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Atrash S, Robinson M, Taneja A, Paul B, Cassetta K, Ndiaye A, Varga C, Block J, Lipford EH, Smith ET, McCall CM, Thurston V, Foureau D, Usmani SZ, Voorhees PM, Bhutani M. Bone marrow Ki-67 index is of prognostic value in newly diagnosed multiple myeloma. Eur J Haematol 2023. [PMID: 37311695 DOI: 10.1111/ejh.14016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Ki-67 is an index of proliferative activity and is an established predictive and prognostic marker in multiple malignancies. However, its prognostic relevance in multiple myeloma (MM) is unclear. We investigated the relationship between Ki-67 expression and survival outcomes in MM in the era of novel therapies. METHODS We interrogated our database to identify patients with MM, newly diagnosed between July 1, 2013 and December 31, 2020, with Ki-67 expression assessed by immunohistochemistry (IHC) on bone marrow biopsies. Using an established threshold of 5% we defined Ki-67low (≤5%) and Ki-67high (>5%) subgroups for association with progression-free survival (PFS) and overall survival (OS). RESULTS Of 167 patients included: 53 (31.7%) had Ki-67high and 114 had Ki-67low. More patients with R-ISS 3 had Ki-67high (22.2% vs. 9.7%). The gain of 1q21 was overrepresented in the Ki-67high group (28% vs. 8%). Median PFS in the Ki-67low group was 3.1 years, and in the Ki-67high group 1.6 years (log-rank p < .001, HR: 1.9). Median OS was not reached in the Ki-67low vs. 4.8 years in the Ki-67high cohort (HR: 1.9; log-rank test: p = .018). In the multivariable modeling, after adjusting for other risk factors, HR for Ki-67high versus Ki-67low was 2.4 (p < .001) for PFS and 2.1 (p = .026) for OS. CONCLUSIONS Our results demonstrate that a high Ki-67 index (>5%) is an independent prognostic marker associated with worse OS and PFS in newly diagnosed MM. IHC staining for Ki-67 on bone marrow biopsies could be easily adopted as a prognostic biomarker for MM in economically constrained healthcare settings.
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Affiliation(s)
- Shebli Atrash
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Myra Robinson
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Alankrita Taneja
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Barry Paul
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Kristen Cassetta
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Ami Ndiaye
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Cindy Varga
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Jared Block
- Department of Hematopathology, Carolinas Pathology Group, Charlotte, North Carolina, USA
| | - Edward H Lipford
- Department of Hematopathology, Carolinas Pathology Group, Charlotte, North Carolina, USA
| | - Elton T Smith
- Department of Hematopathology, Carolinas Pathology Group, Charlotte, North Carolina, USA
| | - Chad M McCall
- Department of Hematopathology, Carolinas Pathology Group, Charlotte, North Carolina, USA
| | - Virginia Thurston
- Department of Hematopathology, Carolinas Pathology Group, Charlotte, North Carolina, USA
| | - David Foureau
- Immune Monitoring Core Laboratory, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Saad Z Usmani
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Peter M Voorhees
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Manisha Bhutani
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
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2
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Panakkal V, Lakshman A, Shi M, Olteanu H, Horna P, Timm MM, Otteson GE, Baughn LB, Greipp PT, Gonsalves WI, Kapoor P, Gertz MA, Binder M, Buadi FK, Dispenzieri A, Rajkumar SV, Kumar SK, Jevremovic D. Utility of flow cytometry screening before MRD testing in multiple myeloma. Blood Cancer J 2023; 13:55. [PMID: 37080968 PMCID: PMC10119092 DOI: 10.1038/s41408-023-00832-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/31/2023] [Accepted: 04/06/2023] [Indexed: 04/22/2023] Open
Affiliation(s)
- Vandana Panakkal
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Arjun Lakshman
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Min Shi
- Division of Hematopathology, Mayo Clinic, Rochester, MN, USA
| | - Horatiu Olteanu
- Division of Hematopathology, Mayo Clinic, Rochester, MN, USA
| | - Pedro Horna
