1
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Dima D, Orland M, Ullah F, Anwer F, Mazzoni S, Raza S, Chaulagain CP, Samaras C, Valent J, Williams L, Khouri J. Clinical Efficacy of Retreatment With Venetoclax-Based Therapy in Relapsed-Refractory t(11;14) Multiple Myeloma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:857-860. [PMID: 37558531 DOI: 10.1016/j.clml.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 07/13/2023] [Accepted: 07/20/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Danai Dima
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
| | - Mark Orland
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH
| | - Fauzia Ullah
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Faiz Anwer
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Sandra Mazzoni
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Shahzad Raza
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Chakra P Chaulagain
- Department of Hematology and Medical Oncology, Cleveland Clinic Florida, Maroone Cancer Center, Weston, FL
| | - Christy Samaras
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Jason Valent
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Louis Williams
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Jack Khouri
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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2
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Abdallah AO, Mahmoudjafari Z, Ahmed N, Cui W, Shune L, McGuirk J, Mohan M, Mohyuddin GR, Afrough A, Alkharabsheh O, Atrash S. Clinical efficacy of retreatment of daratumumab-based therapy (D2) in daratumumab-refractory multiple myeloma. Eur J Haematol 2023; 110:626-632. [PMID: 36752328 DOI: 10.1111/ejh.13942] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 02/09/2023]
Abstract
Daratumumab demonstrates activity as a single agent and in combination with either immunomodulatory agents (IMiDs) or proteasome inhibitors (PIs) in relapsed refractory multiple myeloma (RRMM). However, little is known about the benefit of daratumumab retreatment in daratumumab-refractory MM. This study aimed to analyze the clinical efficacy of daratumumab-based retreatment (D2) in patients who are daratumumab refractory MM. Retrospectively, we identified 43 RRMM patients from a single-center database review. The median age was 65 years, 42% patients had high-risk cytogenetics, and 23% had an extramedullary disease, while the median time between D2 and prior daratumumab was 1 (0.25-39) month. All D2 patients received combination therapy with either pomalidomide, carfilzomib, bortezomib, or lenalidomide. The response rate, median progression-free, and overall survival were 49%, 7.97 and 32.6 months, respectively. Our study raises the possibility of re-utilizing daratumumab in combination with different classes of anti-myeloma drugs to generate responses in RRMM patients who are daratumumab-refractory.
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Affiliation(s)
- Al-Ola Abdallah
- Division of Hematologic Malignancies & Cellular Therapeutics, University of Kansas Medical Center, Westwood, Kansas, USA.,US Myeloma Innovations Research Collaborative (USMIRC), Westwood, Kansas, USA
| | - Zahra Mahmoudjafari
- US Myeloma Innovations Research Collaborative (USMIRC), Westwood, Kansas, USA.,University of Kansas Medical Center, Westwood, Kansas, USA
| | - Nausheen Ahmed
- Division of Hematologic Malignancies & Cellular Therapeutics, University of Kansas Medical Center, Westwood, Kansas, USA.,US Myeloma Innovations Research Collaborative (USMIRC), Westwood, Kansas, USA
| | - Wei Cui
- US Myeloma Innovations Research Collaborative (USMIRC), Westwood, Kansas, USA.,University of Kansas Medical Center, Westwood, Kansas, USA
| | - Leyla Shune
- Division of Hematologic Malignancies & Cellular Therapeutics, University of Kansas Medical Center, Westwood, Kansas, USA.,US Myeloma Innovations Research Collaborative (USMIRC), Westwood, Kansas, USA
| | - Joseph McGuirk
- Division of Hematologic Malignancies & Cellular Therapeutics, University of Kansas Medical Center, Westwood, Kansas, USA
| | - Meera Mohan
- US Myeloma Innovations Research Collaborative (USMIRC), Westwood, Kansas, USA.,Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Ghulam Rehman Mohyuddin
- Division of Hematology and Hematologic Malignancies, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Aimaz Afrough
- US Myeloma Innovations Research Collaborative (USMIRC), Westwood, Kansas, USA.,Division of Hematology/Oncology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Omar Alkharabsheh
- US Myeloma Innovations Research Collaborative (USMIRC), Westwood, Kansas, USA.,Division of Hematology/Oncology, University of South Alabama, Mobile, Alabama, USA
| | - Shebli Atrash
- US Myeloma Innovations Research Collaborative (USMIRC), Westwood, Kansas, USA.,Division of Hematology, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina, USA
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3
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Kulig P, Milczarek S, Bakinowska E, Szalewska L, Baumert B, Machaliński B. Lenalidomide in Multiple Myeloma: Review of Resistance Mechanisms, Current Treatment Strategies and Future Perspectives. Cancers (Basel) 2023; 15:963. [PMID: 36765919 PMCID: PMC9913106 DOI: 10.3390/cancers15030963] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 01/26/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
Multiple myeloma (MM) is the second most common hematologic malignancy, accounting for approximately 1% of all cancers. Despite the initial poor prognosis for MM patients, their life expectancy has improved significantly with the development of novel agents. Immunomodulatory drugs (IMiDs) are widely used in MM therapy. Their implementation has been a milestone in improving the clinical outcomes of patients. The first molecule belonging to the IMiDs was thalidomide. Subsequently, its novel derivatives, lenalidomide (LEN) and pomalidomide (POM), were implemented. Almost all MM patients are exposed to LEN, which is the most commonly used IMiD. Despite the potent anti-MM activity of LEN, some patients eventually relapse and become LEN-resistant. Drug resistance is one of the greatest challenges of modern oncology and has become the main cause of cancer treatment failures. The number of patients receiving LEN is increasing, hence the problem of LEN resistance has become a great obstacle for hematologists worldwide. In this review, we intended to shed more light on the pathophysiology of LEN resistance in MM, with particular emphasis on the molecular background. Moreover, we have briefly summarized strategies to overcome LEN resistance and we have outlined future directions.
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Affiliation(s)
- Piotr Kulig
- Department of General Pathology, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Sławomir Milczarek
- Department of General Pathology, Pomeranian Medical University, 70-111 Szczecin, Poland
- Department of Hematology and Transplantology, Pomeranian Medical University, 71-252 Szczecin, Poland
| | - Estera Bakinowska
- Department of General Pathology, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Laura Szalewska
- Department of General Pathology, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Bartłomiej Baumert
- Department of General Pathology, Pomeranian Medical University, 70-111 Szczecin, Poland
- Department of Hematology and Transplantology, Pomeranian Medical University, 71-252 Szczecin, Poland
| | - Bogusław Machaliński
- Department of General Pathology, Pomeranian Medical University, 70-111 Szczecin, Poland
- Department of Hematology and Transplantology, Pomeranian Medical University, 71-252 Szczecin, Poland
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4
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Wang PF, Yee CW, Gorsh B, Zichlin ML, Paka P, Bhak RH, Boytsov N, Khanal A, Noman A, DerSarkissian M, Ferrante S, Duh MS. Treatment patterns and overall survival of patients with double-class and triple-class refractory multiple myeloma: a US electronic health record database study. Leuk Lymphoma 2023; 64:398-406. [PMID: 36408998 DOI: 10.1080/10428194.2022.2140284] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Patients with relapsed/refractory multiple myeloma (RRMM) resistant to multiple drug classes remain a high unmet need population. This longitudinal retrospective cohort study assessed real-world treatment patterns and outcomes in adults with RRMM. Patients who had three or more prior lines of therapy including a proteasome inhibitor (PI) and an immunomodulatory agent (double-exposed) were further categorized as refractory to a PI and an immunomodulatory agent (double-class refractory, n = 381) or additionally to an anti-CD38 monoclonal antibody (triple-class refractory, n = 173). Treatment options are limited for patients with double-class or triple-class refractory disease. Retreatment is a part of standard of care. Bortezomib and lenalidomide had the highest retreatment rates among double-class and triple-class refractory patients. Survival outcomes remain poor among RRMM patients with median overall survival (OS) of 22.3 and 11.6 months for double-class refractory and triple-class refractory patients, respectively. This study highlights the need for novel efficacious therapies in this heavily pretreated RRMM population.
