 36-, and 48-month PFS. Dara-VMP also ranked first for 12-, 24-, 36-, and 48-month OS.

CONCLUSION

Our finding supports the incorporation of daratumumab into first-line regimens. Additionally, these results highlight the relative benefit of incorporating novel agents like monoclonal antibodies, immunomodulatory derivatives, and proteasome inhibitors in combination with the currently existing treatment options.

Single response assessment of transplant-ineligible multiple myeloma: a supplementary analysis of JCOG1105 (JCOG1105S1)

Background

The International Myeloma Working Group response criteria require two consecutive assessments of paraprotein levels. We conducted an exploratory analysis to evaluate whether a single response assessment could be a substitute for the International Myeloma Working Group criteria using data from JCOG1105, a randomized phase II study on melphalan, prednisolone and bortezomib.

Methods

Of 91 patients with transplant-ineligible newly diagnosed multiple myeloma, 79 patients were included. We calculated the kappa coefficient to evaluate the degree of agreement between the International Myeloma Working Group criteria and the single response assessment.

Results

Based on the International Myeloma Working Group criteria, 11 (13.9%), 20 (25.3%), 36 (45.6%) and 12 (15.2%) patients had stringent complete response/complete response, very good partial response, partial response and stable disease, respectively. Based on the single response assessment, 17 (21.5%), 19 (24.1%), 35 (44.3%) and 8 (10.1%) patients had stringent complete response/complete response, very good partial response, partial response and stable disease, respectively. The kappa coefficient was 0.76 (95% confidence interval, 0.65–0.88), demonstrating good agreement. The single response assessment was not inferior to the International Myeloma Working Group criteria in the median progression-free survival (3.8 and 2.9 years) in stringent complete response/complete response patients, suggesting that the single response assessment was not an overestimation.

Conclusions

The single response assessment could be a substitute for the current International Myeloma Working Group criteria for transplant-ineligible newly diagnosed multiple myeloma.