- Division of Hematopathology, Mayo Clinic, Rochester, MN, USA
| | - Michael M Timm
- Division of Hematopathology, Mayo Clinic, Rochester, MN, USA
| | | | - Linda B Baughn
- Division of Hematopathology, Mayo Clinic, Rochester, MN, USA
- Division of Laboratory Genetics and Genomics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Patricia T Greipp
- Division of Hematopathology, Mayo Clinic, Rochester, MN, USA
- Division of Laboratory Genetics and Genomics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Wilson I Gonsalves
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Prashant Kapoor
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Morie A Gertz
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Moritz Binder
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Francis K Buadi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Angela Dispenzieri
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - S Vincent Rajkumar
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shaji K Kumar
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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3
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Goel U, Usmani S, Kumar S. Current approaches to management of newly diagnosed multiple myeloma. Am J Hematol 2022; 97 Suppl 1:S3-S25. [PMID: 35234302 DOI: 10.1002/ajh.26512] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 12/16/2022]
Abstract
Major developments in the treatment of multiple myeloma (MM) over the past decade have led to a continued improvement in survival. Significant progress has been made with deeper and longer remissions seen with newer treatment approaches-both for induction as well as maintenance therapy. The treatment approach to MM is guided by several factors including patient age, frailty, comorbidities, eligibility for autologous stem cell transplantation (ASCT), and risk stratification into standard-risk or high-risk MM. High-risk MM is defined by the presence of t(4;14), t(14;16), t(14;20), del (17p), TP53 mutation, or gain (1q). Transplant eligible patients should receive 4-6 cycles of induction followed by stem cell collection. Patients can then undergo ASCT, or continue induction therapy and shift to maintenance, delaying ASCT till first relapse. Transplant ineligible patients should receive induction therapy followed by maintenance. For induction therapy prior to ASCT, a proteasome inhibitor-IMiD combination remains standard with monoclonal antibody-based quadruplets preferred in high-risk patients. Among transplant ineligible patients, those with standard-risk MM should receive DRd continued until disease progression, while bortezomib containing regimens (VRd or VRd lite) can be considered for high-risk patients. Finally, standard-risk patients should receive lenalidomide maintenance after induction/ASCT, while proteasome inhibitor-IMiD combinations should be used for high-risk patients.
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Affiliation(s)
- Utkarsh Goel
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota USA
| | - Saad Usmani
- Multiple Myeloma Service, Department of medicine Memorial Sloan Kettering Cancer Center New York New York USA
| | - Shaji Kumar
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota USA
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4
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Goldman‐Mazur S, Kumar SK. Current approaches to management of high-risk multiple myeloma. Am J Hematol 2021; 96:854-871. [PMID: 33725367 DOI: 10.1002/ajh.26161] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 12/15/2022]
Abstract
The median overall survival in multiple myeloma is rapidly approaching 10 years; however, in nearly a fifth of patients the prognosis remains poor. Therefore, the modern-day management of myeloma patients should be individualized, with a more intense and continuous approach in these high-risk patients. This includes first-line treatment based on multi-drug combinations employing the most effective drug combinations, upfront autologous stem cell transplantation (in eligible patients with tandem transplantation being a consideration), and maintenance based on proteasome inhibitor-based combinations. This paper reviews the results of recent retrospective analyses and clinical trials, but also gives a glance into the future by presenting the ongoing trials.
