Survival in conventionally treated younger (<60 years) multiple myeloma patients: no improvement during two decades. Nordic Myeloma Study Group (NMSG)

Targeting tumour-initiating cells with TRAIL based combination therapy ensures complete and lasting eradication of multiple myeloma tumours in vivo

Multiple myeloma (MM) remains an incurable disease despite improvements to available treatments and efforts to identify new drug targets. Consequently new approaches are urgently required. We have investigated the potential of native tumour necrosis factor-related apoptosis-inducing ligand (TRAIL), in combination with doxorubicin, to induce apoptotic cell death in phenotypically distinct populations of myeloma cells in vitro and in vivo. The cytotoxic potential of TRAIL alone, and in combination with DOX, was assessed in vitro in purified CD138(+) and CD138(-) cells from the MM cell lines and samples from patients with MM. Mouse xenografts obtained by implanting CD138(-) MM cells were used to assess the efficacy of TRAIL, alone and in combination with DOX, in vivo. CD138(-) cells were shown to be more resistant to the cytotoxic activity of TRAIL than CD138(+) cells and have reduced expression of TRAIL death receptors. This resistance results in preferential killing of CD 138(+) cells during exposure of MM culture to TRAIL. Furthermore, prolonged exposure results in the appearance of TRAIL-resistant CD138(-) cells. However, when TRAIL is combined with doxorubicin, this results in complete eradication of MM cells in vivo. Most importantly, this treatment successfully eliminates CD138(-) cells implicated in tumour initiation and growth maintenance. These findings may explain the failure of current therapies and offer a promising new approach in the quest to cure MM and disseminated cancers.

Impact of age on survival after intensive therapy for multiple myeloma: a population-based study by the Nordic Myeloma Study Group

The value of intensive therapy, including autologous stem cell transplantation, in newly diagnosed myeloma patients >60 years is not clear. We evaluated the impact of age (<60 years vs. 60-64 years) on survival in a prospective, population-based setting and compared survival with conventionally treated historic controls. The prospective population comprised 452 patients registered between 1998 and 2000. Of these, 414 received intensive therapy. The historic population, derived from our most recent population-based study on conventional therapy, comprised 281 patients. Of these, 243 fulfilled our eligibility criteria for intensive therapy. For patients undergoing intensive therapy it was found that two factors, beta-2-microglobulin and age <60 years vs. 60-64 years, had independent prognostic impact on survival. However, compared with the historic controls a survival advantage was found both for patients <60 (median 66 months vs. 43 months, P < 0.001) and 60-64 years (median 50 months vs. 27 months; P = 0.001). We conclude that in a population-based setting higher age adversely influences outcome after intensive therapy. Our results indicate that intensive therapy prolongs survival also at age 60-64 years but with less superiority than in younger patients.

Identification and characterization of HLA-class-I-restricted T-cell epitopes in the putative tumor-associated antigens P21-activated serin kinase 2 (PAK2) and cyclin-dependent kinase inhibitor 1A (CDKN1A)

Multiple myeloma (MM) is one of the most common hematological malignancies. Despite a variety of therapeutical approaches including high-dose cytostatic treatment with subsequent autologous or allogeneic stem cell transplantation, as well as vaccination, cures remain rare exceptions. An important issue for future immunological treatments is the identification and characterization of appropriate tumor-associated antigens. However, the number of tumor-associated antigens in MM is limited. PBK/TOPK and activated serin kinase 2 (PAK2) are novel serin kinases that have recently been identified. PBK/TOPK is overexpressed in Burkitt lymphoma, acute lymphoblastic leukemia, and MM; PAK2 is expressed in malignant lymphatic cells. The cyclin kinase inhibitor 1A (CDKN1A) is overexpressed in MM compared to normal plasma cells. We hereby identified and characterized for the first time HLA-class-I-restricted immunogenic peptides in the amino acid sequences of PAK2 and CDKN1A. Using two independent prediction algorithms, we identified two peptides in PAK2 and three peptides in CDK1NA with high binding to HLA-A2. Using an IFN-gamma ELISPOT assay, we could demonstrate the presence and functional activity of CD8-peptide-specific T cells with all tested peptides. To show HLA-A2-restricted antigen recognition, the specific inhibition of T cell recognition was demonstrated with an anti-HLA-A2-blocking antibody. By analysis of peripheral blood of 34 healthy donors for the presence and functional activity of CD8 T cells specific for these peptides, we could demonstrate that peptide T-cell precursors specifically recognizing at least one of the tested peptides are present in 50-60% of the tested donors and that these T-cell precursors can be expanded in vitro. We conclude that PAK2- and CDKN1A-derived peptides can elicit a strong and consistent CD8 T-cell response in an in vitro model. Further investigations will examine the presence and functionality of such T cells in the tumor-bearing host.

