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MRD in multiple myeloma: does CR really matter? Blood 2022; 140:2423-2428. [PMID: 35560160 DOI: 10.1182/blood.2022016170] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/11/2022] [Accepted: 04/26/2022] [Indexed: 01/01/2023] Open
Abstract
Multiple myeloma embodies the paradigm of the deeper the response, the longer the survival. However, results are conflicting regarding achievement of complete remission (CR) and minimal residual disease (MRD) negativity; some patients with persistent M protein have undetectable MRD. We reviewed the frequency of this discordance and outcomes of these patients. We spotlight possible explanations for and consequences of conflicting response criteria and suggest that MRD be assessed in patients achieving very good partial response or better in clinical trials.
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Bravo-Pérez C, Sola M, Teruel-Montoya R, García-Malo MD, Ortuño FJ, Vicente V, de Arriba F, Jerez A. Minimal Residual Disease in Multiple Myeloma: Something Old, Something New. Cancers (Basel) 2021; 13:4332. [PMID: 34503142 PMCID: PMC8430644 DOI: 10.3390/cancers13174332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 12/13/2022] Open
Abstract
The game-changing outcome effect, due to the generalized use of novel agents in MM, has cre-ated a paradigm shift. Achieving frequent deep responses has placed MM among those neoplasms where the rationale for assessing MRD is fulfilled. However, its implementation in MM has raised specific questions: how might we weight standard measures against deep MRD in the emerging CAR-T setting? Which high sensitivity method to choose? Are current response criteria still useful? In this work, we address lessons learned from the use of MRD in other neoplasms, the steps followed for the harmonization of current methods for comprehensively measuring MRD, and the challenges that new therapies and concepts pose in the MM clinical field.
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Affiliation(s)
- Carlos Bravo-Pérez
- Hematology and Medical Oncology Department, University Hospital Morales Meseguer, IMIB, 30003 Murcia, Spain; (C.B.-P.); (M.S.); (M.D.G.-M.); (F.J.O.); (V.V.); (F.d.A.); (A.J.)
| | - María Sola
- Hematology and Medical Oncology Department, University Hospital Morales Meseguer, IMIB, 30003 Murcia, Spain; (C.B.-P.); (M.S.); (M.D.G.-M.); (F.J.O.); (V.V.); (F.d.A.); (A.J.)
| | - Raúl Teruel-Montoya
- Hematology and Medical Oncology Department, University Hospital Morales Meseguer, IMIB, 30003 Murcia, Spain; (C.B.-P.); (M.S.); (M.D.G.-M.); (F.J.O.); (V.V.); (F.d.A.); (A.J.)
- CB15/00055-CIBERER, 30003 Murcia, Spain
| | - María Dolores García-Malo
- Hematology and Medical Oncology Department, University Hospital Morales Meseguer, IMIB, 30003 Murcia, Spain; (C.B.-P.); (M.S.); (M.D.G.-M.); (F.J.O.); (V.V.); (F.d.A.); (A.J.)
| | - Francisco José Ortuño
- Hematology and Medical Oncology Department, University Hospital Morales Meseguer, IMIB, 30003 Murcia, Spain; (C.B.-P.); (M.S.); (M.D.G.-M.); (F.J.O.); (V.V.); (F.d.A.); (A.J.)
| | - Vicente Vicente
- Hematology and Medical Oncology Department, University Hospital Morales Meseguer, IMIB, 30003 Murcia, Spain; (C.B.-P.); (M.S.); (M.D.G.-M.); (F.J.O.); (V.V.); (F.d.A.); (A.J.)
- CB15/00055-CIBERER, 30003 Murcia, Spain
| | - Felipe de Arriba
- Hematology and Medical Oncology Department, University Hospital Morales Meseguer, IMIB, 30003 Murcia, Spain; (C.B.-P.); (M.S.); (M.D.G.-M.); (F.J.O.); (V.V.); (F.d.A.); (A.J.)
| | - Andrés Jerez
- Hematology and Medical Oncology Department, University Hospital Morales Meseguer, IMIB, 30003 Murcia, Spain; (C.B.-P.); (M.S.); (M.D.G.-M.); (F.J.O.); (V.V.); (F.d.A.); (A.J.)
- CB15/00055-CIBERER, 30003 Murcia, Spain
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3
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A large meta-analysis establishes the role of MRD negativity in long-term survival outcomes in patients with multiple myeloma. Blood Adv 2021; 4:5988-5999. [PMID: 33284948 DOI: 10.1182/bloodadvances.2020002827] [Citation(s) in RCA: 200] [Impact Index Per Article: 66.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/10/2020] [Indexed: 12/19/2022] Open
Abstract
The prognostic value of minimal residual disease (MRD) for progression-free survival (PFS) and overall survival (OS) was evaluated in a large cohort of patients with multiple myeloma (MM) using a systematic literature review and meta-analysis. Medline and EMBASE databases were searched for articles published up to 8 June 2019, with no date limit on the indexed database. Clinical end points stratified by MRD status (positive or negative) were extracted, including hazard ratios (HRs) on PFS and OS, P values, and confidence intervals (CIs). HRs were estimated based on reconstructed patient-level data from published Kaplan-Meier curves. Forty-four eligible studies with PFS data from 8098 patients, and 23 studies with OS data from 4297 patients were identified to assess the association between MRD status and survival outcomes. Compared with MRD positivity, achieving MRD negativity improved PFS (HR, 0.33; 95% CI, 0.29-0.37; P < .001) and OS (HR, 0.45; 95% CI, 0.39-0.51; P < .001). MRD negativity was associated with significantly improved survival outcomes regardless of disease setting (newly diagnosed or relapsed/refractory MM), MRD sensitivity thresholds, cytogenetic risk, method of MRD assessment, depth of clinical response at the time of MRD measurement, and MRD assessment premaintenance and 12 months after start of maintenance therapy. The strong prognostic value of MRD negativity and its association with favorable outcomes in various disease and treatment settings sets the stage to adopt MRD as a treatment end point, including development of therapeutic strategies. This large meta-analysis confirms the utility of MRD as a relevant surrogate for PFS and OS in MM.
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Gozzetti A, Raspadori D, Bacchiarri F, Sicuranza A, Pacelli P, Ferrigno I, Tocci D, Bocchia M. Minimal Residual Disease in Multiple Myeloma: State of the Art and Applications in Clinical Practice. J Pers Med 2020; 10:jpm10030120. [PMID: 32927719 PMCID: PMC7565263 DOI: 10.3390/jpm10030120] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/03/2020] [Accepted: 09/08/2020] [Indexed: 12/14/2022] Open
Abstract
Novel drugs have revolutionized multiple myeloma therapy in the last 20 years, with median survival that has doubled to up to 8–10 years. The introduction of therapeutic strategies, such as consolidation and maintenance after autologous stem cell transplants, has also ameliorated clinical results. The goal of modern therapies is becoming not only complete remission, but also the deepest possible remission. In this context, the evaluation of minimal residual disease by techniques such as next-generation sequencing (NGS) and next-generation flow (NGF) is becoming part of all new clinical trials that test drug efficacy. This review focuses on minimal residual disease approaches in clinical trials, with particular attention to real-world practices.
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Romano A, Palumbo GA, Parrinello NL, Conticello C, Martello M, Terragna C. Minimal Residual Disease Assessment Within the Bone Marrow of Multiple Myeloma: A Review of Caveats, Clinical Significance and Future Perspectives. Front Oncol 2019; 9:699. [PMID: 31482061 PMCID: PMC6710454 DOI: 10.3389/fonc.2019.00699] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/15/2019] [Indexed: 12/11/2022] Open
Abstract
There is an increasing clinical interest in the measure and achievement of minimal residual disease (MRD) negativity in the bone marrow of Multiple Myeloma (MM) patients, as defined equally either by Multicolor Flow Cytometry (MFC) or by Next Generation Sequencing (NGS) technologies. At present, modern technologies allow to detect up to one on 104 or on 105 or even on 106 cells, depending on their throughput. MFC approaches, which have been progressively improved up to the so-called Next Generation Flow (NGF), and NGS, which proved clear advantages over ASO-PCR, can detect very low levels of residual disease in the BM. These methods are actually almost superimposable, in terms of MRD detection power, supporting the lack of unanimous preference for either technique on basis of local availability. However, some technical issues are still open: the optimal assay to use to detect either phenotype (e.g., next generation multidimensional flow cytometry, imaging) or genotype aberrations (e.g., ASO-RQ PCR, digital droplet PCR, NGS) and their standardization, the sample source (BM or peripheral blood, PB) and its pre-processing (red-cell lysis vs. Ficoll, fresh vs. frozen samples, requirement of CD138+ cells enrichment). Overall, MRD negativity is considered as the most powerful predictor of favorable long-term outcomes in MM and is likely to represent the major driver of treatment strategies in the near future. In this manuscript, we reviewed the main pitfalls and caveats of MRD detection within bone marrow in MM patients after front-line therapy, highlighting the improving of the currently employed technology and describing alternative methods for MRD testing in MM, such as liquid biopsy.