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5
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Du L, Liu W, Pichiorri F, Rosen ST. SUMOylation inhibition enhances multiple myeloma sensitivity to lenalidomide. Cancer Gene Ther 2022; 30:567-574. [PMID: 35338347 PMCID: PMC10104776 DOI: 10.1038/s41417-022-00450-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 01/18/2022] [Accepted: 02/24/2022] [Indexed: 11/09/2022]
Abstract
Despite the potent effect of lenalidomide (Len) in multiple myeloma (MM) treatment, patients develop Len resistance leading to progressive disease, demanding an urgent need to investigate the mechanisms mediating Len resistance. Our study identified SUMOylation as a potential mechanism regulating Len resistance in MM. Len-resistant MM cell line MMR10R presented much higher SUMO E1 (SAE2) expression and more global SUMOylation than Len-sensitive MM1S cell line. SUMOylation inhibition by using TAK-981, a novel and specific SUMO E1 inhibitor, significantly enhances myeloma sensitivity to Len in MM cell lines. Moreover, the enhanced anti-MM activity by TAK-981 and Len combination has been validated using primary relapsing MM patient samples. Overexpression of IRF4 and c-Myc is a major mechanism of Len resistance. Len showed limited effect on IRF4 and c-Myc level in Len-resistance cell line, but TAK-981 treatment reduced IRF4 and c-Myc expression in Len-resistant line and caused further decrease when combined with Len. We found SUMOylation inhibition decreases IRF4 at transcriptional and post-translational level. SUMOylation inhibition reduced DOT1L with decreased methylation of histone H3 lysine 79, to suppress IRF4 gene transcription. SUMOylation inhibition also reduced IRF4 protein level by enhancing degradation. Overall, our data revealed SUMOylation inhibition enhances Len sensitivity through downregulating IRF4.
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Affiliation(s)
- Li Du
- Toni Stephenson Lymphoma Center, Beckman Research Institute of City of Hope, Duarte, CA, USA. .,Judy and Bernard Briskin Center for Multiple Myeloma Research, Beckman Research Institute of City of Hope, Duarte, CA, USA. .,Department of Hematology and Stem Cell Transplant, Beckman Research Institute of City of Hope, Duarte, CA, USA.
| | - Wei Liu
- Toni Stephenson Lymphoma Center, Beckman Research Institute of City of Hope, Duarte, CA, USA.,Department of Hematology, Xiangya Hospital, Central South University, Changsha, China
| | - Flavia Pichiorri
- Judy and Bernard Briskin Center for Multiple Myeloma Research, Beckman Research Institute of City of Hope, Duarte, CA, USA.,Department of Hematology and Stem Cell Transplant, Beckman Research Institute of City of Hope, Duarte, CA, USA
| | - Steven T Rosen
- Toni Stephenson Lymphoma Center, Beckman Research Institute of City of Hope, Duarte, CA, USA. .,Judy and Bernard Briskin Center for Multiple Myeloma Research, Beckman Research Institute of City of Hope, Duarte, CA, USA. .,Department of Hematology and Stem Cell Transplant, Beckman Research Institute of City of Hope, Duarte, CA, USA. .,City of Hope Comprehensive Cancer Center, City of Hope National Medical Center, Duarte, CA, USA.
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6
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Jan M, Sperling AS, Ebert BL. Cancer therapies based on targeted protein degradation - lessons learned with lenalidomide. Nat Rev Clin Oncol 2021; 18:401-417. [PMID: 33654306 PMCID: PMC8903027 DOI: 10.1038/s41571-021-00479-z] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2021] [Indexed: 02/08/2023]
Abstract
For decades, anticancer targeted therapies have been designed to inhibit kinases or other enzyme classes and have profoundly benefited many patients. However, novel approaches are required to target transcription factors, scaffolding proteins and other proteins central to cancer biology that typically lack catalytic activity and have remained mostly recalcitrant to drug development. The selective degradation of target proteins is an attractive approach to expand the druggable proteome, and the selective oestrogen receptor degrader fulvestrant served as an early example of this concept. Following a long and tragic history in the clinic, the immunomodulatory imide drug (IMiD) thalidomide was discovered to exert its therapeutic activity via a novel and unexpected mechanism of action: targeting proteins to an E3 ubiquitin ligase for subsequent proteasomal degradation. This discovery has paralleled and directly catalysed myriad breakthroughs in drug development, leading to the rapid maturation of generalizable chemical platforms for the targeted degradation of previously undruggable proteins. Decades of clinical experience have established front-line roles for thalidomide analogues, including lenalidomide and pomalidomide, in the treatment of haematological malignancies. With a new generation of 'degrader' drugs currently in development, this experience provides crucial insights into class-wide features of degraders, including a unique pharmacology, mechanisms of resistance and emerging therapeutic opportunities. Herein, we review these past experiences and discuss their application in the clinical development of novel degrader therapies.
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Affiliation(s)
- Max Jan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Adam S Sperling
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Benjamin L Ebert
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
- Broad Institute of Harvard and MIT, Cambridge, MA, USA.
- Howard Hughes Medical Institute, Boston, MA, USA.
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7
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Pomalidomide Plus Low-Dose Dexamethasone in Relapsed/Refractory Multiple Myeloma Patients: Results of the Real-World "POWERFUL" Study. J Clin Med 2021; 10:jcm10071509. [PMID: 33916376 PMCID: PMC8038613 DOI: 10.3390/jcm10071509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 03/29/2021] [Accepted: 04/01/2021] [Indexed: 02/05/2023] Open
Abstract
The “POWERFUL” multicenter, retrospective, and prospective study investigated the effectiveness of pomalidomide plus low-dose dexamethasone (POM/LoDex) therapy in relapsed/refractory multiple myeloma in routine care in Greece. Ninety-nine eligible adult patients treated with POM/LoDex according to the approved label after having received ≥2 prior therapies, including lenalidomide and bortezomib, were consecutively enrolled between 16 November 2017 and 21 February 2019 in 18 hematology departments. Fifty patients (50.5%) started POM/LoDex as third-line treatment. During the treatment period (median: 8.3 months; range: 0.3–47.6 months), the median POM dose was 4 mg/day, and 31.3% of the patients received additional antimyeloma agents. The overall response rate was 32.3%. During a median follow-up period of 13.8 months (Kaplan–Meier estimate), the median progression-free survival (PFS) was 10.5 months (95% CI: 7.4–14.4). The PFS was not significantly different between patients receiving POM/LoDex in the third versus later line of therapy, nor between patients receiving concomitant antimyeloma therapy versus POM/LoDEx doublet. During the prospective safety data collection period (median: 7.6 months) among patients with prospective follow-up (N = 75), POM-related adverse event incidence rate was 42.7% (serious: 18.7%; grade ≥ 3 hematological POM-related adverse events: 8.0%). Only neutropenia (13.3%) was reported at a frequency ≥10%. In conclusion, in this real-world study, POM/LoDex displayed a long PFS with no new safety signals emerging.