Prognostic factors in solitary plasmacytoma of the bone: a multicenter Rare Cancer Network study

BACKGROUND

Solitary plasmacytoma (SP) of the bone is a rare plasma-cell neoplasm. There are no conclusive data in the literature on the optimal radiation therapy (RT) dose in SP. Therefore, in this large retrospective study, we wanted to assess the outcome, prognostic factors, and the optimal RT dose in patients with SP.

METHODS

Data from 206 patients with bone SP without evidence of multiple myeloma (MM) were collected. Histopathological diagnosis was obtained for all patients. The majority (n = 169) of the patients received RT alone; 32 chemotherapy and RT, and 5 surgery. Median follow-up was 54 months (7-245).

RESULTS

Five-year overall survival, disease-free survival (DFS), and local control was 70%, 46%, and 88%; respectively. Median time to MM development was 21 months (2-135) with a 5-year probability of 51%. In multivariate analyses, favorable factors were younger age and tumor size < 5 cm for survival; younger age for DFS; anatomic localization (vertebra vs. other) for local control. Older age was the only predictor for MM. There was no dose-response relationship for doses 30 Gy or higher, even for larger tumors.

CONCLUSION

Younger patients, especially those with vertebral localization have the best outcome when treated with moderate-dose RT. Progression to MM remains the main problem. Further investigation should focus on adjuvant chemotherapy and/or novel therapeutic agents.

High-dose chemotherapy with autologous hematopoietic stem cell transplantation in patients with multiple myeloma

Multiple myeloma, for all practical purposes, remains an incurable malignancy; however, 5-year survival has improved substantially during the past 30 years. A major contribution to improved outcome is the use of high-dose chemotherapy and stem cell transplantation. This multifaceted approach to therapy requires an understanding of appropriate induction therapy, techniques for stem cell mobilization, appropriate conditioning and supportive care. Also of importance are prognosis, features that predict outcome, the suitability of transplant candidates, and post-transplantation maintenance therapy.

Do new therapeutic approaches (autotransplants, thalidomide, dexamethasone) improve the survival of patients with multiple myeloma followed in a rheumatology department?

Survival of patients with multiple myeloma (MM) showed no improvement between the 1960s and 1990s. During the last decade, new therapeutic approaches seemed likely to offer hope of prolonging survival. The aim of this study was to examine if this survival increased with the usage of new treatments. The method involves a retrospective study of 123 patients with MM, diagnosed between 1975 and 1999, all receiving treatment. They were divided into two groups: group 1 included 55 patients given the so-called "old treatments" [melphalan-prednisone, cyclophosphamide-prednisone, polychemotherapy (vincristine, melphalan, cyclophosphamide, prednisone (VMCP), VMCP-VBAP)], and group 2 included 68 patients receiving at least one of the so-called "new treatments" (dexamethasone, thalidomide, high-dose chemotherapy followed by autotransplants, bisphosphonates, interferon). The two groups were similar in terms of age, sex ratio and renal impairment, and the percentage of light-chain MM was identical in both groups. Patients who had been given a "new" treatment (group 2) had longer median survival than the patients in group 1 (54 vs 42 months). Independent analysis of each treatment modality showed increased median survival in MM patients treated using autotransplantation compared with untreated patients (125 vs 45 months). Survival was also longer in MM patients treated with thalidomide than in untreated patients (72 vs 42 months). On the other hand, neither bisphosphonates, interferon-alpha nor dexamethasone result in improved survival. Our findings emphasize the increased survival of the MM patients treated with new therapeutic approaches.

Quality assessment of autografting by probability evaluation: model estimation by clinical end-points in newly diagnosed multiple myeloma patients

BACKGROUND

Pre-transplant clinical evaluation of autografting is an important step in predicting post-transplant support, complications and safety. Today, unfavorable outcomes such as early death or graft failure are rare, making them unsuitable for quality assessment of supportive autografting. However, end-points constructed from frequently occurring clinical events may estimate clinically relevant prognostic models.

METHODS

The present retrospective analysis was based on two consecutive clinical trials in the Nordic area including up to 640 newly diagnosed multiple myeloma patients.