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Affiliation(s)
- Alessandra Romano
- Department of Surgery and Medical Specialties, University of Catania, Catania, Italy
| | - Giuseppe Alberto Palumbo
- Division of Hematology, Azienda Ospedaliero-Universitaria Policlinico Vittorio Emanuele di Catania, Catania, Italy
- Dipartimento di Scienze Mediche, Chirurgiche e Tecnologie avanzate “G.F. Ingrassia,” University of Catania, Catania, Italy
| | - Nunziatina Laura Parrinello
- Division of Hematology, Azienda Ospedaliero-Universitaria Policlinico Vittorio Emanuele di Catania, Catania, Italy
- Dipartimento di Scienze Mediche, Chirurgiche e Tecnologie avanzate “G.F. Ingrassia,” University of Catania, Catania, Italy
| | - Concetta Conticello
- Division of Hematology, Azienda Ospedaliero-Universitaria Policlinico Vittorio Emanuele di Catania, Catania, Italy
| | - Marina Martello
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale (DIMES), Università degli Studi di Bologna, Bologna, Italy
| | - Carolina Terragna
- Istituto di Ematologia “L.A.Seràgnoli,” Azienda Ospedaliera Sant'Orsola-Malpighi, Bologna, Italy
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Rossi G, Falcone AP, Minervini MM, De Cillis GP, De Waure C, Sisti LG, Giambra V, Valente D, Chiello V, Scalzulli PR, Carella AM, Cascavilla N. Minimal residual disease and log-reduction of plasma cells are associated with superior response after double autologous stem cell transplant in younger patients with multiple myeloma. CYTOMETRY PART B-CLINICAL CYTOMETRY 2018; 96:195-200. [PMID: 30549231 DOI: 10.1002/cyto.b.21755] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/15/2018] [Accepted: 11/14/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Optimization of chemotherapy regimens in the treatment of multiple myeloma (MM) has led to increase the frequency of cases with complete response (CR). Nonetheless, many MM patients still experience relapse, suggesting that CR represents a suboptimal response criteria, and that new therapeutic strategies are needed after single transplant. However, the role of double autologous stem cell transplant (ASCT) as new adjunctive strategy remains to be elucidated. Indeed, we investigated the role of minimal residual disease (MRD) and log-reduction of plasma cells (PCs) as predictors of outcome and in quantifying the degree of tumor reduction after any ASCT. METHODS MRD and log-reduction were assessed by a six-color flow cytometry (FC) at different time-points: post induction, post first-, and post-second ASCT. RESULTS A significant difference was evidenced among the three time points for both log-reduction (P < 0.001) and MRD (P = 0.005). MRD levels after double ASCT were lower than MRD levels achieved after single ASCT (P = 0.005) and after induction (P < 0.001). Frequency of MRD positive patients after double ASCT was significantly lower rather than after the first ASCT (P = 0.008) and after induction (P = 0.004). Interestingly, a significant reduction of PFS was observed in patients with an unfavorable-risk cytogenetic (P < 0.001) and patients with MRD over 0.01% (P = 0.001) as well as log-reduction lower than 2.57 (P = 0.018) after double ASCT. CONCLUSIONS Our results show that a better clearance of myeloma cells is observed after the double ASCT, and a longer PFS is associated with a lower MRD. © 2018 International Clinical Cytometry Society.
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Affiliation(s)
- Giovanni Rossi
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Antonietta Pia Falcone
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Maria Marta Minervini
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Giovanni Pio De Cillis
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Chiara De Waure
- Department of Hygiene, Catholic University of Sacred Heart, Rome, Italy
| | | | - Vincenzo Giambra
- Institute of Stem Cells Biology, Regenerative Medicine and Innovative Therapies (ISBReMIT), Fondazione IRCCS "Casa Sollievo della Sofferenza-IRCCS", San Giovanni Rotondo, Italy
| | - Daniela Valente
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Vincenzo Chiello
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Potito Rosario Scalzulli
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Angelo Michele Carella
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Nicola Cascavilla
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
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7
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Methods and role of minimal residual disease after stem cell transplantation. Bone Marrow Transplant 2018; 54:681-690. [PMID: 30116018 DOI: 10.1038/s41409-018-0307-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/28/2018] [Accepted: 06/13/2018] [Indexed: 11/08/2022]
Abstract
Relapse is the major cause of treatment failure after stem cell transplantation. Despite the fact that relapses occurred even if transplantation was performed in complete remission, it is obvious that minimal residual disease is present though not morphologically evident. Since adaptive immunotherapy by donor lymphocyte infusion or other novel cell therapies as well as less toxic drugs, which can be used after transplantation, the detection of minimal residual disease (MRD) has become a clinical important variable for outcome. Besides the increasing options to treat MRD, the most advanced technologies currently allow to detect residual malignant cells with a sensitivity of 10-5 to 10-6.Under the patronage of the European Society for Blood and Marrow Transplantation (EBMT) and the American Society for Blood and Marrow Transplantation (ASBMT) the 3rd workshop was held on 4/5 November 2016 in Hamburg/Germany, with the aim to present an up-to-date status of epidemiology and biology of relapse and to summarize the currently available options to prevent and treat post-transplant relapse. Here the current methods and role of minimal residual disease for myeloid and lymphoid malignancies are summarized.
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8
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Ho C, Arcila ME. Minimal residual disease detection of myeloma using sequencing of immunoglobulin heavy chain gene VDJ regions. Semin Hematol 2018; 55:13-18. [DOI: 10.1053/j.seminhematol.2018.02.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 02/21/2018] [Indexed: 01/29/2023]
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9
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Bai Y, Orfao A, Chim CS. Molecular detection of minimal residual disease in multiple myeloma. Br J Haematol 2017; 181:11-26. [PMID: 29265356 DOI: 10.1111/bjh.15075] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Despite the significantly higher complete remission rates and improved survival achieved in the last decade, multiple myeloma (MM) patients continue to relapse due to persistence of minimal residual disease (MRD). Generally, MRD refers to persistence of low levels of disease in the order of one tumour cell in ≥105 normal cells. Currently, molecular and immunophenotypic techniques are employed for MRD detection. This review focuses on MRD detection by molecular techniques, including allele-specific oligonucleotide polymerase chain reaction (ASO-PCR), next-generation sequencing (NGS) and digital PCR (dPCR), in addition to a brief description of, and comparison with, multiparameter flow cytometry. The basic principles, technical advantages and limitations, and the clinical impact of all three molecular techniques are reviewed and compared. They all have a sensitivity of at least 10-5 , among which ASO real-time quantitative PCR is the most well-standardized, and NGS carries the highest sensitivity and applicability, while dPCR is still under investigation. Furthermore, molecular MRD negativity is a favourable prognostic factor for survival of patients with MM. However, several challenges inherent to molecular detection of MRD still remain to be overcome, particularly false negativity and failure to detect extramedullary disease. Finally, detection of MRD from peripheral blood remains challenging.
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Affiliation(s)
- Yinlei Bai
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Spain
| | - Alberto Orfao
- Department of Medicine, University of Salamanca and University Hospital of Salamanca-IBSAL, Salamanca, Spain
| | - Chor Sang Chim
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Spain
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10
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Innao V, Allegra A, Russo S, Gerace D, Vaddinelli D, Alonci A, Allegra AG, Musolino C. Standardisation of minimal residual disease in multiple myeloma. Eur J Cancer Care (Engl) 2017; 26. [PMID: 28671297 DOI: 10.1111/ecc.12732] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2017] [Indexed: 12/16/2022]
Abstract
The assessment of the effectiveness of chemotherapy in oncology cannot disregard the concept of minimal residual disease (MRD). In fact, the efforts of numerous scientific groups all over the world are currently focusing on this issue, with the sole purpose of defining sensitive, effective assessment criteria that are, above all, able to give acceptable, easily repeatable results worldwide. Regarding this issue, especially with the advent of new drugs, multiple myeloma is one of the haematologic malignancies for which a consensus has not yet been reached. In this review, we analyse various techniques that have been used to improve the sensitivity of response, aimed at reducing the cut-off values previously allowed, as well as serological values like serum-free light chain, or immunophenotypic tools on bone marrow or peripheral blood, like multi-parameter flow cytometry, or molecular ones such as allele-specific oligonucleotide (ASO)-qPCR and next-generation/high-throughput sequencing technologies (NGS). Moreover, our discussion makes a brief reference to promising techniques, such as mass spectrometry for identifying Ig light chain (LC) in peripheral blood, and the assessment of gene expression profile not only in defining prognostic risk at the diagnosis but also as a tool for evaluation of response.