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Affiliation(s)
| | - Shaji K. Kumar
- Division of Hematology Mayo Clinic Rochester Minnesota USA
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5
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Risk and Response-Adapted Treatment in Multiple Myeloma. Cancers (Basel) 2020; 12:cancers12123497. [PMID: 33255368 PMCID: PMC7760158 DOI: 10.3390/cancers12123497] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/19/2020] [Accepted: 11/22/2020] [Indexed: 12/28/2022] Open
Abstract
Simple Summary Therapeutic strategies in multiple myeloma have been adapted only to age and comorbidities for a long time. Given the currently available therapeutic and technologic arsenal, the time may have come to refine this adaptation. First, high-risk patients should benefit from the most intensive and efficient combinations from diagnosis. Here, we review these different strategies and how to define and identify high-risk myeloma patients in current clinical practice. In addition, the advent of technologies detecting minimal residual disease gives us this opportunity to define the quality of response to treatment with an unpreceded sensitivity and adapt treatment accordingly. Finally, even if molecular targeting is still nascent in myeloma, some molecular features are interesting to detect at relapse to determine optimal salvage treatments. Abstract Myeloma therapeutic strategies have been adapted to patients’ age and comorbidities for a long time. However, although cytogenetics and clinical presentations (plasmablastic cytology; extramedullary disease) are major prognostic factors, until recently, all patients received the same treatment whatever their initial risk. No strong evidence allows us to use a personalized treatment according to one cytogenetic abnormality in newly diagnosed myeloma. Retrospective studies showed a benefit of a double autologous transplant in high-risk cytogenetics according to the International Myeloma Working Group definition (t(4;14), t(14;16) or del(17p)). Moreover, this definition has to be updated since other independent abnormalities, namely gain 1q, del(1p32), and trisomies 5 or 21, as well as TP53 mutations, are also prognostic. Another very strong predictive tool is the response to treatment assessed by the evaluation of minimal residual disease (MRD). We are convinced that the time has come to use it to adapt the strategy to a dynamic risk. Many trials are ongoing to answer many questions: when and how should we adapt the therapy, its intensity and duration. Nevertheless, we also have to take into account the clinical outcome for one patient, especially adverse events affecting his or her quality of life and his or her preferences for continuous/fixed duration treatment.
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Abstract
Although therapeutic strategies have been adapted to age and comorbidities of myeloma patients for a long time, all patients currently experiment the same treatment whatever their genomic risk. However, high-risk patients should benefit right now from the most efficient drugs combinations. Herein, we review and discuss how to optimally define risk to adapt treatment and why a modern multiparametric definition of genomic risk is urgently needed. Minimal residual disease status will probably also take a growing place in patient's management, including in treatment adaptation. We also discuss how next-generation sequencing will definitively represent an essential tool to manage risk-based therapeutic strategies. Finally, despite an explosive knowledge of myeloma molecular landscape, targeted therapy perspectives remain poor, with only few exceptions.
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7
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Li F, Yao FS, Zhu XJ, Gu WY, Wang XH, Chen B, Huang DP, Ding JH, Wu TQ, Zhu Y, Zhao Q, Tang YM, Song P, Zhou XG, An ZM, Guo X, Wang XL, Zhong L, Xie XB, Zhai YP. A randomized phase II, open-label and multicenter study of combination regimens of bortezomib at two doses by subcutaneous injection for newly diagnosed multiple myeloma patients. J Cancer Res Clin Oncol 2019; 145:2343-2355. [PMID: 31280348 DOI: 10.1007/s00432-019-02967-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 07/01/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE Combinations of bortezomib (Velcade), cyclophosphamide and dexamethasone have shown significant efficacy and safety for patients of newly diagnosed multiple myeloma (NDMM). In this study, we compared the efficacy and safety of modified VCD regimens with novel changes in bortezomib dose and schedule for NDMM. METHODS Eighty-five NDMM patients from multiple centers were randomly assigned to a high-dose (1.6 mg/m2) (group A) or a low-dose (1.3 mg/m2) (group B) bortezomib, administrated on days 1, 6, 11, and 16 subcutaneously in a 4-week cycle for nine cycles, combined with 40 mg dexamethasone on bortezomib days and cyclophosphamide 300 mg/m2 on days 1-3 intravenously. RESULTS After four cycles, complete response (CR) or better in group A (43.6%) was higher than that in group B (12.8%) (P = 0.002). During induction, for patients with R-ISS stage III, the CR or better rate in group A was superior to that in group B (P = 0.01). Of patients < 65, the CR or better rate of group A was superior to that of group B (P = 0.004). Rapid onset of CR occurred in group A (P < 0.01). Meanwhile, rate of 3-4 diarrhea was higher in group A (P = 0.03), which caused higher rate of dose reduction for patients ≥ 65 (P = 0.041). No significant difference between the two groups in PFS and OS. CONCLUSIONS The studied high-dose VCD as induction regimen had an improved CR rate, especially in patients < 65 or with R-ISS stage III, and is feasible for young and high-risk patients. Trial registration ClinicalTrials.gov: NCT02086942.