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8
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Khouri J, Faiman BM, Grabowski D, Mahfouz RZ, Khan SN, Wei W, Valent J, Dean R, Samaras C, Jha BK, Lazarus H, Campagnaro EL, Malek E, Reed J, Karam MA, Hamilton K, Fada S, Kalaycio M, Liu H, Sobecks R, Saunthararajah Y, Chew Y, Orloff M, Reu FJ. DNA methylation inhibition in myeloma: Experience from a phase 1b study of low-dose continuous azacitidine in combination with lenalidomide and low-dose dexamethasone in relapsed or refractory multiple myeloma. Semin Hematol 2020; 58:45-55. [PMID: 33509443 DOI: 10.1053/j.seminhematol.2020.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 01/08/2023]
Abstract
The DNA methyltransferase inhibitor azacytidine (aza) may reactivate pathways associated with plasma cell differentiation, cell cycle control, apoptosis, and immune recognition and thereby restore sensitivity to lenalidomide (len) and dexamethasone (dex) in relapsed and/or refractory multiple myeloma (RRMM). We aimed to develop an aza regimen that reaches epigenetically active levels 8 times in 28 days with less bone marrow toxicity than the myeloid malignancy standard of 7 consecutive doses to enable safe combination with len. Aza was escalated from 30 mg/m2 once a week up to a predefined maximum of 50 mg/m2 twice a week in combination with GFR-adjusted len (≥ 60 mL/min: 25 mg, 3059 mL/min: 10 mg) day 1 to 21 every 28 days and dex 40 mg once a week followed by a limited expansion study to a total N of 23 at the highest tolerated dose. Fifty-one patients (pts) with RRMM were screened, 42 were treated and 41 were evaluable for response based on at least 1 response assessment or progression after treatment start. The median number of prior lines of therapy was 5 (1-11) and 81% (34) were refractory to len and/or pomalidomide (pom). Two DLTs occurred in different cohorts, 1 neutropenic fever in 1/6 pts on the aza 40 mg/m2 twice a week GFR ≥ 60 mL/min cohort and 1 GGT elevation in 1/6 pts on the aza 50 mg/m2 GFR 30-59 mL/min cohort. An MTD was not reached and aza 50 mg/m2 SC twice a week was chosen for the expansion study. At least possibly related Grade 3/4 AEs occurred in 28 pts (67%) with the following in > 1 pt: neutropenia (N = 16, 38%), anemia (N = 6, 14%), lymphopenia (N = 5, 12%), thrombocytopenia (N = 4, 10%), leukopenia (N = 4, 10%), febrile neutropenia (N = 4, 10%), fatigue (N = 3, 7%), fever (N = 2, 5%), and infection (N = 2, 5%). At a median follow up time for alive pts of 60.2 months (range: 36.1-82.5 months), the overall response rate (≥ partial response) and clinical benefit response rate (≥ minor response) was 22 and 32%, respectively, with 4 very good partial responses (10%), 5 partial responses (12%), and 4 minor responses (10%). The median PFS was 3.1 months (95% confidence interval [CI]: 2.1-5.1 months), median TTP 2.7 months (95% CI: 2.1-7.5 months), and median OS 18.6 months (95% CI: 12.9-33.0 months). Achieving at least minor response and reaching TTP > 6 months was associated with approximately 35% lower median plasma levels of the enzyme that inactivates aza, plasma cytidine deaminase (CDA, P< .0001). Two of the len refractory pts achieved longer disease control than with any prior regimen and 1 responded immediately after progression on len, bortezomib, and prednisone. Analyses of the methylation state of over 480,000 CpG sites in purified myeloma cells at screening were possible in 11 pts and on day 28 in 8 of them. As in other studies, the majority of differentially methylated CpGs compared to normal plasma cells were hypomethylated in myeloma. Treatment decreased the number of CpGs that were differentially methylated in normal plasma cells by > 0.5% in 6 and by > 5% in 3 of the 8 pts, most pronounced in 2 pts with clinically convincing aza contribution who achieved a reduction in overall differentially methylated CpGs by 23 and 68%, respectively, associated with increased expression of immunoglobulin genes. The study demonstrated tolerability of twice a week SC aza at 50 mg/m2 with len and dex in RRMM and suggested aza may help overcome the len/pom refractory state, possibly by activating differentiation pathways. Relatively low response rates and association of clinical benefit with low plasma levels of the aza inactivating enzyme CDA suggest the aza regimen will need to be optimized further and pt selection may be required to maximize benefit.
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Affiliation(s)
- Jack Khouri
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH
| | - Beth M Faiman
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH
| | - Dale Grabowski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Reda Z Mahfouz
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Department of Clinical Pathology, Menoufia University, Shebin-Elkom, Egypt
| | - Shahper N Khan
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Interdisciplinary Nanotechnology Centre, Aligarh Muslim University, Aligarh, India
| | - Wei Wei
- Taussig Cancer Institute, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Jason Valent
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH
| | - Robert Dean
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH
| | - Christy Samaras
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH
| | - Babal K Jha
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Hillard Lazarus
- Case Comprehensive Cancer Center, Cleveland, OH; Department of Hematology and Oncology, Seidman Cancer Center, University Hospitals, Cleveland, OH
| | - Erica L Campagnaro
- Case Comprehensive Cancer Center, Cleveland, OH; Department of Hematology and Oncology, Seidman Cancer Center, University Hospitals, Cleveland, OH; University of Michigan Comprehensive Cancer Center, Ann Arbor, MI
| | - Ehsan Malek
- Case Comprehensive Cancer Center, Cleveland, OH; Department of Hematology and Oncology, Seidman Cancer Center, University Hospitals, Cleveland, OH
| | - Janice Reed
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Mary Ann Karam
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Kimberly Hamilton
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Sherry Fada
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Matt Kalaycio
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH
| | - Hien Liu
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Ronald Sobecks
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH
| | - Yogen Saunthararajah
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH; Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | | | - Mohammed Orloff
- Lerner Research Institute, Genomic Core Facility, Cleveland Clinic, Cleveland, OH; Department of Epidemiology, University of Arkansas for Medical Sciences, Little Rock, AR; Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Frederic J Reu
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Case Comprehensive Cancer Center, Cleveland, OH; Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Morsani College of Medicine, University of South Florida, Tampa, FL.
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9
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Papadimitriou K, Tsakirakis N, Malandrakis P, Vitsos P, Metousis A, Orologas-Stavrou N, Ntanasis-Stathopoulos I, Kanellias N, Eleutherakis-Papaiakovou E, Pothos P, Fotiou D, Gavriatopoulou M, Kastritis E, Dimopoulos MA, Terpos E, Tsitsilonis OE, Kostopoulos IV. Deep Phenotyping Reveals Distinct Immune Signatures Correlating with Prognostication, Treatment Responses, and MRD Status in Multiple Myeloma. Cancers (Basel) 2020; 12:E3245. [PMID: 33158030 PMCID: PMC7692501 DOI: 10.3390/cancers12113245] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/16/2020] [Accepted: 10/29/2020] [Indexed: 12/16/2022] Open
Abstract
Despite recent advances, Multiple Myeloma (MM) remains an incurable disease with apparent heterogeneity that may explain patients' variable clinical outcomes. While the phenotypic, (epi)genetic, and molecular characteristics of myeloma cells have been thoroughly examined, there is limited information regarding the role of the bone marrow (BM) microenvironment in the natural history of the disease. In the present study, we performed deep phenotyping of 32 distinct immune cell subsets in a cohort of 94 MM patients to reveal unique immune profiles in both BM and peripheral blood (PB) that characterize distinct prognostic groups, responses to induction treatment, and minimal residual disease (MRD) status. Our data show that PB cells do not reflect the BM microenvironment and that the two sites should be studied independently. Adverse ISS stage and high-risk cytogenetics were correlated with distinct immune profiles; most importantly, BM signatures comprised decreased tumor-associated macrophages (TAMs) and erythroblasts, whereas the unique Treg signatures in PB could discriminate those patients achieving complete remission after VRd induction therapy. Moreover, MRD negative status was correlated with a more experienced CD4- and CD8-mediated immunity phenotype in both BM and PB, thus highlighting a critical role of by-stander cells linked to MRD biology.
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Affiliation(s)
- Konstantinos Papadimitriou
- Department of Biology, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (K.P.); (N.T.); (P.V.); (A.M.); (N.O.-S.); (P.P.)
| | - Nikolaos Tsakirakis
- Department of Biology, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (K.P.); (N.T.); (P.V.); (A.M.); (N.O.-S.); (P.P.)
| | - Panagiotis Malandrakis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Panagiotis Vitsos
- Department of Biology, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (K.P.); (N.T.); (P.V.); (A.M.); (N.O.-S.); (P.P.)
| | - Andreas Metousis
- Department of Biology, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (K.P.); (N.T.); (P.V.); (A.M.); (N.O.-S.); (P.P.)
| | - Nikolaos Orologas-Stavrou
- Department of Biology, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (K.P.); (N.T.); (P.V.); (A.M.); (N.O.-S.); (P.P.)
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Nikolaos Kanellias
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Evangelos Eleutherakis-Papaiakovou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Panagiotis Pothos
- Department of Biology, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (K.P.); (N.T.); (P.V.); (A.M.); (N.O.-S.); (P.P.)
| | - Despina Fotiou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Meletios-Athanasios Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece; (P.M.); (I.N.-S.); (N.K.); (E.E.-P.); (D.F.); (M.G.); (E.K.); (M.-A.D.); (E.T.)
| | - Ourania E. Tsitsilonis
- Department of Biology, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (K.P.); (N.T.); (P.V.); (A.M.); (N.O.-S.); (P.P.)
| | - Ioannis V. Kostopoulos
- Department of Biology, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece; (K.P.); (N.T.); (P.V.); (A.M.); (N.O.-S.); (P.P.)
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10
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Lee JH, Kim SH. Treatment of relapsed and refractory multiple myeloma. Blood Res 2020; 55:S43-S53. [PMID: 32719176 PMCID: PMC7386890 DOI: 10.5045/br.2020.s008] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 01/23/2023] Open
Abstract
The therapeutic strategy for relapsed and refractory multiple myeloma (RRMM) integrates a holistic approach regarding patient, disease, and drug-related factors. Patient-related factors include age, frailty status, and underlying comorbidities, especially cardiovascular and renal diseases and peripheral neuropathies that affect tolerability to multiple drug combinations or transplantations. Disease-related factors encompass these multiple patient-related factors, particularly the aggressiveness of the disease and cytogenetics. Regarding drug-related factors, the approval of novel proteasome inhibitors (such as carfilzomib and ixazomib), immunomodulatory agents (such as pomalidomide), monoclonal antibodies (such as daratumumab and elotuzumab), and new classes of drugs increasingly makes the choice treatment more complex and necessitates a comprehensive summary and an update of the efficacy and toxicities of each antimyeloma drug and its combinations. Further, careful monitoring of the side effects and supportive care throughout the course of treatment are important to achieve better outcomes for patients with RRMM.