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Affiliation(s)
- V Innao
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - A Allegra
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - S Russo
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - D Gerace
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - D Vaddinelli
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - A Alonci
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - A G Allegra
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - C Musolino
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
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11
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Kumar S, Paiva B, Anderson KC, Durie B, Landgren O, Moreau P, Munshi N, Lonial S, Bladé J, Mateos MV, Dimopoulos M, Kastritis E, Boccadoro M, Orlowski R, Goldschmidt H, Spencer A, Hou J, Chng WJ, Usmani SZ, Zamagni E, Shimizu K, Jagannath S, Johnsen HE, Terpos E, Reiman A, Kyle RA, Sonneveld P, Richardson PG, McCarthy P, Ludwig H, Chen W, Cavo M, Harousseau JL, Lentzsch S, Hillengass J, Palumbo A, Orfao A, Rajkumar SV, Miguel JS, Avet-Loiseau H. International Myeloma Working Group consensus criteria for response and minimal residual disease assessment in multiple myeloma. Lancet Oncol 2017; 17:e328-e346. [PMID: 27511158 DOI: 10.1016/s1470-2045(16)30206-6] [Citation(s) in RCA: 1733] [Impact Index Per Article: 247.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/21/2016] [Accepted: 05/24/2016] [Indexed: 12/16/2022]
Abstract
Treatment of multiple myeloma has substantially changed over the past decade with the introduction of several classes of new effective drugs that have greatly improved the rates and depth of response. Response criteria in multiple myeloma were developed to use serum and urine assessment of monoclonal proteins and bone marrow assessment (which is relatively insensitive). Given the high rates of complete response seen in patients with multiple myeloma with new treatment approaches, new response categories need to be defined that can identify responses that are deeper than those conventionally defined as complete response. Recent attempts have focused on the identification of residual tumour cells in the bone marrow using flow cytometry or gene sequencing. Furthermore, sensitive imaging techniques can be used to detect the presence of residual disease outside of the bone marrow. Combining these new methods, the International Myeloma Working Group has defined new response categories of minimal residual disease negativity, with or without imaging-based absence of extramedullary disease, to allow uniform reporting within and outside clinical trials. In this Review, we clarify several aspects of disease response assessment, along with endpoints for clinical trials, and highlight future directions for disease response assessments.
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Affiliation(s)
- Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
| | - Bruno Paiva
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), Pamplona, Spain
| | | | - Brian Durie
- Cedars-Sinai Comprehensive Cancer Center, Los Angeles, CA, USA
| | - Ola Landgren
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Sagar Lonial
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Meletios Dimopoulos
- Department of Clinical Therapeutics, University of Athens, School of Medicine, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, University of Athens, School of Medicine, Athens, Greece
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Citta della Salute e della Scienza di Torino, Torino, Italy; Mount Sinai Cancer Institute, New York, NY, USA
| | | | - Hartmut Goldschmidt
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | | | - Jian Hou
- Chang Zheng Hospital, Shanghai, China
| | | | - Saad Z Usmani
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA
| | - Elena Zamagni
- Seragnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
| | | | | | - Hans E Johnsen
- Department of Hematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Evangelos Terpos
- Department of Clinical Therapeutics, University of Athens, School of Medicine, Athens, Greece
| | - Anthony Reiman
- Dalhousie University Medical School, Dalhousie, Nova Scotia, Canada
| | - Robert A Kyle
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Heinz Ludwig
- Wilhelminenspital Der Stat Wien, Vienna, Austria
| | | | - Michele Cavo
- Seragnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
| | | | | | - Jens Hillengass
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Antonio Palumbo
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Citta della Salute e della Scienza di Torino, Torino, Italy
| | - Alberto Orfao
- University Hospital of Salamanca/IBSAL, Salamanca, Spain
| | | | - Jesus San Miguel
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), Pamplona, Spain
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Keeney M, Wood BL, Hedley BD, DiGiuseppe JA, Stetler-Stevenson M, Paietta E, Lozanski G, Seegmiller AC, Greig BW, Shaver AC, Mukundan L, Higley HR, Sigman CC, Kelloff G, Jessup JM, Borowitz MJ. A QA Program for MRD Testing Demonstrates That Systematic Education Can Reduce Discordance Among Experienced Interpreters. CYTOMETRY PART B-CLINICAL CYTOMETRY 2017; 94:239-249. [PMID: 28475275 DOI: 10.1002/cyto.b.21528] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 03/30/2017] [Accepted: 04/10/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Minimal residual disease (MRD) in B lymphoblastic leukemia (B-ALL) by flow cytometry is an established prognostic factor used to adjust treatment in most pediatric therapeutic protocols. MRD in B-ALL has been standardized by the Children's Oncology Group (COG) in North America, but not routine clinical labs. The Foundation for National Institutes of Health sought to harmonize MRD measurement among COG, oncology groups, academic, community and government, laboratories. METHODS Listmode data from post-induction marrows were distributed from a reference lab to seven different clinical FCM labs with variable experience in B-ALL MRD. Labs were provided with the COG protocol. Files from 15 cases were distributed to the seven labs. Educational sessions were implemented, and 10 more listmode file cases analyzed. RESULTS Among 105 initial challenges, the overall discordance rate was 26%. In the final round, performance improved considerably; out of 70 challenges, there were five false positives and one false negative (9% discordance), and no quantitative discordance. Four of six deviations occurred in a single lab. Three samples with hematogones were still misclassified as MRD. CONCLUSIONS Despite the provision of the COG standardized analysis protocol, even experienced laboratories require an educational component for B-ALL MRD analysis by FCM. Recognition of hematogones remains challenging for some labs when using the COG protocol. The results from this study suggest that dissemination of MRD testing to other North American laboratories as part of routine clinical management of B-ALL is possible but requires additional educational components to complement standardized methodology. © 2017 International Clinical Cytometry Society.
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Affiliation(s)
- Michael Keeney
- Pathology and Laboratory Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Brent L Wood
- Seattle Cancer Care Alliance, Seattle, Washington.,University of Washington, Seattle, Washington
| | - Benjamin D Hedley
- Pathology and Laboratory Medicine, London Health Sciences Centre, London, Ontario, Canada
| | | | | | | | - Gerard Lozanski
- Department of Pathology, Ohio State University, Columbus, Ohio
| | - Adam C Seegmiller
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bruce W Greig
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aaron C Shaver
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | | | - Gary Kelloff
- Cancer Imaging Program, National Cancer Institute, Bethesda, Maryland
| | | | - Michael J Borowitz
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Munshi NC, Avet-Loiseau H, Rawstron AC, Owen RG, Child JA, Thakurta A, Sherrington P, Samur MK, Georgieva A, Anderson KC, Gregory WM. Association of Minimal Residual Disease With Superior Survival Outcomes in Patients With Multiple Myeloma: A Meta-analysis. JAMA Oncol 2017; 3:28-35. [PMID: 27632282 DOI: 10.1001/jamaoncol.2016.3160] [Citation(s) in RCA: 369] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Numerous studies have evaluated the prognostic value of minimal residual disease (MRD) in patients with multiple myeloma (MM). Most studies were small and varied in terms of patient population, treatment, and MRD assessment methods. Objective To evaluate the utility of MRD detection in patients with newly diagnosed MM. Data Sources A Medline search was conducted for articles published in English between January 1990 and January 2016. Study Selection Eligible studies reported MRD status and progression-free survival (PFS) or overall survival (OS) in 20 or more patients following treatment. Among 405 articles identified, 21 met the initial eligibility criteria and were included in the analysis. Data Extraction and Synthesis Information on patient characteristics, treatment, MRD assessment, and outcomes were extracted using a standard form. Main Outcomes and Measures The impact of MRD status on PFS and OS was assessed by pooling data from relevant trials. Data were adjusted to allow for different proportions of patients with MRD in different studies, and analyzed using the Peto method. Forest plots were created based on Cox model analysis. Other prespecified research questions were addressed qualitatively. Results Fourteen studies (n = 1273) provided data on the impact of MRD on PFS, and 12 studies (n = 1100) on OS. Results were reported specifically in patients who had achieved conventional complete response (CR) in 5 studies for PFS (n = 574) and 6 studies for OS (n = 616). An MRD-negative status was associated with significantly better PFS overall (hazard ratio [HR], 0.41; 95% CI, 0.36-0.48; P < .001) and in studies specifically looking at CR patients (HR, 0.44; 95% CI, 0.34-0.56; P < .001). Overall survival was also favorable in MRD-negative patients overall (HR, 0.57; 95% CI, 0.46-0.71; P < .001) and in CR patients (HR, 0.47; 95% CI, 0.33-0.67; P < .001). Tests of heterogeneity found no significant differences among the studies for PFS and OS. Conclusions and Relevance Minimal residual disease-negative status after treatment for newly diagnosed MM is associated with long-term survival. These findings provide quantitative evidence to support the integration of MRD assessment as an end point in clinical trials of MM.