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Affiliation(s)
- Feng Li
- Department of Hematology, Jinling Hospital, School of Medicine, Nanjing University, 305 Zhongshan EAST Rd, Nanjing, 210002, Jiangsu, People's Republic of China
| | - Fu-Sheng Yao
- Department of Hematology, An Qing Municipal Hospital, Anqing, Anhui, People's Republic of China
| | - Xi-Jun Zhu
- Department of Hematology, Xuancheng People's Hospital, Xuancheng, Anhui, People's Republic of China
| | - Wei-Ying Gu
- Department of Hematology, The First People's Hospital of Changzhou, Third Affiliated to Suzhou University, Changzhou, Jiangsu, People's Republic of China
| | - Xiao-Hua Wang
- Department of Hematology, The Second People's Hospital of Wuhu, Wuhu, Anhui, People's Republic of China
| | - Bing Chen
- Department of Hematology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, People's Republic of China
| | - Dong-Ping Huang
- Department of Hematology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, People's Republic of China
| | - Jia-Hua Ding
- Department of Hematology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Tian-Qin Wu
- Department of Hematology, The 904th Hospital of Chinese People's Liberation Army, Suzhou, Jiangsu, People's Republic of China
| | - Yan Zhu
- Department of Hematology, Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, People's Republic of China
| | - Qian Zhao
- Department of Hematology, Jinling Hospital, School of Medicine, Nanjing University, 305 Zhongshan EAST Rd, Nanjing, 210002, Jiangsu, People's Republic of China
| | - Yu-Mei Tang
- Department of Hematology, Jinling Hospital, School of Medicine, Nanjing University, 305 Zhongshan EAST Rd, Nanjing, 210002, Jiangsu, People's Republic of China
| | - Ping Song
- Department of Hematology, Jinling Hospital, School of Medicine, Nanjing University, 305 Zhongshan EAST Rd, Nanjing, 210002, Jiangsu, People's Republic of China
| | - Xiao-Gang Zhou
- Department of Hematology, Jinling Hospital, School of Medicine, Nanjing University, 305 Zhongshan EAST Rd, Nanjing, 210002, Jiangsu, People's Republic of China
| | - Zhi-Ming An
- Department of Hematology, Jinling Hospital, School of Medicine, Nanjing University, 305 Zhongshan EAST Rd, Nanjing, 210002, Jiangsu, People's Republic of China
| | - Xing Guo
- Department of Hematology, Jinling Hospital, School of Medicine, Nanjing University, 305 Zhongshan EAST Rd, Nanjing, 210002, Jiangsu, People's Republic of China
| | - Xu-Li Wang
- Department of Hematology, Jinling Hospital, School of Medicine, Nanjing University, 305 Zhongshan EAST Rd, Nanjing, 210002, Jiangsu, People's Republic of China
| | - Long Zhong
- Department of Hematology, An Qing Municipal Hospital, Anqing, Anhui, People's Republic of China
| | - Xiao-Bao Xie
- Department of Hematology, The First People's Hospital of Changzhou, Third Affiliated to Suzhou University, Changzhou, Jiangsu, People's Republic of China
| | - Yong-Ping Zhai
- Department of Hematology, Jinling Hospital, School of Medicine, Nanjing University, 305 Zhongshan EAST Rd, Nanjing, 210002, Jiangsu, People's Republic of China.