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Affiliation(s)
- Ji Hyun Lee
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Sung-Hyun Kim
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
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11
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Oriol A, Abril L, Ibarra G, Senin A. Limited treatment options in refractory multiple myeloma: promising therapeutic developments. Expert Rev Anticancer Ther 2020; 20:31-44. [PMID: 31865804 DOI: 10.1080/14737140.2020.1708721] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Introduction: Combinations of proteasome inhibitors, immunomodulators, and monoclonal antibodies are highly active against multiple myeloma. Consequently, several combinations have moved from the relapsed to the front-line setting. In the context of lenalidomide and bortezomib being used upfront, salvage options need to be evaluated.Areas covered: This manuscript reviews available data for the treatment of patients progressing on optimal frontline strategies, with a focus on the role of second-generation proteasome inhibitors and immunomodulators, monoclonal antibodies and immunotherapy.Expert opinion: Remarkable progress has been made in myeloma treatment due to the integration of immunomodulators, proteasome inhibitors and more recently monoclonal antibodies in the front-line setting. However, we work on the assumption that most individuals will eventually relapse. Optimized upfront therapy negatively selects more resistant patients among still relapsing individuals. Bortezomib and lenalidomide-exposed patients are under-represented in trials leading to currently approved combinations. Evidence needs to be reviewed taking into account how the improvement of frontline therapy has modified the characteristics of patients at the time of relapse. Second generation immunomodulatory agents and proteasome inhibitors, monoclonal antibodies and other agents have shown efficacy in this new landscape. Immunotherapeutic agents, including CAR-T cells are promising for patients failing standard combinations, despite current data are still immature.
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Affiliation(s)
- Albert Oriol
- Hematology Service and Hemato-Oncology Clinical Trial Unit, Institut Català d'Oncologia, Badalona, Barcelona, Spain.,Josep Carreras Institute and Germans Trias i Pujol Hospital, Badalona, Barcelona, Spain
| | - Laura Abril
- Hematology Service and Hemato-Oncology Clinical Trial Unit, Institut Català d'Oncologia, Badalona, Barcelona, Spain.,Josep Carreras Institute and Germans Trias i Pujol Hospital, Badalona, Barcelona, Spain
| | - Gladys Ibarra
- Hematology Service and Hemato-Oncology Clinical Trial Unit, Institut Català d'Oncologia, Badalona, Barcelona, Spain.,Josep Carreras Institute and Germans Trias i Pujol Hospital, Badalona, Barcelona, Spain
| | - Alicia Senin
- Hematology Service and Hemato-Oncology Clinical Trial Unit, Institut Català d'Oncologia, Badalona, Barcelona, Spain.,Josep Carreras Institute and Germans Trias i Pujol Hospital, Badalona, Barcelona, Spain
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12
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Jung KS, Kim K, Kim HJ, Kim SH, Lee JO, Kim JS, Lee JJ, Eom HS, Min CK, Shin HJ. Analysis of the Efficacy of Thalidomide Plus Dexamethasone-Based Regimens in Patients With Relapsed/Refractory Multiple Myeloma Who Received Prior Chemotherapy, Including Bortezomib and Lenalidomide: KMM-166 Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 20:e97-e104. [PMID: 31831372 DOI: 10.1016/j.clml.2019.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 10/04/2019] [Accepted: 10/23/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND For patients with multiple myeloma (MM) that relapsed after treatment with bortezomib- and lenalidomide-based regimens, there were no other treatment options in Korea until 2016. We aimed to determine the efficacy of thalidomide plus dexamethasone-based regimens in patients with relapsed/refractory MM (RRMM). PATIENTS AND METHODS We conducted a multicenter retrospective analysis in Korea for patients with RRMM treated with thalidomide-based regimens who previously received bortezomib and immunomodulatory agents (IMiDs), including thalidomide and lenalidomide. RESULTS In 47 patients with RRMM, the median age was 64 years and the median number of previous treatment lines, including bortezomib and IMiDs, was 3. Primary resistance to bortezomib and lenalidomide was observed in 12 (26%) and 8 (17%) patients, respectively. The most common regimen was a combination of thalidomide, cyclophosphamide, and dexamethasone. The overall response rate was 38%; 2 patients (4%) experienced a complete response, and 2 patients (4%) experienced a very good partial response. The overall response rate of patients previously exposed to thalidomide was 53%. The median progression-free survival was 5.9 months, and overall survival was 9.2 months. Patients with disease that responded to the thalidomide-based regimen had better progression-free survival compared to those who did not (median, 8.8 vs. 2.5 months; P = .008). The most common adverse events were anemia (51%) for hematologic toxicities and peripheral neuropathy (30%) for nonhematologic toxicities. CONCLUSION Thalidomide-based regimens are potential salvage treatment options for patients with RRMM, even those with disease with prior resistance to IMiDs.
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Affiliation(s)
- Ki Sun Jung
- Division of Hematology-Oncology, Departments of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Kihyun Kim
- Division of Hematology-Oncology, Departments of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyo Jung Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Sung Hyun Kim
- Department of Internal Medicine, Dong-A Medical Center, Dong-A University College of Medicine, Busan, Korea
| | - Jeong-Ok Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Je-Jung Lee
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Jeollanamdo, Korea
| | - Hyeon-Seok Eom
- Hematology-Oncology Clinic, National Cancer Center, Goyang-si, Korea
| | - Chang-Ki Min
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul, St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ho-Jin Shin
- Division of Hematology-Oncology, Department of Internal Medicine, Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea.
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13
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Eleutherakis-Papaiakovou E, Gavriatopoulou M, Ntanasis-Stathopoulos I, Kastritis E, Terpos E, Dimopoulos MA. Elotuzumab in combination with pomalidomide and dexamethasone for the treatment of multiple myeloma. Expert Rev Anticancer Ther 2019; 19:921-928. [DOI: 10.1080/14737140.2019.1685879] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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14
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Kalff A, Khong T, Mithraprabhu S, Bergin K, Reynolds J, Bowen KM, Thakurta A, Guzman R, Wang M, Couto S, Ren Y, Spencer A. Oral azacitidine (CC-486) in combination with lenalidomide and dexamethasone in advanced, lenalidomide-refractory multiple myeloma (ROAR study). Leuk Lymphoma 2019; 60:2143-2151. [DOI: 10.1080/10428194.2019.1571201] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Anna Kalff
- Myeloma Research Group, Australian Centre for Blood Diseases, Alfred Hospital/Monash University, Melbourne, Australia
- Malignant Hematology and Stem Cell Transplantation, Alfred Hospital, Melbourne, Australia
| | - Tiffany Khong
- Myeloma Research Group, Australian Centre for Blood Diseases, Alfred Hospital/Monash University, Melbourne, Australia
| | - Sridurga Mithraprabhu
- Myeloma Research Group, Australian Centre for Blood Diseases, Alfred Hospital/Monash University, Melbourne, Australia
| | - Krystal Bergin
- Malignant Hematology and Stem Cell Transplantation, Alfred Hospital, Melbourne, Australia
| | - John Reynolds
- Alfred Health and Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Kathryn M. Bowen
- Malignant Hematology and Stem Cell Transplantation, Alfred Hospital, Melbourne, Australia
| | | | | | | | | | - Yan Ren
- Celgene Corporation, San Diego, CA, USA
| | - Andrew Spencer
- Myeloma Research Group, Australian Centre for Blood Diseases, Alfred Hospital/Monash University, Melbourne, Australia
- Malignant Hematology and Stem Cell Transplantation, Alfred Hospital, Melbourne, Australia
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15
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Kumar SK. Recycling therapies for myeloma: The need for prospective trials. Cancer 2019; 125:2920-2922. [PMID: 31090923 DOI: 10.1002/cncr.32177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 04/18/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Shaji K Kumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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16
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Nooka AK, Joseph NS, Kaufman JL, Heffner LT, Gupta VA, Gleason C, Boise LH, Lonial S. Clinical efficacy of daratumumab, pomalidomide, and dexamethasone in patients with relapsed or refractory myeloma: Utility of re-treatment with daratumumab among refractory patients. Cancer 2019; 125:2991-3000. [PMID: 31090928 DOI: 10.1002/cncr.32178] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 12/02/2018] [Accepted: 12/05/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND The efficacy of daratumumab (DARA) both as a monotherapy and in combination with standard-of-care regimens in multiple myeloma (MM) has been established in clinical trials. This article presents a retrospective analysis of the safety and efficacy of DARA in combination with pomalidomide (POM) and dexamethasone (ie, daratumumab, pomalidomide, and dexamethasone [DARA-POM-D]) and, more importantly, the long-term follow-up of a cohort that was naive to DARA and POM as well as a cohort in which the utility of re-treatment was evaluated among patients who were DARA- and/or POM-refractory. METHODS Thirty-four consecutive patients with relapsed and/or refractory MM treated with DARA-POM-D at the Winship Cancer Institute of Emory University from January 2015 through July 2016 were included in the analysis. The study was approved by Emory University's institutional review board. All received prior proteasome inhibitors and immunomodulatory drugs (IMiDs) and were refractory to their last line of therapy. RESULTS All patients were lenalidomide-refractory, and 91% were bortezomib-refractory. Two cohorts were identified on the basis of prior exposure to DARA and/or POM. Cohort 1 (12 patients) was DARA- and POM-naive, and cohort 2 (22 patients) was DARA- and/or POM-refractory. A subgroup of 12 patients in cohort 2 (cohort 3) was DARA- and POM-refractory. The combination's tolerability was consistent with the results of the published phase 1b study (EQUULES) that evaluated the combination and no new safety signals were observed. The overall response rates (ORRs) were 91.7%, 40.9%, and 33.3% in cohorts 1, 2, and 3, respectively. Deep responses, including 4 stringent complete responses, were observed in cohort 1. In cohort 2, the ORR comprised 8 partial responses (PRs) and 1 very good PR. The median progression-free survival (PFS) was not reached in cohort 1 at a median follow-up of 41 months, and it was 3.2 months in cohort 2. DARA-POM-D not only was effective in DARA- and POM-naive patients but also produced clinical responses in a third of patients re-treated with these drugs. CONCLUSIONS A better than quadrupled PFS benefit observed in cohort 1 in comparison with the previously reported benefit in the EQUULEUS trial (which led to US Food and Drug Administration approval of the DARA-POM-D combination) highlights the fact that the introduction of monoclonal antibody combination strategies and IMiDs as earlier lines of therapeutic options potentially could deliver better clinical outcomes. One-third of patients refractory to separate lines of DARA and/or POM responded when they were re-treated with a combination, and this resulted in survival benefits equivalent to those of other antimyeloma agents/combinations available for DARA-refractory patients.