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Affiliation(s)
- Nikhil C Munshi
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Herve Avet-Loiseau
- Unit for Genomics in Myeloma, Institut Universitaire du Cancer, Toulouse, France
| | | | - Roger G Owen
- St James's University Hospital, Leeds, United Kingdom
| | | | | | | | - Mehmet Kemal Samur
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | | | - Kenneth C Anderson
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
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van de Velde H, Londhe A, Ataman O, Johns HL, Hill S, Landers E, Berlin JA. Association between complete response and outcomes in transplant-eligible myeloma patients in the era of novel agents. Eur J Haematol 2016; 98:269-279. [PMID: 27859769 DOI: 10.1111/ejh.12829] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Achieving complete response (CR) has been linked to improved progression-free (PFS) and overall (OS) survival in myeloma. A meta-analysis was conducted to investigate whether this holds true in the era of novel agents (bortezomib, lenalidomide, thalidomide). METHODS A total of 24 studies in newly diagnosed patients undergoing autologous stem cell transplantation (ASCT) that reported associations between responses and long-term outcomes (PFS/OS rates post-ASCT by response, or hazard ratios with 95% confidence intervals from Cox models) were identified and analyzed. RESULTS Achievement of CR vs. <CR post-ASCT reduced risk of progression/death by 38% [risk ratio (RR): 0.62, P < 0.0001]; risk of death was 41% lower (RR: 0.59, P < 0.0001). Subgroup meta-analyses showed significant PFS risk reduction with CR post-ASCT with novel (RR: 0.32, P < 0.006) and non-novel (RR: 0.72, P < 0.0001) agents, and corresponding OS risk reduction with novel (RR: 0.33, P = 0.0013) and non-novel (RR: 0.64, P < 0.0001) agents. Risk reduction was greater with novel vs. non-novel agents (PFS: P = 0.047; OS: P = 0.058). CONCLUSIONS Achieving CR during first-line therapy remains important in the novel-agent era; magnitude of association between achieving CR and outcomes appears higher for CR obtained using novel vs. non-novel agents.
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Affiliation(s)
- Helgi van de Velde
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Anil Londhe
- Janssen Research and Development, Horsham, PA, USA
| | - Ozlem Ataman
- Janssen Research & Development, High Wycombe, UK
| | - Helen L Johns
- FireKite, an Ashfield Company, part of UDG Healthcare plc, Maidenhead, UK
| | - Stephen Hill
- FireKite, an Ashfield Company, part of UDG Healthcare plc, Maidenhead, UK
| | - Emma Landers
- FireKite, an Ashfield Company, part of UDG Healthcare plc, Maidenhead, UK
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Dhakal B, D'Souza A, Martens M, Kapke J, Harrington AM, Pasquini M, Saber W, Drobyski WR, Zhang MJ, Hamadani M, Hari PN. Allogeneic Hematopoietic Cell Transplantation in Multiple Myeloma: Impact of Disease Risk and Post Allograft Minimal Residual Disease on Survival. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16:379-86. [DOI: 10.1016/j.clml.2016.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 02/26/2016] [Accepted: 03/21/2016] [Indexed: 10/22/2022]
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16
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Nishihori T, Song J, Shain KH. Minimal Residual Disease Assessment in the Context of Multiple Myeloma Treatment. Curr Hematol Malig Rep 2016; 11:118-26. [PMID: 26898557 PMCID: PMC4819726 DOI: 10.1007/s11899-016-0308-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
With contemporary therapeutic strategies in multiple myeloma, heretofore unseen depth and rate of responses are being achieved. These strategies have paralleled improvements in outcome of multiple myeloma patients. The integration of the next generation of proteasome inhibitors and antibody therapeutics promise continued improvements in therapy with the expectation of consistent depth of response not quantifiable by current clinical methods. As such, there is a growing need to develop adequate tools to evaluate deeper disease response after therapy and to refine the response criteria including the minimal residual disease. Several emerging techniques are being evaluated for these purposes including multi-parameter flow cytometry, allele-specific oligonucleotide polymerase chain reaction, next-generation sequencing, and imaging modalities. In this review, we highlight the recent developments and evaluate advantages and limitations of the current technologies to assess minimal residual disease. We also discuss future applications of these methodologies in potentially guiding multiple myeloma treatment decisions.
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Affiliation(s)
- Taiga Nishihori
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
- Department of Oncologic Sciences, Moffitt Cancer Center/University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Jinming Song
- Department of Oncologic Sciences, Moffitt Cancer Center/University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Department of Hematopathology, Moffitt Cancer Center, Tampa, FL, USA
| | - Kenneth H Shain
- Department of Oncologic Sciences, Moffitt Cancer Center/University of South Florida Morsani College of Medicine, Tampa, FL, USA.
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA.
- Tumor Biology Department, Moffitt Cancer Center, Tampa, FL, USA.
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
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Muz B, de la Puente P, Azab F, Luderer MJ, King J, Vij R, Azab AK. A CD138-independent strategy to detect minimal residual disease and circulating tumour cells in multiple myeloma. Br J Haematol 2016; 173:70-81. [PMID: 26729247 DOI: 10.1111/bjh.13927] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 11/18/2015] [Indexed: 12/26/2022]
Abstract
CD138 (also termed SDC1) has been the gold-standard surface marker to detect multiple myeloma (MM) cells for decades; however, drug-resistant residual and circulating MM cells were shown to have lower expression of this marker. In this study, we have shown that residual MM cells following bortezomib treatment are hypoxic. This combination of drug exposure and hypoxia down-regulates their CD138 expression, thereby making this marker unsuitable for detecting residual or other hypoxic MM cells, such as circulating tumour cells, in MM. Hence, we developed an alternative biomarker set which detects myeloma cells independent of their hypoxic and CD138 expression status in vitro, in vivo and in primary MM patients. The new markers were able to identify a clonal CD138-negative population as minimal residual disease in the bone marrow and peripheral blood of MM patients. Further investigation to characterize the role of this population as a prognostic marker in MM is warranted.
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Affiliation(s)
- Barbara Muz
- Department of Radiation Oncology, Cancer Biology Division, Washington University School of Medicine, St. Louis, MO, USA
| | - Pilar de la Puente
- Department of Radiation Oncology, Cancer Biology Division, Washington University School of Medicine, St. Louis, MO, USA
| | - Feda Azab
- Department of Radiation Oncology, Cancer Biology Division, Washington University School of Medicine, St. Louis, MO, USA
| | - Micah John Luderer
- Department of Radiation Oncology, Cancer Biology Division, Washington University School of Medicine, St. Louis, MO, USA
| | - Justin King
- Section of Stem Cell Transplant and Leukemia, Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ravi Vij
- Section of Stem Cell Transplant and Leukemia, Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Abdel Kareem Azab
- Department of Radiation Oncology, Cancer Biology Division, Washington University School of Medicine, St. Louis, MO, USA
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Abstract
Assessment of minimal residual disease (MRD) is becoming standard diagnostic care for potentially curable neoplasms such as some acute leukemias as well as chronic myeloid and lymphocytic leukemia. Although multiple myeloma (MM) remains as an incurable disease, around half of the patients achieve complete remission (CR), and recent data suggests increasing rates of curability with "total-therapy-like" programs. This landscape is likely to be improved with the advent of new antibodies and small molecules. Therefore, conventional serological and morphological techniques have become suboptimal for sensitive evaluation of highly effective treatment strategies. Although, existing data suggests that MRD could be used as a biomarker to evaluate treatment efficacy, help on therapeutic decisions, and act as surrogate for overall survival, the role of MRD in MM is still a matter of extensive debate. Here, we review the different levels of remission used to define depth of response in MM and their clinical significance, as well as the prognostic value and unique characteristics of MRD detection using immunophenotypic, molecular, and imaging techniques. Key facts The higher efficacy of new treatment strategies for MM demand the incorporation of highly sensitive techniques to monitor treatment efficacy MRD could be used as a more potent surrogate biomarker for survival than standard CR We need to understand the pros and cons of the different MRD techniques The time has come to incorporate highly sensitive, cost-effective, readily available, and standardized MRD techniques into clinical trials to assess its role in therapeutic decisions.
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Affiliation(s)
- Bruno Paiva
- Centro de Investigacion Medica Aplicada (CIMA), Clinica Universidad de Navarra, IDISNA, Pamplona, Spain
| | - Ramón García-Sanz
- Hospital Universitario de Salamanca, Centro de Investigación Del Cancer (IBMCC-USAL, CSIC), Instituto de Investigaion Biomedica de Salamanca (IBSAL), Salamanca, Spain
| | - Jesús F San Miguel
- Centro de Investigacion Medica Aplicada (CIMA), Clinica Universidad de Navarra, IDISNA, Pamplona, Spain.
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19
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Minimal residual disease testing after stem cell transplantation for multiple myeloma. Bone Marrow Transplant 2015; 51:2-12. [DOI: 10.1038/bmt.2015.164] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 05/28/2015] [Accepted: 06/02/2015] [Indexed: 12/21/2022]
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20
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Paiva B, Puig N, García-Sanz R, San Miguel JF. Is This the Time to Introduce Minimal Residual Disease in Multiple Myeloma Clinical Practice? Clin Cancer Res 2015; 21:2001-8. [DOI: 10.1158/1078-0432.ccr-14-2841] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 02/06/2015] [Indexed: 11/16/2022]
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Abstract
"The daintiest last, to make the end most sweet," comes to us from Shakespeare’s Richard II, but in the most recent edition of Blood, the paper from Martinez-Lopez et al suggests that by using minimal residual disease (MRD) testing by sequencing, we may be nearing the "end most sweet" or, in 21st century vernacular, the cure of myeloma.