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8
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Requirand G, Robert N, Boireau S, Vincent L, Seckinger A, Bouhya S, Ceballos P, Cartron G, Hose D, Klein B, Moreaux J. BrdU incorporation in multiparameter flow cytometry: A new cell cycle assessment approach in multiple myeloma. CYTOMETRY PART B-CLINICAL CYTOMETRY 2018; 96:209-214. [PMID: 30417559 DOI: 10.1002/cyto.b.21730] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/19/2018] [Accepted: 07/27/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND Mutiple myeloma (MM) is a neoplasia characterized by the accumulation of malignant plasma cells (PC) in the bone marrow. Although proliferation markers have been studied in MM, none of the current staging systems include them. Moreover, approaches used to analyze proliferation do not separate MM cells (MMCs) from normal PC. METHODS In this study, we combined multiparameter flow cytometry and BrdU incorporation or Ki67 staining to analyze MM cell proliferation in 44 monoclonal gammopathy of undetermined significance (MGUS), 153 newly diagnosed MM patients and 69 MM patients at relapse. The prognostic value of proliferation assessment was analyzed in 60 newly diagnosed patients treated with high-dose chemotherapy supported by autologous hematopoietic stem cell transplantation. RESULTS The median number of proliferating malignant PC significantly increases during MM disease progression. MM patients with a percentage of proliferating MMCs greater than 1.42% using BrdU/DAPI or greater than 1.1% using ki67/DAPI, are associated with a significantly shorter event free survival compared with patients with a lower percentage of proliferating MMCs. CONCLUSIONS Combination of flow cytometry with BrdU or ki67/DAPI staining could become a standard for the determination of MM cell proliferation. Furthermore, in the context of new effective myeloma treatment options, assessment of MM cell proliferation may be valuable, in clinical trials, to identify novel agents that could significantly affect the small proliferative compartment of MM cells. © 2018 International Clinical Cytometry Society.
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Affiliation(s)
- Guilhem Requirand
- CHU Montpellier, Department of Biological Hematology, Montpellier, France.,IGH, CNRS, University of Montpellier, Montpellier, France
| | - Nicolas Robert
- CHU Montpellier, Department of Biological Hematology, Montpellier, France.,IGH, CNRS, University of Montpellier, Montpellier, France
| | - Stéphanie Boireau
- CHU Montpellier, Department of Biological Hematology, Montpellier, France.,IGH, CNRS, University of Montpellier, Montpellier, France
| | - Laure Vincent
- CHU Montpellier, Department of Clinical Hematology, Montpellier, France
| | - Anja Seckinger
- Medizinische Klinik und Poliklinik V, Universitätsklinikum Heidelberg, Heidelberg, Germany.,Nationales Centrum für Tumorerkrankungen, Heidelberg, Germany
| | | | - Patrice Ceballos
- CHU Montpellier, Department of Clinical Hematology, Montpellier, France
| | - Guillaume Cartron
- CHU Montpellier, Department of Clinical Hematology, Montpellier, France.,University of Montpellier, UFR de Médecine, Montpellier, France
| | - Dirk Hose
- Medizinische Klinik und Poliklinik V, Universitätsklinikum Heidelberg, Heidelberg, Germany.,Nationales Centrum für Tumorerkrankungen, Heidelberg, Germany
| | - Bernard Klein
- CHU Montpellier, Department of Biological Hematology, Montpellier, France.,IGH, CNRS, University of Montpellier, Montpellier, France.,University of Montpellier, UFR de Médecine, Montpellier, France
| | - Jérôme Moreaux
- CHU Montpellier, Department of Biological Hematology, Montpellier, France.,IGH, CNRS, University of Montpellier, Montpellier, France.,University of Montpellier, UFR de Médecine, Montpellier, France.,UMR CNRS 5235, University of Montpellier, Montpellier, France
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9
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Perrot A, Corre J, Avet-Loiseau H. Risk Stratification and Targets in Multiple Myeloma: From Genomics to the Bedside. Am Soc Clin Oncol Educ Book 2018; 38:675-680. [PMID: 30231368 DOI: 10.1200/edbk_200879] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In the past 15 years, significant improvements in overall survival have been observed in multiple myeloma (MM), mainly due to the availability of novel drugs with variable mechanisms of action. However, these improvements do not benefit all patients, and some of them, defined as high risk, still display short survival. The most important risk factors are the genetic abnormalities present in the malignant plasma cells. The most important high-risk features are the del(17p), the del(1p32), the t(4;14), and 1q gains. Assessing these markers is mandatory at diagnosis and at least at first relapse, since it has been clearly shown that the lenalidomide-dexamethasone combination is not efficient in these high-risk patients. In contrast, a triplet combination adding a proteasome inhibitor or a monoclonal antibody to the lenalidomide-dexamethasone backbone clearly improves the survival. Another way to improve the outcome would be to specifically target genetic abnormalities with specific inhibitors. The sequencing of more than 1,000 MM exomes revealed again a huge heterogeneity. The most frequent mutations involve the KRAS and NRAS genes (20%-25% each). However, to date, no good RAS-inhibitors are clinically available, preventing targeted therapy. The only drugable target is the V600E BRAF mutation. Unfortunately, this specific mutation is present in only 3% of the patients. Finally, it has been recently reported a specific efficiency of the BCL2-inhibitor venetoclax in patients with the t(11;14) translocation, which is found in 20% of the patients.