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Affiliation(s)
- Ajay K Nooka
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Nisha S Joseph
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jonathan L Kaufman
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Leonard T Heffner
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Vikas A Gupta
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Charise Gleason
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Lawrence H Boise
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Sagar Lonial
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Oostvogels R, Jak M, Raymakers R, Mous R, Minnema MC. Efficacy of retreatment with immunomodulatory drugs and proteasome inhibitors following daratumumab monotherapy in relapsed and refractory multiple myeloma patients. Br J Haematol 2018; 183:60-67. [PMID: 30080247 PMCID: PMC6220946 DOI: 10.1111/bjh.15504] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 06/07/2018] [Indexed: 12/19/2022]
Abstract
This single‐centre retrospective observational study analysed the efficacy of retreatment with immunomodulatory agents (IMiDs) and proteasome inhibitors (PIs) after treatment with daratumumab monotherapy in patients with relapsed and/or refractory multiple myeloma (RRMM). In total 55 patients were treated with daratumumab monotherapy between 2010 and 2017. From this group 29 (53%) IMiD‐refractory patients were retreated with an IMiD after daratumumab and 6 (11%) PI‐refractory patients were retreated with a PI‐based regimen. For the IMiD‐refractory patients the overall response rate (ORR) was 52% (15/29 patients, partial response or better) upon IMiD retreatment, whereas the ORR to PI retreatment was 67% (4/6 patients) in the PI‐refractory group. The immunomodulatory effects of daratumumab may play a role in these high response rates in previously refractory patients. Due to the >6 month‐long persistence of daratumumab in the plasma the subsequent therapies can effectively be considered as combination therapy. Furthermore, the excellent tolerability of daratumumab treatment may enable patients to recover from prior lines of treatment and receive full dosing of subsequent therapies. In conclusion, a high proportion of RRMM patients benefitted from retreatment with IMiDs and PIs after daratumumab treatment. These retreatment options should therefore be explored in RRMM patients progressing on daratumumab monotherapy.
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Affiliation(s)
- Rimke Oostvogels
- Department of Haematology, University Medical Centre, Utrecht, The Netherlands
| | - Margot Jak
- Department of Haematology, University Medical Centre, Utrecht, The Netherlands
| | - Reinier Raymakers
- Department of Haematology, University Medical Centre, Utrecht, The Netherlands
| | - Rogier Mous
- Department of Haematology, University Medical Centre, Utrecht, The Netherlands
| | - Monique C Minnema
- Department of Haematology, University Medical Centre, Utrecht, The Netherlands
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18
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Allogeneic stem cell transplantation and subsequent treatments as a comprehensive strategy for long-term survival of multiple myeloma patients. Bone Marrow Transplant 2017; 52:1602-1608. [PMID: 28892086 DOI: 10.1038/bmt.2017.183] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 06/19/2017] [Accepted: 07/17/2017] [Indexed: 11/08/2022]
Abstract
We evaluated 71 patients treated with allogeneic hematopoietic cell transplantation (allo-HCT) for multiple myeloma (MM). Forty-three patients (61%) received allo-HCT after the first line of therapy. Fifty-eight patients (82%) had chemosensitive disease at the time of allo-HCT. A HLA-matched related or unrelated donor was available for 68 patients (96%). Non-myeloablative or reduced-intensity conditioning regimen and peripheral blood hematopoietic cells as a graft source were used in most patients. The cumulative incidence of grade II-IV acute GVHD at day +100 and chronic GVHD at 5 years was 13% (95% CI 7-23%) and 35% (95% CI 24-46), respectively. Non-relapse mortality and relapse/progression incidence at 5 years were 12% (95% CI 5-23) and 65% (95% CI 49-76), respectively. With a median follow-up in survivors of 100 months (range 16-186), the 5-year PFS and OS were 39% (95% CI 27-52) and 60% (95% CI 55-77), respectively. On multivariate analysis: age >55 years was associated with both a reduced PFS (RR 2.11, 95% CI 1.15-3.87) and OS (RR 5.53, 95% CI 2.22-13.76); chemorefractory disease at allo-HCT was associated with both reduced PFS (RR 3.09, 95% CI 1.37-7.00) and OS (RR 3.19, 95% CI 1.23-8.22). At relapse, 24 patients (56%) received bortezomib, 28 (65%) lenalidomide, 11 (26%) pomalidomide, 16 (37%) donor lymphocytes infusion as part of salvage therapy after allo-HCT relapse. Median PFS from time of salvage treatment was 7 months (range 0-113 months) for bortezomib-based therapy, 14 months (range 0-79 months) for lenalidomide and 10 months (range 1-28) for pomalidomide. Allo-HCT is a feasible and effective strategy in selected patients with MM and could be an effective platform for subsequent therapies.