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Abstract
CONTEXT Hematopathology is a dynamic field that has always been on the frontier of clinical research within the scope of pathology. Several recent developments in hematopathology will likely affect its practice clinically. OBJECTIVE To review 5 important recent advances in hematopathology: (1) detection and prognostic implication of MYC in diffuse large B-cell lymphomas, (2) determining origin and prognosis through immunoglobulin gene usage in mature B-cell neoplasms, (3)detecting minimal residual disease in multiple myeloma, (4) using genome-wide analysis in myelodysplastic syndromes, and (5) employing whole-genome sequencing in acute myeloid leukemias. DATA SOURCES Literature review and the authors' experiences in an academic center. CONCLUSIONS These advances will bring hematopathology into a new molecular era and help us to better understand the molecular, pathologic mechanisms of lymphomas, leukemias, myelomas, and myelodysplastic syndromes. They will help us to identify diagnostic and prognostic markers and eventually provide new therapeutic targets and treatments for these diseases.
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Affiliation(s)
- Min Shi
- From the Department of Pathology, UMass Memorial Medical Center, Worcester, Massachusetts
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24
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Vij R, Mazumder A, Klinger M, O'Dea D, Paasch J, Martin T, Weng L, Park J, Fiala M, Faham M, Wolf J. Deep Sequencing Reveals Myeloma Cells in Peripheral Blood in Majority of Multiple Myeloma Patients. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 14:131-139.e1. [DOI: 10.1016/j.clml.2013.09.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 09/04/2013] [Accepted: 09/24/2013] [Indexed: 12/15/2022]
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Prognostic value of deep sequencing method for minimal residual disease detection in multiple myeloma. Blood 2014; 123:3073-9. [PMID: 24646471 DOI: 10.1182/blood-2014-01-550020] [Citation(s) in RCA: 322] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
We assessed the prognostic value of minimal residual disease (MRD) detection in multiple myeloma (MM) patients using a sequencing-based platform in bone marrow samples from 133 MM patients in at least very good partial response (VGPR) after front-line therapy. Deep sequencing was carried out in patients in whom a high-frequency myeloma clone was identified and MRD was assessed using the IGH-VDJH, IGH-DJH, and IGK assays. The results were contrasted with those of multiparametric flow cytometry (MFC) and allele-specific oligonucleotide polymerase chain reaction (ASO-PCR). The applicability of deep sequencing was 91%. Concordance between sequencing and MFC and ASO-PCR was 83% and 85%, respectively. Patients who were MRD(-) by sequencing had a significantly longer time to tumor progression (TTP) (median 80 vs 31 months; P < .0001) and overall survival (median not reached vs 81 months; P = .02), compared with patients who were MRD(+). When stratifying patients by different levels of MRD, the respective TTP medians were: MRD ≥10(-3) 27 months, MRD 10(-3) to 10(-5) 48 months, and MRD <10(-5) 80 months (P = .003 to .0001). Ninety-two percent of VGPR patients were MRD(+). In complete response patients, the TTP remained significantly longer for MRD(-) compared with MRD(+) patients (131 vs 35 months; P = .0009).
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Long-term results in multiple myeloma after high-dose melphalan and autologous transplantation according to response categories in the era of old drugs. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2013; 14:148-54. [PMID: 24417912 DOI: 10.1016/j.clml.2013.11.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Revised: 11/12/2013] [Accepted: 11/17/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND The aim of this study was to investigate the correlation between the long-term prognosis of multiple myeloma (MM) and the quality of response to therapy in a cohort of 173 patients treated with high-dose melphalan (HDM) and autologous transplantation in the era of old drugs. PATIENTS AND METHODS A total of 173 patients with de novo MM who received a transplant between 1994 and 2010 were analyzed. VAD (vincristine, doxorubicin [Adriamycin], dexamethasone) was used as front-line regimen before auto-HPCT. The conditioning was HDM 200 mg/m(2). Patients were evaluated for clinical response using the criteria from the European Group for Blood and Marrow Transplantation, modified to include near complete remission (nCR) and very good partial remission (VGPR). RESULTS The response distribution after transplantation in our series was complete remission (CR) in 33 cases (19%), nearly complete remission (nCR) in 38 cases (22%), VGPR in 30 cases (17%), partial remission (PR) in 65 cases (38%), and stable disease (SD) in 7 cases (4%). Patients were followed for 48 ± 36 months. Median overall survival (OS) was not reached for the CR group. Progression-free survival (PFS) was 122 months for CR, 55 months for nCR, 56 months for VGPR, 32 months for PR, and 22 months for SD. Significant differences in PFS and OS were found between the CR and nCR groups (P = .003 and P = .001, respectively), between the CR and VGPR groups (P = .002 and P = .001, respectively), and between the CR and PR groups (P = .000 and P = .001, respectively). Responses were clustered in 3 main categories, ie, CR, nCR + VGPR + PR, and SD. The respective 10-year PFS and OS values were 58% and 70% for CR, 15% and 18% for nCR + VGPR + PR, and 0% and 0% for SD. CONCLUSION The achievement of depth and prolonged response represents the most important prognostic factor. The relapse rate is low for patients in CR after 10 years of follow-up, possibly signifying a cure.
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Martinez-Lopez J, Fernández-Redondo E, García-Sánz R, Montalbán MA, Martínez-Sánchez P, Pavia B, Mateos MV, Rosiñol L, Martín M, Ayala R, Martínez R, Blanchard MJ, Alegre A, Besalduch J, Bargay J, Hernandez MT, Sarasquete ME, Sanchez-Godoy P, Fernández M, Blade J, San Miguel JF, Lahuerta JJ. Clinical applicability and prognostic significance of molecular response assessed by fluorescent-PCR of immunoglobulin genes in multiple myeloma. Results from a GEM/PETHEMA study. Br J Haematol 2013; 163:581-9. [DOI: 10.1111/bjh.12576] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 08/14/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Joaquin Martinez-Lopez
- Servicio de Hematología & Instituto de Investigación; Hospital Universitario 12 de Octubre; Madrid Spain
| | - Elena Fernández-Redondo
- Servicio de Hematología & Instituto de Investigación; Hospital Universitario 12 de Octubre; Madrid Spain
| | - Ramón García-Sánz
- Servicio de Hematología; Hospital Clínico Universitario de Salamanca; IBSAL. IBMCC (USAL-CSIC); Salamanca Spain
| | - María Angeles Montalbán
- Servicio de Hematología & Instituto de Investigación; Hospital Universitario 12 de Octubre; Madrid Spain
| | - Pilar Martínez-Sánchez
- Servicio de Hematología & Instituto de Investigación; Hospital Universitario 12 de Octubre; Madrid Spain
| | - Bruno Pavia
- Servicio de Hematología; Hospital Clínico Universitario de Salamanca; IBSAL. IBMCC (USAL-CSIC); Salamanca Spain
| | - María Victoria Mateos
- Servicio de Hematología; Hospital Clínico Universitario de Salamanca; IBSAL. IBMCC (USAL-CSIC); Salamanca Spain
| | - Laura Rosiñol
- Servicio de Hematologia, Hospital Clinic i Provincial de Barcelona, IDIBAPS; Barcelona Spain
| | - Marisa Martín
- Servicio de Hematología & Instituto de Investigación; Hospital Universitario 12 de Octubre; Madrid Spain
| | - Rosa Ayala
- Servicio de Hematología & Instituto de Investigación; Hospital Universitario 12 de Octubre; Madrid Spain
| | - Rafael Martínez
- Servicio de Hematología; Hospital Clínico Universitario San Carlos; Madrid Spain
| | | | - Adrian Alegre
- Servicio de Hematología; Hospital Universitario La Princesa; Madrid Spain
| | | | - Joan Bargay
- Hospital Son Llatzer; Palma de Mallorca Spain
| | | | - María Eugenia Sarasquete
- Servicio de Hematología; Hospital Clínico Universitario de Salamanca; IBSAL. IBMCC (USAL-CSIC); Salamanca Spain
| | | | - Manuela Fernández
- Servicio de Hematología & Instituto de Investigación; Hospital Universitario 12 de Octubre; Madrid Spain
| | - Joan Blade
- Servicio de Hematologia, Hospital Clinic i Provincial de Barcelona, IDIBAPS; Barcelona Spain
| | - Jesús F. San Miguel
- Servicio de Hematología; Hospital Clínico Universitario de Salamanca; IBSAL. IBMCC (USAL-CSIC); Salamanca Spain
| | - Juan Jose Lahuerta
- Servicio de Hematología & Instituto de Investigación; Hospital Universitario 12 de Octubre; Madrid Spain
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Association of response endpoints with survival outcomes in multiple myeloma. Leukemia 2013; 28:258-68. [PMID: 23868105 PMCID: PMC3918869 DOI: 10.1038/leu.2013.220] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 06/26/2013] [Accepted: 07/01/2013] [Indexed: 12/23/2022]
Abstract
Since the introduction of the proteasome inhibitor bortezomib and the immunomodulatory drugs (IMiDs) thalidomide and lenalidomide, more patients with multiple myeloma are achieving deep, durable responses and disease control, and are living longer. These improvements have afforded more robust analyses of the relationship between response and survival. Generally, these studies have demonstrated that improvements in the quality of response across all stages of treatment are associated with better disease control and longer survival. Thus, achievement of maximal response should be strongly considered, particularly in the frontline setting, but must also be balanced with tolerability, quality of life and patient preferences. In select patients, achievement of a lesser response may be adequate to prolong survival, and attempts to treat these patients to a deeper response may place them at unnecessary risk without significant benefit. Maintenance therapy has been shown to improve the quality of response and disease control and, in some studies, survival. Studies support maintenance therapy for high-risk patients as a standard of care, and there are emerging data supporting maintenance therapy in standard-risk patients to improve progression-free and possibly overall survival. Multidrug regimens combining a proteasome inhibitor and an IMiD have shown exceptional response outcomes with acceptable increases in toxicity in both the frontline and salvage settings, and are becoming a standard treatment approach. Moving forward, the use of immunophenotypic and molecular response criteria will be essential in better understanding the impact of highly active and continuous treatment regimens across myeloma patient populations. Future translational studies will help to develop antimyeloma agents to their fullest potential. The introduction of novel targeted therapies, including the IMiD pomalidomide and the proteasome inhibitors carfilzomib and ixazomib (MLN9708), will provide greater options to individualize treatment and help patients achieve a clinically meaningful response.