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Affiliation(s)
- Aurore Perrot
- From the Hematology Department, University Hospital, Nancy, France; Myeloma Genomics Laboratory, University Hospital, Toulouse, France; and Myeloma Genomics Laboratory, University Hospital, Toulouse, France
| | - Jill Corre
- From the Hematology Department, University Hospital, Nancy, France; Myeloma Genomics Laboratory, University Hospital, Toulouse, France; and Myeloma Genomics Laboratory, University Hospital, Toulouse, France
| | - Hervé Avet-Loiseau
- From the Hematology Department, University Hospital, Nancy, France; Myeloma Genomics Laboratory, University Hospital, Toulouse, France; and Myeloma Genomics Laboratory, University Hospital, Toulouse, France
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10
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Sidiqi MH, Aljama MA, Jevremovic D, Morice WG, Timm M, Buadi FK, Warsame R, Lacy MQ, Dispenzieri A, Dingli D, Gonsalves WI, Kumar S, Kapoor P, Kourelis T, Leung N, Hogan WJ, Muchtar E, Lust JA, Rajkumar VS, Gertz MA. Plasma cell proliferative index post-transplant is a powerful predictor of prognosis in myeloma patients failing to achieve a complete response. Bone Marrow Transplant 2018; 54:442-447. [PMID: 30087461 DOI: 10.1038/s41409-018-0280-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 06/20/2018] [Accepted: 06/26/2018] [Indexed: 11/09/2022]
Abstract
Myeloma patients failing to achieve a complete response post autologous stem cell transplantation are heterogeneous, some ultimately achieving deeper responses and prolonged remission, whilst others relapse rapidly with poor outcomes. We evaluated the prognostic impact of the plasma cell proliferative index (PCPI) post-therapy, in 382 patients with myeloma failing to achieve complete response at 100 days post-transplant. Sixty percent (n = 230) of patients had zero clonal or too few clonal plasma cells to accurately assess PCPI (No PCPI). The remaining 40% (n = 152) of patients had PCPI performed with 79% (n = 120) having a low PCPI and 21% (n = 32) having an elevated PCPI. Patients with an elevated PCPI had significantly shorter progression free and overall survival. The median PFS was 8 months for elevated PCPI vs. 19 months for low PCPI vs. 24 months for no PCPI (p < 0.0001). The median OS was 27 months for elevated PCPI vs. 79 months for low PCPI vs. not reached for no PCPI, p < 0.0001). On multivariable analysis post-therapy PCPI was an independent predictor of progression free and overall survival. The PCPI post-therapy is a powerful predictor of survival and risk stratifies myeloma patients failing to achieve complete response early in the disease course.
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Affiliation(s)
- M Hasib Sidiqi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA
| | - Mohammed A Aljama
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA
| | - Dragan Jevremovic
- Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, USA
| | - William G Morice
- Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, USA
| | - Michael Timm
- Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, USA
| | - Francis K Buadi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA
| | - Rahma Warsame
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA
| | - Martha Q Lacy
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA
| | - Angela Dispenzieri
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA
| | - David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA
| | - Wilson I Gonsalves
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA
| | - Shaji Kumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA
| | - Prashant Kapoor
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA
| | - Taxiarchis Kourelis
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic Rochester, Rochester, USA
| | - William J Hogan
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA
| | - Eli Muchtar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA
| | - John A Lust
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA
| | - Vincent S Rajkumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA
| | - Morie A Gertz
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA.