RESULTS

In the model, the efficacy (time on antibiotics and use of transfusions) was influenced by pre-transplant variables, including sex, nationality, serum creatinine, hemoglobin, disease stage at diagnosis, response following induction therapy, length of priming and average graft CD34+ cell number per day of harvest. The toxicity end-point (time to blood cell recovery) was influenced by nationality, marrow plasma cell percentage, serum creatinine, M-component isotype, response to induction therapy, length of priming and graft CD34+ cell number. The safety (early disease recurrence or death) was influenced by serum creatinine, hemoglobin, treatment response and CD34+ cell number.

DISCUSSION

In conclusion, the model illustrates that intervention strategies in quality assessment of autografting may benefit from probability estimates of graded clinical end-points.

Multiple myeloma in elderly patients: prognostic factors and outcome

OBJECTIVES

Purpose of this study was to compare prognostic factors and outcome of patients with multiple myeloma (MM) aged >70 yr at diagnosis with those of younger patients. We also applied the recently proposed International Staging System (ISS) for MM in these patients.

PATIENTS AND METHODS

Among 1,162 newly diagnosed, symptomatic MM patients included in our database, 357 (31%) were >70 yr of age. Clinical and laboratory variables were evaluated in patients >70 yr and in younger patients and were assessed for possible correlation with survival in patients >70 yr of age.

RESULTS

Most clinical and laboratory features were similar in the two groups of patients but older patients presented more frequently with advanced ISS (P = 0.02). Despite similar response rates to primary treatment, younger patients survived longer than patients >70 yr of age (40 vs. 28 months, P = 0.001). There was a longer survival of younger patients than that of older patients diagnosed with ISS stage 1 (median 71 vs. 54 months, P = 0.007) and ISS stage-2 patients (median: 38 vs. 26 months, P = 0.0008) but for patients with ISS stage 3 median survival was similarly poor in the younger and older age group (21 and 20 months, P = 0.283). Other variables associated with impaired prognosis were severe anemia, extensive bone marrow plasmacytosis and elevated serum LDH.

CONCLUSIONS

Older patients with MM present more often with advanced ISS and have significantly shorter survival than younger patients. The ISS retained its prognostic significance within the group of elderly patients.

Prospective randomised trial of amifostine cytoprotection in myeloma patients undergoing high-dose melphalan conditioned autologous stem cell transplantation

In this prospective multicentre trial, 90 patients undergoing autologous stem cell transplantation (ASCT) were randomised to receive (n=43) or not receive (n=47) amifostine 910 mg/m(2) prior to melphalan 200 mg/m(2). Patients were monitored for regimen-related toxicity, engraftment, supportive care, response and survival. Both groups underwent ASCT at a median of 8 months from diagnosis and were matched for disease characteristics, prior therapy and pre-ASCT disease responsiveness. Amifostine infusional side-effects were frequent, occurring in 65% of patients, but of mild severity. Amifostine use was associated with a reduction in the median grade of oral mucositis (1 vs 2, P=0.01) and the frequency of severe (WHO grades 3 or 4) mucositis (12 vs 33%, P=0.02), but no reduction in the requirement for parenteral nutrition or analgesic use. Conversion to complete remission post-ASCT occurred in 30 and 14% of the amifostine and control groups, respectively (P=0.09). With a median follow-up of 35 months, there was no statistically significant difference between the median progression-free or overall survival times for the two groups. We conclude that amifostine can be safely administered prior to high-dose melphalan and significantly reduces the frequency and severity of therapy-induced oral mucositis.

Enrichment of functional CD8 memory T cells specific for MUC1 in bone marrow of patients with multiple myeloma

Multiple myeloma (MM) is one of the most common hematologic malignancies. Despite extensive therapeutical approaches, cures remain rare exceptions. An important issue for future immunologic treatments is the characterization of appropriate tumor-associated antigens. Recently, a highly glycosylated mucin MUC1 was detected on a majority of multiple myeloma cell lines. We analyzed bone marrow and peripheral blood of 68 patients with HLA-A2-positive myeloma for the presence and functional activity of CD8 T cells specific for the MUC1-derived peptide LLLLTVLTV. Forty-four percent of the patients with MM contained elevated frequencies of MUC1-specific CD8 T cells in freshly isolated samples from peripheral blood (PB) or bone marrow (BM) compared with corresponding samples from healthy donors. BM-residing T cells possessed a higher functional capacity upon specific reactivation than PB-derived T cells with regard to interferon gamma (IFN-gamma) secretion, perforin production, and cytotoxicity.