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Puig N, Sarasquete ME, Balanzategui A, Martínez J, Paiva B, García H, Fumero S, Jiménez C, Alcoceba M, Chillón MC, Sebastián E, Marín L, Montalbán MA, Mateos MV, Oriol A, Palomera L, de la Rubia J, Vidriales MB, Bladé J, Lahuerta JJ, González M, Miguel JFS, García-Sanz R. Critical evaluation of ASO RQ-PCR for minimal residual disease evaluation in multiple myeloma. A comparative analysis with flow cytometry. Leukemia 2013; 28:391-7. [DOI: 10.1038/leu.2013.217] [Citation(s) in RCA: 129] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 06/14/2013] [Accepted: 07/10/2013] [Indexed: 11/09/2022]
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Takamatsu H, Ogawa Y, Kobayashi N, Obata K, Narisawa T, Nakayama K, Munemoto S, Aoki G, Ohata K, Kumano Y, Ozaki J, Murata R, Kondo Y, Terasaki Y, Kurokawa T, Miyamoto T, Shimizu N, Fukushima T, Yoshida A, Ueda T, Yoshida T, Nakao S. Detection of minimal residual disease in patients with multiple myeloma using clonotype-specific PCR primers designed from DNA extracted from archival bone marrow slides. Exp Hematol 2013; 41:894-902. [PMID: 23727584 DOI: 10.1016/j.exphem.2013.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 05/18/2013] [Accepted: 05/21/2013] [Indexed: 12/20/2022]
Abstract
Polymerase chain reaction (PCR)-negative molecular complete remission (mCR) can be induced by stem cell transplantation in some patients with multiple myeloma (MM) and is associated with long-term progression-free survival (PFS). The detection of molecular minimal residual disease (MRD), however, requires fresh or frozen materials for designing clone-specific primers, which are not always readily available. In this study, we used DNA extracted from archival bone marrow (BM) slides for PCR to detect MRD in 50 patients with MM who received various induction therapies and autologous peripheral blood stem cell transplantation (ASCT). Clonotype-specific immunoglobulin (Ig) H PCR primers were prepared for 32 of 50 cases (64%) using BM slides, and for 9 of 14 cases (64%) using fresh BM cells. DNA in peripheral blood stem cell autografts of the 22 patients who achieved at least a partial response after ASCT was subjected to PCR to amplify clonotype-specific rearranged IgH gene sequences. The median PFS of the eight patients with MRD-positive autografts was 18 months, whereas that of 14 patients with MRD-negative autografts was not reached at a median follow-up of 27 months (p = 0.012). Post-ASCT PFS of the four patients who achieved mCR was 100% at a median follow-up of 47 months. These results indicate that archival BM slides can serve as a source of DNA for preparing clonotype-specific primers for MRD monitoring in patients with MM whose cryopreserved myeloma cells are not available for DNA preparation. Our results also suggest that patients with MM who received MRD-negative autografts and achieved mCR have a long PFS.
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Affiliation(s)
- Hiroyuki Takamatsu
- Cellular Transplantation Biology (Hematology/Respirology), Kanazawa University Graduate School of Medical Sciences, Ishikawa, Japan.
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Dmoszyńska A, Walter-Croneck A, Usnarska-Zubkiewicz L, Stella-Hołowiecka B, Walewski J, Charliński G, Jędrzejczak WW, Wiater E, Lech-Marańda E, Mańko J, Dytfeld D, Komarnicki M, Jamroziak K, Robak T, Jurczyszyn A, Skotnicki A, Giannopoulos K. Zalecenia Polskiej Grupy Szpiczakowej dotyczące rozpoznawania i leczenia szpiczaka plazmocytowego oraz innych dyskrazji plazmocytowych na rok 2013. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.achaem.2013.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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In non-transplant patients with multiple myeloma, the pre-treatment level of clonotypic cells predicts event-free survival. Mol Cancer 2012; 11:78. [PMID: 23083101 PMCID: PMC3522007 DOI: 10.1186/1476-4598-11-78] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 10/17/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In multiple myeloma (MM), the immunoglobulin heavy chain VDJ gene rearrangement is a unique clonotypic signature that identifies all members of the myeloma clone independent of morphology or phenotype. Each clonotypic MM cell has only one genomic copy of the rearranged IgH VDJ. METHODS Pre-treatment bone marrow aspirates from myeloma patients at diagnosis or in relapse were evaluated for the number of clonotypic cells using real time quantitative PCR (RPCR). RPCR measured the level of clonal cells, termed VDJ%, in 139 diagnosis and relapse BM aspirates from MM patients. RESULTS Patients with a VDJ% below the median had a significantly longer event free survival (EFS) then those with a VDJ% higher than the median (p=0.0077, HR=0.57). Further, although the VDJ% from non-transplant patients predicted EFS (p=0.0093), VDJ% failed to predict outcome after autologous stem cell transplant (p=0.53). CONCLUSIONS Our results suggest that for non-transplant patients, the tumor burden before treatment, perhaps reflecting cancer stem cell progeny/output, is an indirect measure that may indicate the number of MM cancer stem cells and hence event free survival.
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Puig N, Sarasquete ME, Alcoceba M, Balanzategui A, Chillón MC, Sebastián E, Marín LA, Díaz MG, San Miguel JF, Sanz RG. The use of CD138 positively selected marrow samples increases the applicability of minimal residual disease assessment by PCR in patients with multiple myeloma. Ann Hematol 2012; 92:97-100. [DOI: 10.1007/s00277-012-1566-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Accepted: 08/24/2012] [Indexed: 11/29/2022]
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Puig N, Sarasquete ME, Alcoceba M, Balanzategui A, Chillón MC, Sebastián E, Díaz MG, San Miguel JF, García-Sanz R. Kappa deleting element as an alternative molecular target for minimal residual disease assessment by real-time quantitative PCR in patients with multiple myeloma. Eur J Haematol 2012; 89:328-35. [PMID: 22805350 DOI: 10.1111/ejh.12000] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2012] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Minimal residual disease (MRD) assessment by PCR in multiple myeloma (MM) has several shortcomings, including the lack of a suitable target. Kappa deleting element (KDE) rearrangements occur in virtually all Ig-lambda B-cell malignancies and in 1/3 of Ig-kappa are not affected by somatic hypermutation and, as in ALL, could be used as PCR targets. METHODS We have first investigated the incidence, gene segment usage, and CDR3 composition of IGK-KDE rearrangements in 96 untreated myeloma patients. Second, we tested 16 KDE gene rearrangements as molecular targets for MRD assessment by RQ-PCR using a germline reverse primer and a germline Taqman probe in combination with allele-specific oligonucleotides (ASO) as forward primers. RESULTS Monoclonal KDE rearrangements were amplified in 45% (43/96) of cases, monoallelic in 2/3 of them (29 cases), and biallellic in the remaining 14 cases. Overall, 88% of cases were successfully sequenced, KDE being equally frequently rearranged with VK and with intron-Recombination signal sequence (RSS). Median numbers of inserted and deleted nucleotides in the junctional region were one and five, respectively. CONCLUSIONS Using KDE rearrangements as additional PCR target for MRD assessment in MM improves the applicability of these studies in 9% of cases overall and in 20% of lambda cases. Its use in the latter subset could represent a significant advance.