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Ely S, Forsberg P, Ouansafi I, Rossi A, Modin A, Pearse R, Pekle K, Perry A, Coleman M, Jayabalan D, Di Liberto M, Chen-Kiang S, Niesvizky R, Mark TM. Cellular Proliferation by Multiplex Immunohistochemistry Identifies High-Risk Multiple Myeloma in Newly Diagnosed, Treatment-Naive Patients. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17:825-833. [DOI: 10.1016/j.clml.2017.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 08/07/2017] [Accepted: 09/11/2017] [Indexed: 10/18/2022]
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12
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Schwartz LA, Brumley LD. What a Pain: The Impact of Physical Symptoms and Health Management on Pursuit of Personal Goals Among Adolescents with Cancer. J Adolesc Young Adult Oncol 2016; 6:142-149. [PMID: 27792462 DOI: 10.1089/jayao.2016.0031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE This study examined health-related hindrance (HRH) of personal goals among adolescents receiving treatment for cancer and healthy peers. METHODS Adolescents and parents completed measures of demographics and psychosocial variables. Adolescents reported on their HRH, measured by ratings of the impact of pain, fatigue, other physical symptoms, and doing things to manage their health on self-identified personal goals. Disease-related information was abstracted from patient charts. RESULTS Adolescents with cancer experienced significantly more HRH than healthy peers, and their HRH was significantly associated with poorer health-related quality of life (p < 0.001), negative affect (p = 0.03), and depressive symptoms (p = 0.03). Risk and resilience factors associated with HRH for those with cancer included pain (current and past month severity, frequency, and pain-related quality of life), fatigue, nausea, cognitive problems, worse parent-reported family functioning, and female gender. When testing these significant associates in a regression model predicting HRH among adolescents with cancer, those with more severe pain (p < 0.001) and worse parent-reported family functioning (p = 0.01) were significantly associated with HRH; fatigue was marginally (p = 0.09) significant. CONCLUSIONS Results suggest that HRH is a significant problem for adolescents with cancer, particularly those who are experiencing pain. Addressing pain and other symptom management, enhancing family functioning, and helping adolescents adjust their goals or enhance support for goal pursuit may reduce HRH among adolescents with cancer. This may improve psychosocial well-being, address adolescent unmet needs, and ultimately help adolescents with cancer maintain normal developmental trajectories.
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Affiliation(s)
- Lisa A Schwartz
- 1 Division of Oncology, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania.,2 Perelman School of Medicine, The University of Pennsylvania , Philadelphia, Pennsylvania
| | - Lauren D Brumley
- 3 Department of Psychology, The University of Pennsylvania , Philadelphia, Pennsylvania
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13
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Muchtar E, Magen H, Gertz MA. High-risk multiple myeloma: a multifaceted entity, multiple therapeutic challenges. Leuk Lymphoma 2016; 58:1283-1296. [PMID: 27734720 DOI: 10.1080/10428194.2016.1233540] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The term high-risk multiple myeloma is aimed to identify a heterogeneous group of patients who are more likely to progress and die early of their disease. Therefore, recognition of these patients is crucial. With the increase in the number of treatment options, the outcome for high-risk patients has probably improved, although the true extent of this improvement remains unknown, due to both the heterogeneous components of high-risk disease and its under-representation in clinical trials. In this article, we review the definitions of high-risk disease, emphasizing the fact that no single definition can represent the entire high-risk population. In the second part, we review the treatment options available for the management of high-risk myeloma as well as our general approach for high-risk disease. In light of the poor prognosis associated with high-risk myeloma, even in the current era, new approaches for the management of this subset of patients are needed.