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19
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Bloudek L, Roy A, Kish JK, Siegel DS, Jagannath S, Globe D, Orloski L, Kuriakose ET. Estimating the Economic Impact of Adding Panobinostat to a U.S. Formulary for Relapsed and/or Refractory Multiple Myeloma: A Budget Impact and Cost-Benefit Model. J Manag Care Spec Pharm 2017; 22:991-1002. [PMID: 27459662 PMCID: PMC10397815 DOI: 10.18553/jmcp.2016.22.8.991] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Multiple myeloma is an incurable B-cell malignancy with a natural history that involves alternating periods of remission and subsequent relapse. For relapsed and/or refractory multiple myeloma (RRMM), the typical patient currently receives more lines of therapy than has been feasible in the past, translating into longer progression-free survival (PFS). Consequently, cost issues have become more prominent because patients may be offered newer and more expensive therapies during a more prolonged overall treatment course. OBJECTIVE To estimate the economic impact of adding panobinostat to a U.S. health plan formulary as a treatment option with bortezomib and dexamethasone for patients with RRMM previously treated with a proteasome inhibitor (PI) and immunomodulatory drug (IMiD), using a budget impact and cost-benefit model. METHODS Total costs of commonly used salvage therapy regimens were combined with market share data and population prevalence estimates of RRMM to yield the total cost of treatment, from the perspective of a U.S. third-party payer (commercial or Medicare) with a time horizon of 1 year. Comparator treatment regimens included bortezomib-dexamethasone, lenalidomide-dexamethasone, lenalidomide-bortezomib-dexamethasone, carfilzomib monotherapy, carfilzomib-lenalidomide-dexamethasone, and pomalidomide-dexamethasone. Costs (2015 U.S. dollars) included drug costs for oral oncology agents, medical and administration costs for injectable oncology agents, costs of adverse event (AE) prophylaxis and monitoring, and costs of grade 3/4 AEs. RESULTS In a hypothetical health plan with 1 million members, the annual number of RRMM patients with previous PI and IMiD treatments was estimated at 16 and 118 for a commercial and Medicare plan, respectively. Introduction of panobinostat as part of the panobinostat-bortezomib-dexamethasone regimen was not expected to result in a substantial budget impact to either commercial or Medicare plans, with an incremental cost < $0.01 per member per month. Panobinostat-bortezomib-dexamethasone had a low cost per treated patient per month without progression, owing to the minimal increase in expenditure over existing bortezomib-based regimens and long median PFS, compared with median duration of treatment. CONCLUSIONS Adding panobinostat to a plan formulary as a treatment option is expected to be cost neutral (and potentially cost saving in the context of new and more expensive treatment regimens). With a low cost per month without progression, panobinostat-bortezomib-dexamethasone represents good value for the money. DISCLOSURES Funding for this study was sponsored by Novartis, East Hanover, New Jersey. Bloudek and Kish are employees of Xcenda, a consulting company contracted by Novartis to conduct this analysis. Roy, Globe, and Kuriakose are employees of Novartis. Siegel is on the advisory boards and speaker's bureau of Celgene, Onyx/Amgen, Millennium/Takeda, and Novartis and is on the advisory boards of Merck. Jagannath is a consultant to Sanofi, Bristol-Meyers Squibb, and Celgene. Orloski is a contractor to Xcenda and provided medical writing support, which was funded by Novartis. Study design and concept were contributed by Bloudek, Roy, and Kish, assisted by Globe. Bloukek took the lead in data collection, along with Kish, and data interpretation was performed by Siegal, Jagannath, Globe, and Kuriakose. The manuscript was written primarily by Orloski, along with Roy and Kish, and revised by Roy, along with Siegal, Jagannath, Globe, Orloski, and Kuriakose.
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Affiliation(s)
| | - Anuja Roy
- 2 Novartis, East Hanover, New Jersey
| | | | - David S Siegel
- 3 Myeloma Division, Hackensack University Medical Center, Hackensack, New Jersey
| | - Sundar Jagannath
- 4 Multiple Myeloma Program and Hematology and Medical Oncology, The Tisch Cancer Institute, Mount Sinai Hospital, New York, New York
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Yee AJ, Raje NS. Sequencing of nontransplant treatments in multiple myeloma patients with active disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:495-503. [PMID: 27913521 PMCID: PMC6142445 DOI: 10.1182/asheducation-2016.1.495] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The approval of several different classes of drugs in recent years has resulted in a dramatic expansion of treatment options for multiple myeloma patients, improving both survival and quality of life. Lenalidomide and bortezomib are now core components of treatment both at time of diagnosis and at relapse. Next-generation immunomodulatory drugs, like pomalidomide, and newer proteasome inhibitors like carfilzomib and ixazomib are available for use at relapse. Drugs with novel mechanisms of action such as the histone deacetylase inhibitor panobinostat and the monoclonal antibodies targeting SLAMF7 (elotuzumab) and CD38 (daratumumab) are significant steps forward. Recent clinical trials describing novel combinations of these drugs have demonstrated unprecedented improvements in efficacy while maintaining tolerability. All of these options provide not only a challenge for choice of therapy, but also the opportunity to aim for increasing depth of response. This chapter will describe an approach on how to sequence and incorporate these therapies, focusing on patients where high-dose melphalan and autologous stem cell transplant are deferred or not applicable.
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Affiliation(s)
- Andrew J Yee
- Center for Multiple Myeloma, Massachusetts General Hospital Cancer Center, Boston, MA; and Harvard Medical School, Boston, MA
| | - Noopur S Raje
- Center for Multiple Myeloma, Massachusetts General Hospital Cancer Center, Boston, MA; and Harvard Medical School, Boston, MA
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21
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Malard F, Harousseau JL, Mohty M. Multiple myeloma treatment at relapse after autologous stem cell transplantation: A practical analysis. Cancer Treat Rev 2016; 52:41-47. [PMID: 27888768 DOI: 10.1016/j.ctrv.2016.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 10/19/2016] [Accepted: 11/05/2016] [Indexed: 11/30/2022]
Abstract
Over the past decade, significant advances have been made in the field of multiple myeloma. Introduction of the so-called novel agents, proteasome inhibitors (PI) and immunomodulatory drugs (IMiD), and improved supportive care have resulted in significantly better outcome. Standard first line treatment in fit patients include PI and IMiD based induction, high dose melphalan with autologous hematopoietic stem cell transplantation (ASCT) and consolidation/maintenance. However, despite these progresses MM remains incurable for the majority of patients and most patients will relapse. Next generation PI (carfilzomib, ixazomib) and IMiD (pomalidomide) and new therapeutic classes: monoclonal antibody (elotuzumab, daratumumab) and pan-deacetylase inhibitors (panobinostat) have been successfully evaluated in relapse multiple myeloma. Some of these new agents are now approved for multiple myeloma treatment at relapse. However choosing the most appropriate treatment at relapse may be difficult. This review sum up the most important studies and provide evidence to choose the most relevant therapeutic strategy for relapse after ASCT, based on disease, patient and previous treatment related parameters.
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Affiliation(s)
- F Malard
- Department of Haematology, Saint Antoine Hospital, Paris, France; INSERM UMRs 938, Paris, France; Université Pierre et Marie Curie, Paris, France.
| | | | - M Mohty
- Department of Haematology, Saint Antoine Hospital, Paris, France; INSERM UMRs 938, Paris, France; Université Pierre et Marie Curie, Paris, France
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Cornell RF, Kassim AA. Evolving paradigms in the treatment of relapsed/refractory multiple myeloma: increased options and increased complexity. Bone Marrow Transplant 2016; 51:479-91. [PMID: 26726946 PMCID: PMC4827007 DOI: 10.1038/bmt.2015.307] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 10/08/2015] [Accepted: 10/22/2015] [Indexed: 12/12/2022]
Abstract
The use of modern therapies such as thalidomide, bortezomib and lenalidomide coupled with upfront high-dose therapy and autologous stem cell transplant (ASCT) has resulted in improved survival in patients with newly diagnosed multiple myeloma (MM). However, patients with relapsed/refractory multiple myeloma (RRMM) often have poorer clinical outcomes and might benefit from novel therapeutic strategies. Emerging therapies, such as deacetylase inhibitors, monoclonal antibodies and new proteasome inhibitors, appear promising and may change the therapeutic landscape in RRMM. A limited number of studies has shown a benefit with salvage ASCT in patients with RRMM, although there remains ongoing debate about its timing and effectiveness. Improvement in transplant outcomes has re-ignited a debate on the timing and possible role for salvage ASCT and allogeneic stem cell transplant in RRMM. As the treatment options for management of patients with RRMM become increasingly complex, physicians must consider both disease- and patient-related factors in choosing the appropriate therapeutic approach, with the goal of improving efficacy while minimizing toxicity.
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Affiliation(s)
- R F Cornell
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - A A Kassim
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt University School of Medicine, Nashville, TN, USA
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Sonneveld P, Broijl A. Treatment of relapsed and refractory multiple myeloma. Haematologica 2016; 101:396-406. [PMID: 27033237 PMCID: PMC5004403 DOI: 10.3324/haematol.2015.129189] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 01/13/2016] [Indexed: 12/22/2022] Open
Abstract
The approach to the patient with relapsed or relapsed/refractory multiple myeloma (RRMM) requires a careful evaluation of the results of previous treatments, the toxicities associated with them and an assessment of prognostic factors. Since the majority of patients will have received prior therapy with drug combinations including a proteasome inhibitor and/or an immunomodulatory drug (IMiD), it is the physician's task to choose the right moment for the start of therapy and define with the patient which goals need to be achieved. The choice of regimen is usually based on prior responsiveness, drugs already received, prior adverse effects, the condition of the patient and expected effectiveness and tolerability. Many double and triple drug combinations are available. In addition, promising new drugs like pomalidomide, carfilzomib and monoclonal antibodies are, or will be, available shortly, while other options can be tried in clinical studies. Finally, supportive care and palliative options need to be considered in some patients. It is becoming increasingly more important to consider the therapeutic options for the whole duration of the disease rather than take a step by step approach, and to develop a systematic approach for each individual patient.