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Affiliation(s)
- Noemí Puig
- Department of Hematology, University Hospital of Salamanca, Paseo de San Vicente, Salamanca, Spain
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Blanes M, Lahuerta JJ, González JD, Ribas P, Solano C, Alegre A, Bladé J, San Miguel JF, Sanz MA, de la Rubia J. Intravenous busulfan and melphalan as a conditioning regimen for autologous stem cell transplantation in patients with newly diagnosed multiple myeloma: a matched comparison to a melphalan-only approach. Biol Blood Marrow Transplant 2012; 19:69-74. [PMID: 22897964 DOI: 10.1016/j.bbmt.2012.08.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 08/08/2012] [Indexed: 11/16/2022]
Abstract
Melphalan 200 mg/m(2) (MEL200) is the standard conditioning regimen administered to newly diagnosed patients with multiple myeloma (MM) undergoing autologous stem cell transplantation (ASCT). Few alternatives have been explored in order to improve the antimyeloma activity of this conditioning. We compare i.v. busulfan (BU) 9.6 mg/kg and MEL 140 mg/m(2) (MEL140) versus MEL200 mg/m(2) as a conditioning regimen before ASCT for newly diagnosed patients with MM. For this purpose, 51 patients receiving i.v. BU plus MEL were compared to 102 patients receiving MEL200 mg/m(2) in a 1:2 matched control analysis. Matching criteria included age, clinical stage at diagnosis, and response to induction therapy. No differences in the overall and complete response (CR) rates were observed after ASCT between both groups. After a median follow-up of 63 and 50 months in control and BU plus MEL groups, progression-free survival (PFS) was 24 and 33 months, respectively (P = .10). Most frequent toxicities included mucositis and febrile neutropenia in both groups. No case of sinusoidal obstruction syndrome was observed. Transplant-related mortality was 4% and 2% in BU plus MEL and control groups, respectively. ASCT conditioned with i.v. BU plus MEL may be considered an effective and well-tolerated alternative to a MEL-only approach as a conditioning regimen for patients with MM who are candidates for ASCT.
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Hart AJ, Jagasia MH, Kim AS, Mosse CA, Savani BN, Kassim A. Minimal residual disease in myeloma: are we there yet? Biol Blood Marrow Transplant 2012; 18:1790-9. [PMID: 22626785 DOI: 10.1016/j.bbmt.2012.05.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 05/03/2012] [Indexed: 12/20/2022]
Abstract
Measurement of minimal residual disease is routine in diseases such as chronic myelogenous leukemia, precursor B cell acute lymphoblastic leukemia, and acute promyelocytic leukemia because it provides important prognostic information. However, the role of minimal residual disease testing has not been widely adopted in multiple myeloma (MM), with other parameters such as the International Staging System (ISS) and cytogenetic analysis primarily guiding therapy and determination of prognosis. Until recently, achieving a complete response (CR), as defined by the International Myeloma Working Group (IMWG) criteria, was rare in patients with MM. The use of novel agents with or without autologous peripheral blood stem cell transplantation (auto-PBSCT) has significantly increased CR rates, thus increasing overall survival (OS) rates. The majority of patients with MM have persistent levels of residual disease that are below the sensitivity of bone marrow (BM) morphology, protein electrophoresis with immunofixation, and light chain quantitation even after attaining CR and will eventually relapse. Measurement of minimal residual disease by more sensitive methods, and the use of these methods as a tool for predicting patient outcomes and guiding therapeutic decisions, has thus become more relevant. Methods available for monitoring minimal residual disease in MM include PCR and multiparameter flow cytometry (MFC), both of which have been shown to be valuable in other hematologic malignancies; however, neither has become a standard of care in MM. Here, we review current evidence for using minimal residual disease measurement for risk assessment in MM as well as incorporating pretreatment factors and posttreatment minimal residual disease monitoring as a prognostic tool for therapeutic decisions, and we outline challenges to developing uniform criteria for minimal residual disease monitoring.
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Affiliation(s)
- Andrew J Hart
- Department of Medicine, Division of Hematology/Oncology, Section of Hematology and Stem Cell Transplant, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Paiva B, Martinez-Lopez J, Vidriales MB, Mateos MV, Montalban MA, Fernandez-Redondo E, Alonso L, Oriol A, Teruel AI, de Paz R, Laraña JG, Bengoechea E, Martin A, Mediavilla JD, Palomera L, de Arriba F, Bladé J, Orfao A, Lahuerta JJ, San Miguel JF. Comparison of Immunofixation, Serum Free Light Chain, and Immunophenotyping for Response Evaluation and Prognostication in Multiple Myeloma. J Clin Oncol 2011; 29:1627-33. [DOI: 10.1200/jco.2010.33.1967] [Citation(s) in RCA: 177] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
To investigate the impact of immunophenotypic response (IR) versus complete response (CR) and CR plus normal serum free light chain (sFLC) ratio (stringent CR) in elderly patients with multiple myeloma (MM) treated with novel agents. Patients and Methods From a total of 260 elderly patients newly diagnosed with MM included in the GEM05>65y trial, 102 patients achieving at least a partial response with ≥ 70% reduction in M-component after the six planned induction cycles were simultaneously analyzed by immunofixation, sFLC, and multiparameter flow cytometry (MFC) immunophenotyping; this population is the focus of this study. Results Forty-three percent of patients achieved CR, 30% achieved stringent CR, and 30% achieved IR. Patients in stringent CR showed no significant survival advantage compared with those in CR, whereas patients in IR showed significantly increased progression-free survival (PFS) and time to progression (TTP) compared with those in stringent CR or CR; this was confirmed by multivariate analysis (hazard ratio, 4.1; P = .01 for PFS). Discrepancies between the three techniques were relatively common. Notably, in all seven patients achieving IR but remaining immunofixation positive, the M-component disappeared in follow-up analysis. In contrast, MFC-positive patients who were immunofixation negative (n = 20) showed a tendency toward early reappearance of the M-component (median, 3 months). Similarly, in five of 11 stringent CR but MFC-positive patients, symptomatic disease progression was recorded at a median of 13 months after induction. Conclusion Achieving an IR translates into superior PFS and TTP compared with conventional CR or stringent CR. These techniques provide complementary information and thus, an effort should be made to refine response criteria in MM.
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Affiliation(s)
- Bruno Paiva
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Joaquin Martinez-Lopez
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Maria-Belen Vidriales
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Maria-Victoria Mateos
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Maria-Angeles Montalban
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Elena Fernandez-Redondo
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Lourdes Alonso
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Albert Oriol
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Ana-Isabel Teruel
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Raquel de Paz
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - José-Garcia Laraña
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Enrique Bengoechea
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Alejandro Martin
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Joaquin Diaz Mediavilla
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Luis Palomera
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Felipe de Arriba
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Joan Bladé
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Alberto Orfao
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Juan-Jose Lahuerta
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
| | - Jesus F. San Miguel
- From the Hospital Universitario de Salamanca; Servicio General de Citometría, Universidad de Salamanca; Centro de Investigación del Cáncer, Salamanca; Hospital 12 de Octubre; Hospital Universitario La Paz; Hospital Ramon y Cajal; Hospital Clinico San Carlos, Madrid; Hospital Universitari Germans Trias i Pujol, Badalona; Hospital Clinico de Valencia, Valencia; Hospital de Donostia, San Sebastian Hospital Virgen de la Concha, Zamora; Hospital Lozano Blesa, Zaragoza; Hospital Morales Meseguer, Murcia; and
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Long-term prognostic significance of response in multiple myeloma after stem cell transplantation. Blood 2011; 118:529-34. [PMID: 21482708 DOI: 10.1182/blood-2011-01-332320] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
For establishing the true effect of different response categories in patients with multiple myeloma (MM) treated with autologous stem cell transplantation, we evaluated, after a median follow-up of 153 months, 344 patients with MM who received a transplant between 1989 and 1998. Overall survival (OS) at 12 years was 35% in complete response (CR) patients, 22% in near complete response (nCR), 16% in very good partial response (VGPR), and 16% in partial response (PR) groups. Significant differences in OS and progression-free survival were found between CR and nCR groups (P = .01 and P = .002, respectively), between CR and VGPR groups (P = .0001 and P = .003), or between CR and PR groups (P = .003 and P = < 10(-5)); no differences were observed between the nCR and VGPR groups (P = .2 and P = .9) or between these groups and the PR group (P = .1 and P = .8). A landmark study found a plateau phase in OS after 11 years; 35% patients in the CR group and 11% in the nCR+VGPR+PR group are alive at 17 years; 2 cases had relapsed in the nCR+VGPR+PR group. In conclusion, MM achieving CR after autologous stem cell transplantation is a central prognostic factor. The relapse rate is low in patients with > 11 years of follow-up, possibly signifying a cure for patients in CR.