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Affiliation(s)
- Eli Muchtar
- a Division of Hematology , Mayo Clinic , Rochester , MN , USA
| | - Hila Magen
- b Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center , Petah-Tikva , Israel
| | - Morie A Gertz
- a Division of Hematology , Mayo Clinic , Rochester , MN , USA
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14
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van de Donk NWCJ, Sonneveld P. Diagnosis and risk stratification in multiple myeloma. Hematol Oncol Clin North Am 2014; 28:791-813. [PMID: 25212883 DOI: 10.1016/j.hoc.2014.06.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Multiple myeloma (MM) is a tumor of monoclonal plasma cells, which produce a monoclonal antibody and expand predominantly in the bone marrow. Patients present with hypercalcemia, renal impairment, anemia, and/or bone disease. Only patients with symptomatic MM require therapy, whereas asymptomatic patients receive regular follow-up. Survival of patients with MM is very heterogeneous. The variety in outcome is explained by host factors as well as tumor-related characteristics reflecting biology of the MM clone and tumor burden. The identification of cytogenetic abnormalities by fluorescence in situ hybridization is currently the most important and widely available prognostic factor in MM.
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Affiliation(s)
- Niels W C J van de Donk
- Department of Hematology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht 3584CX, The Netherlands
| | - Pieter Sonneveld
- Department of Hematology, Erasmus MC Cancer Institute, 's Gravendijkwal 230, Rotterdam 3015CE, The Netherlands.
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Byrne M, Katz J, Moreb J. Multiple Myeloma and Evolution of Novel Biomarkers and Therapies. Cancer Biomark 2014. [DOI: 10.1201/b16389-39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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16
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Paiva B, Vídriales MB, Montalbán MÁ, Pérez JJ, Gutiérrez NC, Rosiñol L, Martínez-López J, Mateos MV, Cordón L, Oriol A, Terol MJ, Echeveste MA, De Paz R, De Arriba F, Palomera L, de la Rubia J, Díaz-Mediavilla J, Sureda A, Gorosquieta A, Alegre A, Martin A, Lahuerta JJ, Bladé J, Orfao A, San Miguel JF. Multiparameter flow cytometry evaluation of plasma cell DNA content and proliferation in 595 transplant-eligible patients with myeloma included in the Spanish GEM2000 and GEM2005<65y trials. THE AMERICAN JOURNAL OF PATHOLOGY 2012; 181:1870-8. [PMID: 22974582 DOI: 10.1016/j.ajpath.2012.07.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 06/22/2012] [Accepted: 07/19/2012] [Indexed: 10/27/2022]
Abstract
The incorporation of high-dose therapy/autologous stem cell transplantation (HDT/ASCT) and novel agents has significantly improved survival in patients with multiple myeloma (MM), but whether this improvement also benefits patients harboring poor prognostic features, such as nonhyperdiploid MM (NH-MM) and a high proliferation index, remains largely unknown. We analyzed the DNA content and proliferation index of bone marrow plasma cells (PCs) by multiparameter flow cytometry in 595 newly diagnosed transplant-eligible patients with MM included in two consecutive PETHEMA/GEM trials: GEM2000 [VBMCP/VBAD (vincristine, carmustine, melphalan, cyclophosphamide, prednisone/vincristine, bischloroethylnitrosourea, adriamycin, and dexamethasone) followed by HDT/ASCT; n = 319] and GEM2005<65y (randomized induction with VBMCP/VBAD/bortezomib or thalidomide/dexamethasone or bortezomib/thalidomide/dexamethasone followed by HDT/ASCT; n = 276). Of the 595 patients, 295 were classified as NH-MM (49.6%) and 336 (56.5%) as high-proliferative MM (≥1% PCs in S-phase). Detection of NH-MM DNA content and ≥1% PCs in S-phase were of independent prognostic value for overall survival. Treatment with bortezomib-based regimens abrogated the inferior overall survival of patients with ≥1% PCs in S-phase but not of patients with NH-MM. Finally, a comparative analysis of PC proliferation index at diagnosis versus disease progression showed a twofold increase at relapse in 44 of 52 patients (85%) analyzed at both time points. NH-MM and a high proliferation index assessed by multiparameter flow cytometry remain as independent prognostic factors in MM, but the latter may be overcome by incorporating novel agents in the HDT/ASCT setting.
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Iterative decomposition of water and fat with echo asymmetry and least-squares estimation (IDEAL) imaging of multiple myeloma: initial clinical efficiency results. Eur Radiol 2011; 22:1114-21. [DOI: 10.1007/s00330-011-2351-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 10/31/2011] [Accepted: 11/09/2011] [Indexed: 10/14/2022]
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