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Affiliation(s)
- Pieter Sonneveld
- Erasmus MC Cancer Institute, Department of Hematology, Rm Na824, Rotterdam, the Netherlands
| | - Annemiek Broijl
- Erasmus MC Cancer Institute, Department of Hematology, Rm Na824, Rotterdam, the Netherlands
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24
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Abstract
Survival outcomes of patients with Multiple Myeloma (MM) have improved over the last decade due to the introduction of novel agents such as the immunomodulatory drugs thalidomide, lenalidomide (Len) and pomalidomide, and the proteasome inhibitors bortezomib (BTZ) and carfilzomib [1, 2]. However, despite these major advances, MM remains largely incurable and almost all patients relapse and require additional therapy [3]. The successful introduction of next generation novel agents including oral proteasome inhibitors, deacetylase inhibitors, and especially monoclonal antibodies as part of immunotherapy promises to further improve outcome.
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Affiliation(s)
- Paola Neri
- Southern Alberta Cancer Research Institute, University of Calgary, Calgary, AB, Canada
| | - Nizar J Bahlis
- Southern Alberta Cancer Research Institute, University of Calgary, Calgary, AB, Canada
| | - Claudia Paba-Prada
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Paul Richardson
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Boston, MA, USA.
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Ozkan MC, Tombuloglu M, Sahin F, Saydam G. Evaluation of immunomodulatory drugs in multiple myeloma: single center experience. AMERICAN JOURNAL OF BLOOD RESEARCH 2015; 5:95-100. [PMID: 27069758 PMCID: PMC4769352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 11/09/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Multiple myeloma (MM) comprises 1% of all cancers and 10% of hematologic malignancies and known as an incurable disease. The introduction of immunomodulatory drugs (IMiDs) has brought a major shift in therapeutic paradigm in the treatment of newly diagnosed and relapsed/refractory MM patients. The aim of this study was to evaluate the relationship between response status and hematological parameters in patients with MM treated with thalidomide or lenalidomide. METHODS Sixty-eight patients who were treated with IMiDs in Ege University, School of Medicine, Department of Hematology, between 2005 and 2012, were evaluated, retrospectively. RESULTS AND CONCLUSION We could not find any difference between the hematological parameters before and after the treatment neither with thalidomide nor lenalidomide. However, the heterogenity of our groups, the difference in treatment strategies and potential side effects would have an impact on this result. It is needed to perform prospective clinical trials to prove that whether correction of hematological parameters would reflect the response status in patients with myeloma that treated with IMiDs.
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Affiliation(s)
| | - Murat Tombuloglu
- Department of Hematology, Ege University Medical School Izmir, Turkey
| | - Fahri Sahin
- Department of Hematology, Ege University Medical School Izmir, Turkey
| | - Guray Saydam
- Department of Hematology, Ege University Medical School Izmir, Turkey
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26
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Dimopoulos MA, Terpos E, Niesvizky R, Palumbo A. Clinical characteristics of patients with relapsed multiple myeloma. Cancer Treat Rev 2015; 41:827-35. [PMID: 26296679 DOI: 10.1016/j.ctrv.2015.07.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 07/13/2015] [Accepted: 07/26/2015] [Indexed: 12/27/2022]
Abstract
Although survival outcomes have improved over the last decade for patients with multiple myeloma (MM), few patients remain free of disease and most inevitably relapse. Selecting a treatment for patients with relapsed MM is challenging given the number and diversity of regimens patients may have previously received, which can affect subsequent therapeutic choices. Importantly, a number of patient- and disease-related factors can also have an effect on treatment choice, treatment efficacy, and tolerability; thus, an understanding of the heterogeneity of patients in the setting of relapsed MM is important for appropriate treatment selection. Here, we review select patient and disease characteristics reported in key interventional and observational studies in relapsed MM (including age, sex, race, and the presence of high-risk disease, renal impairment, or peripheral neuropathy at baseline) to examine common and disparate features of patients with relapsed MM. As therapeutic regimens can have varying efficacy and/or tolerability in patients depending on these factors, we also provide treatment recommendations for patients with select baseline characteristics.
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Affiliation(s)
- Meletios A Dimopoulos
- National and Kapodistrian University of Athens, School of Medicine, 80 Vas. Sofias Avenue, Athens 11528, Greece.
| | - Evangelos Terpos
- National and Kapodistrian University of Athens, School of Medicine, 80 Vas. Sofias Avenue, Athens 11528, Greece.
| | - Ruben Niesvizky
- Weill Cornell Medical College/New York Presbyterian Hospital, Myeloma Center, 428 East 72nd Street, Oxford 300, New York, NY 10021, United States.
| | - Antonio Palumbo
- Department of Hematology, University of Torino, Via Genova 3, 10126 Torino, Italy.
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Roy A, Kish JK, Bloudek L, Siegel DS, Jagannath S, Globe D, Kuriakose ET, Migliaccio-Walle K. Estimating the Costs of Therapy in Patients with Relapsed and/or Refractory Multiple Myeloma: A Model Framework. AMERICAN HEALTH & DRUG BENEFITS 2015; 8:204-215. [PMID: 26157542 PMCID: PMC4489189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 05/15/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND Multiple myeloma is a progressive cancer for which there is no cure. Despite treatment, almost all patients eventually experience periods of disease relapse and remission. With the increasing use of novel therapies, including bortezomib, lenalidomide, carfilzomib, pomalidomide, and panobinostat, benchmarks for assessing the value of these therapies in treating patients with relapsed or refractory multiple myeloma (RRMM) are needed for physicians and payers alike. OBJECTIVES To develop a model framework and to calculate an annual estimate of the total costs per patient for the treatment of patients with RRMM using 7 common treatment regimens, including bortezomib plus dexamethasone; panobinostat, bortezomib, and dexamethasone; lenalidomide plus dexamethasone; lenalidomide, bortezomib, and dexamethasone; carfilzomib; carfilzomib, lenalidomide, and dexamethasone; and pomalidomide plus dexamethasone. METHODS The expenditures for drugs and their administration, for prophylaxis and adverse event monitoring, and for the treatment of grade 3 or 4 adverse events were included in the calculations of the total pharmacy and medical costs. The drug costs were based on published pricing and labeled dosing schedules; the adverse event prophylaxis and monitoring costs were obtained from peer-reviewed publications; and the adverse event incidence rates were obtained from each regimen's prescribing information and from clinical trials. All the costs were summed over the duration of therapy for which the drugs were administered and were calculated separately for commercial and Medicare plans. The duration of therapy for each regimen was the time for which a patient had to be receiving the regimen to obtain 12 months of progression-free survival based on the duration-of-therapy to progression-free survival ratio observed from published clinical trials and/or the drug's labeling. RESULTS The pharmacy costs were highest for pomalidomide plus dexamethasone, whereas the medical costs were highest for the combination of carfilzomib, lenalidomide, and dexamethasone. The total cost associated with available treatments for RRMM was highest for regimens that included lenalidomide (approximate range, $126,000-$256,000). Only bortezomib plus dexamethasone and the combination of panobinostat, bortezomib, and dexamethasone had total costs that were lower than $125,000 per patient. CONCLUSION This study represents the first model developed to comprehensively estimate the costs of managing RRMM with all currently approved and guideline-recommended regimens in the United States. As such, it provides the framework and basis for further budget impact analyses and for cost-effectiveness comparisons with these regimens.
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Affiliation(s)
- Anuja Roy
- Associate Director, Health Economics and Outcomes Research, Novartis Pharmaceuticals, East Hanover, NJ
| | - Jonathan K Kish
- Manager, Global Health Economics and Outcomes Research, Xcenda, Palm Harbor, FL
| | - Lisa Bloudek
- Assistant Director, Global Health Economics and Outcomes Research, Xcenda, Palm Harbor, FL
| | - David S Siegel
- Chief of the Myeloma Division, Hackensack University Medical Center, NJ
| | - Sundar Jagannath
- Director of the Multiple Myeloma Program and Professor of Medicine, Hematology and Medical Oncology, Tisch Cancer Institute, Mount Sinai Hospital, New York
| | - Denise Globe
- Executive Director, US Health Economics and Outcomes Research, Novartis Pharmaceuticals, East Hanover, NJ
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Torimoto Y, Shindo M, Ikuta K, Kohgo Y. Current therapeutic strategies for multiple myeloma. Int J Clin Oncol 2015; 20:423-30. [DOI: 10.1007/s10147-015-0826-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 03/27/2015] [Indexed: 01/24/2023]
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Holstein SA, Richardson PG, Laubach JP, McCarthy PL. Management of relapsed multiple myeloma after autologous stem cell transplant. Biol Blood Marrow Transplant 2015; 21:793-8. [PMID: 25652690 DOI: 10.1016/j.bbmt.2014.12.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 12/22/2014] [Indexed: 11/28/2022]
Abstract
Autologous stem cell transplantation (ASCT) remains a standard of care for multiple myeloma patients who are eligible to receive high-dose therapy, recognizing that the optimal timing and integration of this approach is now under study in a number of randomized trials. Despite the improved response rates with induction therapy consisting of immunomodulatory drugs and/or proteasome inhibitors, as well as the increasing use of post-ASCT maintenance therapy, most myeloma patients relapse and die of their disease. Here we discuss the options for managing post-ASCT relapse, including the role of various salvage regimens in the setting of relapsed and refractory myeloma, salvage ASCT, and salvage allogeneic SCT.