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Lahuerta JJ, Mateos MV, Martínez-López J, Grande C, de la Rubia J, Rosiñol L, Sureda A, García-Laraña J, Díaz-Mediavilla J, Hernández-García MT, Carrera D, Besalduch J, de Arriba F, Oriol A, Escoda L, García-Frade J, Rivas-González C, Alegre A, Bladé J, San Miguel JF. Busulfan 12 mg/kg plus melphalan 140 mg/m2 versus melphalan 200 mg/m2 as conditioning regimens for autologous transplantation in newly diagnosed multiple myeloma patients included in the PETHEMA/GEM2000 study. Haematologica 2010; 95:1913-20. [PMID: 20663944 DOI: 10.3324/haematol.2010.028027] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The aim of this study was to compare the long-term safety and efficacy of oral busulfan 12 mg/kg plus melphalan 140 mg/m(2) and melphalan 200 mg/m(2) as conditioning regimens for autologous stem cell transplantation in newly diagnosed patients with multiple myeloma in the GEM2000 study. DESIGN AND METHODS The first 225 patients received oral busulfan 12 mg/kg plus melphalan 140 mg/m(2); because of a high frequency of veno-occlusive disease, the protocol was amended and a further 542 patients received melphalan 200 mg/m(2). RESULTS Engraftment and hospitalization times were similar in both groups. Oral busulfan 12 mg/kg plus melphalan 140 mg/m(2) resulted in higher transplant-related mortality (8.4% versus 3.5%; P=0.002) due to the increased frequency of veno-occlusive disease in this group. Response rates were similar in both arms. With respective median follow-ups of 72 and 47 months, the median progression-free survival was significantly longer with busulfan plus melphalan (41 versus 31 months; P=0.009), although survival was similar to that in the melphalan 200 mg/m(2) group. However, access to novel agents as salvage therapy after relapse/progression was significantly lower for patients receiving busulfan plus melphalan (43%) than for those receiving melphalan 200 mg/m(2) (58%; P=0.01). CONCLUSIONS Conditioning with oral busulfan 12 mg/kg plus melphalan 140 mg/m(2) was associated with longer progression-free survival but equivalent survival to that achieved with melphalan 200 mg/m(2) but this should be counterbalanced against the higher frequency of veno-occlusive disease-related deaths. This latter fact together with the limited access to novel salvage therapies in patients conditioned with oral busulfan 12 mg/kg plus melphalan 140 mg/m(2) may explain the absence of a survival difference. Oral busulfan was used in the present study; use of the intravenous formulation may reduce toxicity and result in greater efficacy, and warrants further investigation in myeloma patients. (Clinicaltrials.gov identifier: NCT00560053).
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Kröger N, Bacher U, Bader P, Böttcher S, Borowitz MJ, Dreger P, Khouri I, Olavarria E, Radich J, Stock W, Vose JM, Weisdorf D, Willasch A, Giralt S, Bishop MR, Wayne AS. NCI first international workshop on the biology, prevention, and treatment of relapse after allogeneic hematopoietic stem cell transplantation: report from the committee on disease-specific methods and strategies for monitoring relapse following allogeneic stem cell transplantation. part II: chronic leukemias, myeloproliferative neoplasms, and lymphoid malignancies. Biol Blood Marrow Transplant 2010; 16:1325-46. [PMID: 20637879 DOI: 10.1016/j.bbmt.2010.07.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2010] [Accepted: 07/06/2010] [Indexed: 12/31/2022]
Abstract
Relapse has become the major cause of treatment failure after allogeneic hematopoietic stem cell transplantation. Outcome of patients with clinical relapse after transplantation generally remains poor, but intervention prior to florid relapse improves outcome for certain hematologic malignancies. To detect early relapse or minimal residual disease, sensitive methods such as molecular genetics, tumor-specific molecular primers, fluorescence in situ hybridization (FISH), and multiparameter flow cytometry (MFC) are commonly used after allogeneic stem cell transplantation to monitor patients, but not all of them are included in the commonly employed disease-specific response criteria. The highest sensitivity and specificity can be achieved by molecular monitoring of tumor- or patient-specific markers measured by polymerase chain reaction-based techniques, but not all diseases have such targets for monitoring. Similar high sensitivity can be achieved by determination of recipient-donor chimerism, but its specificity regarding detection of relapse is low and differs substantially among diseases. Here, we summarize the current knowledge about the utilization of such sensitive monitoring techniques in chronic leukemias, myeloproliferative neoplasms, and lymphoid malignancies based on tumor-specific markers and cell chimerism and how these methods might augment the standard definitions of posttransplant remission, persistence, progression, relapse, and the prediction of relapse. Critically important is the need for standardization of the different residual disease techniques and to assess the clinical relevance of minimal residual disease and chimerism surveillance in individual diseases, which in turn must be followed by studies to assess the potential impact of specific interventional strategies.
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Affiliation(s)
- Nicolaus Kröger
- Department for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Germany.
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Superior outcomes associated with complete response in newly diagnosed multiple myeloma patients treated with nonintensive therapy: analysis of the phase 3 VISTA study of bortezomib plus melphalan-prednisone versus melphalan-prednisone. Blood 2010; 116:3743-50. [PMID: 20628153 DOI: 10.1182/blood-2010-03-275800] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The phase 3 Velcade as Initial Standard Therapy in Multiple Myeloma: Assessment with Melphalan and Prednisone study in newly diagnosed multiple myeloma patients ineligible for high-dose therapy demonstrated that bortezomib-melphalan-prednisone (VMP) was superior to melphalan-prednisone across all efficacy end points. We assessed the prognostic impact of response on time-to-event parameters in the intent-to-treat population. Patients received nine 6-week cycles of treatment. Time to progression, time to next therapy, and treatment-free interval were associated with quality of response. When European Group for Blood and Marrow Transplantation criteria were used, complete response (CR) was associated with significantly longer time to progression (hazard ratio [HR] = 0.45, P = .004), time to next therapy (HR = 0.46, P = .0004), and treatment-free interval (HR = 0.38, P < .0001) versus partial response, but there was no significant difference in overall survival (HR = 0.87, P = .54); similar differences were seen with CR versus very good partial response by uniform criteria. Quality of response improved with prolonged VMP treatment, with 28% of CRs achieved during cycles 5-9. CR duration appeared similar among patients with "early" (cycles 1-4) and "late" CRs (cycles 5-9) and among patients receiving 9 versus < 9 cycles of bortezomib within VMP. These results highlight that CR is an important treatment goal and support prolonged VMP therapy to achieve maximal response. This study is registered at http://www.clinicaltrials.gov as NCT00111319.
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Chanan-Khan AA, Giralt S. Importance of achieving a complete response in multiple myeloma, and the impact of novel agents. J Clin Oncol 2010; 28:2612-24. [PMID: 20385994 DOI: 10.1200/jco.2009.25.4250] [Citation(s) in RCA: 164] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The goal of treatment for multiple myeloma (MM) is to improve patients' long-term outcomes. One important factor that has been associated with prolonged progression-free and overall survival is the quality of response to treatment, particularly achievement of a complete response (CR). There is extensive evidence from clinical studies in the transplant setting in first-line MM demonstrating that CR or maximal response post-transplant is significantly associated with prolonged progression-free and overall survival, with some studies demonstrating a similar association with postinduction response. Supportive evidence is also available from studies in the nontransplant and relapsed settings. With the introduction of bortezomib, thalidomide, and lenalidomide, higher rates of CR are being achieved in both first-line and relapsed MM compared with previous chemotherapeutic approaches, thereby potentially improving long-term outcomes. While standard CR by established response criteria has been shown to have differential prognostic impact compared with lesser responses, increasingly sensitive analytic techniques are now being explored to define more stringent degrees of CR or elimination of minimal residual disease (MRD), including multiparameter flow cytometry and polymerase chain reaction. Demonstrating eradication of MRD by these techniques has already been shown to predict for improved outcomes. Here, we review the prognostic significance of achieving CR in MM and highlight the importance of CR as an increasingly realizable goal at all stages of treatment. We discuss clinical management issues and provide recommendations relevant to practicing oncologists, such as the routine use of sensitive techniques for assessment of disease status to inform evidence-based decisions on optimal patient management.
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Affiliation(s)
- Asher A Chanan-Khan
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY 14263, USA.
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Kröger N, Badbaran A, Lioznov M, Schwarz S, Zeschke S, Hildebrand Y, Ayuk F, Atanackovic D, Schilling G, Zabelina T, Bacher U, Klyuchnikov E, Shimoni A, Nagler A, Corradini P, Fehse B, Zander A. Post-transplant immunotherapy with donor-lymphocyte infusion and novel agents to upgrade partial into complete and molecular remission in allografted patients with multiple myeloma. Exp Hematol 2009; 37:791-8. [PMID: 19487069 DOI: 10.1016/j.exphem.2009.03.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2009] [Revised: 03/24/2009] [Accepted: 03/26/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To investigate post-transplant immunotherapy with escalating donor-lymphocyte infusions (DLI) and novel agents (thalidomide, bortezomib, and lenalidomide) to target complete remission (CR). MATERIALS AND METHODS Thirty-two patients with multiple myeloma who achieved only partial remission after allogeneic stem cell transplantation were treated with DLI. If no CR was achieved, one of the novel agents was added to target CR. RESULTS CR defined either by European Group for Blood and Marrow Transplantation criteria, flow cytometry, or molecular methods as assessed by patient-specific immunoglobulin H-polymerase chain reaction or plasma cell chimerism polymerase chain reaction was accomplished in 59%, 63%, and 50% of patients, respectively. Achievement of CR resulted in improved 5-year progressive-free and overall survival, according to European Group for Blood and Marrow Transplantation criteria (53% vs 35%; p=0.03 and 90% vs 62%; p=0.06), flow cytometry (74% vs 15%; p=0.001 and 100% vs 52%; p=0.1), or molecular methods (84% vs 38%; p=0.001 and 100% vs 71%; p=0.03). CONCLUSIONS Our finding demonstrates the clinical relevance of posttransplantation therapies to upgrade remission, and of remission's depth for long-term survival in myeloma patients.
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Affiliation(s)
- Nicolaus Kröger
- Department for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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