Recent Developments and Future Directions in the Treatment of Multiple Myeloma

Multiple Myeloma (MM) is a B cell neoplasia affecting approximately 14,400 new individuals in the United States each year. Although MM remains an incurable disease, encouraging advances have been made in its therapy in the recent past. High dose chemotherapy with autologous stem cell transplantation has been shown in randomized controlled trials to improve survival in MM and is currently considered the first line treatment for all patients except those with advanced age of co-morbidities. For such patients, conventional chemotherapy with melphalan and steroids continue to be the treatment of choice. The use of tandem stem cell transplants and the use of both myeloablative and nonmyeloablative allogeneic stem cell transplantation remains investigational. Thalidomide is a new therapeutic option with promising results; however, it is associated with significant side effects including deep venous thrombosis and peripheral neuropathy. Its use in combination with other chemotherapy agents is still under investigation. Novel promising agents are currently under clinical trials including Proteosome Inhibitors and much more potent thalidomide analogs or immunomodulators. This review summarizes recent developments in the therapy and supportive care of MM and introduces the newer drugs in preclinical and early clinical trials.

Henoch-Schönlein IgA glomerulonephritis complicating myeloma kidneys: case report

Myeloma kidney is the principal pathological substrate of rapidly progressive renal failure in multiple myeloma. We report the unusual case of a 72-year-old male diagnosed with kappa Bence Jones myeloma with renal failure which needed dialysis. After treatment with vincristine, doxorubicin (Adriamycin), dexamethasone (VAD), and plasmapheresis, the renal function was recovered until serum creatinine level was <2 mg/dl. Six months later, the pathological counterpart of rapidly progressive renal failure was crescentic IgA proliferative glomerulonephritis as a manifestation of Henoch-Schönlein syndrome associated with sepsis caused by coagulase-negative staphylococci. This case suggests that mesangial IgA deposition should be considered within the spectrum of consequent glomerular lesion-associated chemotherapy occurring in multiple myeloma.

Individual quality assessment of autografting by probability evaluation: a model estimated by analysis of graft-related end points in 204 patients with malignancies

Haematological toxicity is considered a secondary end point important for graft evaluation - in today's practice graft evaluation focuses on the primary impact of health economic end points. This report illustrates the benefit of combining CD34 enumeration and demographic as well as disease-related variables in models for individual quality assessment of autografting following high-dose therapy. A total of 24 centres in Scandinavia enrolled 204 patients younger than 67 years who received high-dose therapy with autologous peripheral blood stem cell transplantation. Using the binary Logistic Regression Analysis, the prognostic value of diagnostic demographic variables, therapy and graft-related factors was entered into a multivariate analysis and the final significant models were used to estimate probabilities for acceptable or unacceptable outcome among different patient scenarios. The model that estimated post-transplant efficacy by selected primary end points (time on antibiotics and use of transfusions) includes six independent variables related to sex, age, disease, conditioning, growth factor administration, and graft CD34+ cell number. The model that estimated transplantation-related toxicity by selected secondary end points (time to blood cell recovery) included four independent variables related to age, disease, growth factor administration and graft CD34+ cell number.

Health-related quality of life in multiple myeloma patients receiving high-dose chemotherapy with autologous blood stem-cell support

In a population-based study, the Nordic Myeloma Study Group found a survival advantage for high-dose melphalan with autologous blood stem-cell support compared to conventional chemotherapy in myeloma patients under 60 yr of age (risk ratio: 1.62; confidence interval [CI] 1.22-2.15; p = 0.001). A study of health-related quality of life (HRQoL) was integrated in the trial, using the EORTC QLQ-C30 questionnaire. Of the 274 patients receiving intensive therapy 221 (81%) were compared to 113 (94%) of 120 patients receiving conventional melphalan-prednisone treatment. Prior to treatment, there were no statistically significant differences in any HRQoL score between the two groups. One month after the start of induction chemotherapy, the patients on intensive treatment had more sleep disturbance than the control patients. At 6 mo, corresponding to a mean of 52 d after high-dose melphalan, the patients on intensive treatment had moderately lower scores for global QoL and role and social functioning and there was also a significantly higher score for appetite loss. At 12 and 24 mo, the HRQoL was similar to that of the control patients. At 36 mo, there was a trend toward less fatigue, pain, nausea, and appetite loss in the intensive-treatment group. Thus, the 18 mo of prolonged survival seem to be associated with a good health-related quality of life. Despite the moderate HRQoL reduction associated with the early intensive chemotherapy phase, this treatment modality must be regarded as an important step forward in the care of multiple myeloma.

TRAIL-induced eradication of primary tumour cells from multiple myeloma patient bone marrows is not related to TRAIL receptor expression or prior chemotherapy

TNF-related apoptosis-inducing ligand (TRAIL) shares significant homology with CD95 (Fas) ligand and has the ability to induce apoptosis in sensitive cells through a caspase-mediated pathway. We have evaluated the activity of purified human recombinant soluble TRAIL (S-TRAIL, comprising residues 114-281; Biomol, Plymouth Meeting, PA, USA) and a leucine zipper construct of TRAIL (LZ-TRAIL; Immunex, Seattle WA, USA) against myeloma cell lines NCI H929, U266, RPMI 8226, the FasL-sensitive Jurkat T cell ALL line, the lymphoblastoid cell line MC/CAR and primary tumour cells from 16 myeloma patients. Furthermore, we examined the relationship between TRAIL-induced apoptosis and TRAIL receptor expression utilising RT-PCR and flow cytometry. Two of three myeloma cell lines and Jurkat were TRAIL sensitive whereas MC/CAR was relatively resistant. Five of 16 (31%) primary tumours demonstrated > or =20% reduction in myeloma cells following TRAIL incubation (20-59%). This did not correlate with prior therapy. Four cell lines (two sensitive) and five primary tumours (two sensitive) demonstrated mRNA expression of the intra-cellular death domain containing TRAIL-R1. Variable expression of the two decoy (TRAIL-R3 and R4) and soluble (osteoprotegerin) receptors was seen and this did not correlate with TRAIL resistance. We conclude that myeloma cell expression of death effector receptors for TRAIL is insufficient to confer sensitivity to TRAIL-induced apoptosis but that in a significant minority of patients, irrespective of prior therapy, tumour cells are sensitive to TRAIL. The further investigation of TRAIL as an adjunct to presently available therapies for myeloma is justified.

Cost-utility analysis of high-dose melphalan with autologous blood stem cell support vs. melphalan plus prednisone in patients younger than 60 years with multiple myeloma

We evaluated the costs and the cost utility of high-dose melphalan and autologous stem cell support followed by interferon maintenance relative to conventional treatment with melphalan and prednisone, in patients less than 60 yr of age with multiple myeloma. From March 1994 to July 1997, 274 patients with newly diagnosed, symptomatic multiple myeloma were enrolled in a prospective, non-randomized, population-based, multicenter study to evaluate the treatment with high-dose melphalan and autologous blood stem cell support. Health-related quality-of-life was measured prior to treatment and during follow-up, using the EORTC QLQ-C30 questionnaire. Resource consumption was also recorded prospectively. The intensive treatment yielded a significant increase in median survival time from 44 to 62 months compared to conventionally treated patients. The corresponding gain in quality-adjusted life years (QALY) was found to be 1.2. Cost per QALY gained by the treatment with high-dose melphalan and autologous blood stem cell support was estimated at NOK 249,000 (USD 27,000).

High-dose therapy autotransplantation/intensification vs continued standard chemotherapy in multiple myeloma in first remission. Results of a non-randomized study from a single institution

The purpose of this study was to analyze the outcome of patients with multiple myeloma (MM) responding to initial chemotherapy who received intensification with high-dose therapy/autotransplantation (HDT) as compared to that of those who were continued on standard chemotherapy. From 1 January 1990 to 30 June 1998, 64 patients with MM who were younger than 65 years achieved a response to initial chemotherapy. Due to referral reasons, patients preference or inclusion in trials, 31 patients received HDT as early intensification while 33 were continued on standard chemotherapy. The presenting features were similar in both groups, except for the median age, which was lower in the HDT group (53 vs 58 years, P = 0.007). Complete response negative immunofixation - (CR) was achieved in 12 of 31 (39%) patients intensified with HDT and in two of 33 (6%) patients who were continued on conventional chemotherapy (P = 0.002). Event-free survival (EFS) was significantly longer in the HDT group (median, 43 vs 21 months; P = 0.007). Overall survival (OS) was not significantly different between groups (median, 62 vs 38 months; P = 0.21). However, patients in the HDT group who achieved CR had an EFS (median, 51 vs 31 months; P = 0.03) as well as an OS (median, not reached vs 50 months; P = 0.0006) significantly longer than those achieving a lower degree of response. In conclusion, this non-randomized study shows that early HDT increases CR rate and prolongs EFS. In addition, these results highlight CR as a crucial step for achieving long-lasting disease control and prolonged survival in patients with MM.