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Affiliation(s)
- Sarah A Holstein
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Paul G Richardson
- Department of Hematologic Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Jacob P Laubach
- Department of Hematologic Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Philip L McCarthy
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York.
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Dimopoulos MA, Richardson PG, Moreau P, Anderson KC. Current treatment landscape for relapsed and/or refractory multiple myeloma. Nat Rev Clin Oncol 2014; 12:42-54. [PMID: 25421279 DOI: 10.1038/nrclinonc.2014.200] [Citation(s) in RCA: 158] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Recent developments in the treatment of multiple myeloma have led to improvements in response rates and to increased survival; however, relapse is inevitable in almost all patients. Recurrence of myeloma is typically more aggressive with each relapse, leading to the development of treatment-refractory disease, which is associated with a shorter survival. Several phase II and III trials have demonstrated the efficacy of recently approved agents in the setting of relapsed and/or refractory multiple myeloma, including immunomodulatory agents, such as lenalidomide and pomalidomide, and proteasome inhibitors, such as bortezomib and carfilzomib. Currently, however, there is no standard treatment for patients with relapsed and/or refractory disease. This Review discusses the current treatment landscape for patients with relapsed and/or refractory multiple myeloma and highlights disease-related and patient-related factors--such as pre-existing comorbidities or toxicities--that are important considerations for clinicians when selecting an appropriate treatment regimen.
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Affiliation(s)
- Meletios A Dimopoulos
- Department of Clinical Therapeutics, University of Athens, School of Medicine, 80 Vas Sofias Avenue, 11528 Athens, Greece
| | - Paul G Richardson
- Dana-Farber Cancer Institute, 44 Binney Street, Dana 1B02, Boston, MA 02115, USA
| | - Philippe Moreau
- Haematology Department, University Hôspital Hôtel-Dieu, 44093 Nantes Cedex 01, France
| | - Kenneth C Anderson
- Dana-Farber Cancer Institute, 44 Binney Street, Dana 1B02, Boston, MA 02115, USA
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João C, Coelho I, Costa C, Esteves S, Lucio P. Efficacy and safety of lenalidomide in relapse/refractory multiple myeloma--real life experience of a tertiary cancer center. Ann Hematol 2014; 94:97-105. [PMID: 25038919 DOI: 10.1007/s00277-014-2164-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 07/06/2014] [Indexed: 12/11/2022]
Abstract
Lenalidomide was approved for the treatment of relapsed and refractory multiple myeloma (rrMM) based on MM009 and MM010 clinical trials. However, its effectiveness and safety profile in real clinical practice should be further assessed. We retrospectively evaluated 90 consecutive patients treated in our center with lenalidomide and dexamethasone (LenDex) between 2007 and 2012. The overall response rate to this treatment was 68 % and the median duration of response was 13.6 months. Patients treated in first relapse and those treated with LenDex longer than 1 year achieved the best responses. Cytogenetics was associated with PFS and best response to treatment was the only variable associated with longer PFS and OS in univariate and multivariate analyses. Our analysis confirmed that LenDex is effective in rrMM patient, well tolerated, and applicable to the majority of patients outside clinical trials; patients achieving a complete response, even in the context of relapse, have a longer survival; quality of response is better when lenalidomide is used in second line than later on and it is a good surrogate marker for OS. Accordingly, CR should be aimed in the rrMM setting, especially in fit patients. Previous treatment with thalidomide should not hamper the option for lenalidomide therapy.
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Affiliation(s)
- Cristina João
- Department of Hematology, Instituto Português de Oncologia de Lisboa, Lisboa, Portugal,
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Zelis N, Devos T, Dierickx D, Janssens A, Raddoux J, Verhoef G, Delforge M. Treatment with lenalidomide (Revlimid®), cyclophosphamide (Endoxan®) and prednisone (REP) in relapsed/refractory multiple myeloma patients: results of a single centre retrospective study. Acta Clin Belg 2014; 69:98-103. [PMID: 24724748 DOI: 10.1179/0001551214z.00000000030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Lenalidomide (Revlimid®) combined with intermittent dexamethasone (the RD regimen) is one of the current standards for treatment of patients with relapsed/refractory multiple myeloma (MM). However, since the disease in the majority of patients will become resistant to RD, or treatment with RD needs to be discontinued due to side effects, we evaluated the combination lenalidomide, low-dose oral cyclophosphamide, with prednisone (REP) in patients with relapsed/refractory MM previously exposed to RD. For this purpose, we performed a single centre retrospective study of the efficacy of REP in 19 patients with relapsed/refractory MM. Overall response rate (partial response or better) with REP was 68% compared with 83% with RD, but with a shorter time to response with the triplet REP. Time to progression after REP was 6 months. Overall the REP regimen was better tolerated compared to RD. We conclude that the REP regimen is an effective treatment regimen for patients with relapsed/refractory MM with good tolerance, warranting further exploration in prospective randomized trials.
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Kourelis TV, Kumar SK, Srivastava G, Gertz MA, Lacy MQ, Buadi FK, Hayman SR, Zeldenrust SR, Leung N, Kyle RA, Russell SJ, Dingli D, Lust JA, Lin Y, Kapoor P, Go R, Rajkumar SV, Dispenzieri A. Long-term disease control in patients with newly diagnosed multiple myeloma after suspension of lenalidomide therapy. Am J Hematol 2014; 89:302-5. [PMID: 24265187 DOI: 10.1002/ajh.23634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 11/18/2013] [Indexed: 12/13/2022]
Abstract
There are no systematic data regarding nonmaintained induction for those patients with multiple myeloma (MM) who do not receive consolidative autologous stem cell transplantation. Of 173 patients with newly diagnosed MM treated with lenalidomide and dexamethasone (LenDex) as primary therapy, 31 patients had their lenalidomide discontinued for reasons other than progression or alternate therapy. Median progression free survival (PFS) from the time of discontinuing lenalidomide was longer in patients who received lenalidomide ≥ 1 year (39 vs. 13 months, P < 0.05); there was no difference in PFS for those treated for 1-2 years as compared to ≥ 2 years. Among those taking lenalidomide for ≥ 1 year PFS was superior in patients who were in very good partial response (VGPR) or better as compared to those with partial response (48.4 versus 14.8 months, P < 0.05). All patients who progressed and were rechallenged with LenDex responded. These analyses illustrate that discontinuation of lenalidomide after 1 year among those patients achieving a ≥VGPR can result in long-term disease control.
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Affiliation(s)
| | - Shaji K. Kumar
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - Geetika Srivastava
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - Morie A. Gertz
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - Martha Q. Lacy
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - Francis K. Buadi
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - Suzanne R. Hayman
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - Steven R. Zeldenrust
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - Nelson Leung
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - Robert A. Kyle
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - Stephen J. Russell
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - David Dingli
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - John A. Lust
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - Yi Lin
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - Prashant Kapoor
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - Ronald Go
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - S. Vincent Rajkumar
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
| | - Angela Dispenzieri
- Division of Hematology, Department of Medicine; Mayo Clinic; Rochester Minnesota
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Replacement of bortezomib with carfilzomib for multiple myeloma patients progressing from bortezomib combination therapy. Leukemia 2014; 28:1529-36. [PMID: 24429497 DOI: 10.1038/leu.2014.27] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 11/22/2013] [Accepted: 12/18/2013] [Indexed: 12/25/2022]
Abstract
In this open-label, intra-patient phase I/II trial, bortezomib was replaced with carfilzomib (escalated from 20 to 45 mg/m(2) on days 1, 2, 8, 9, 15 and 16 of a 28-day cycle) for multiple myeloma (MM) patients who progressed while on or within 12 weeks of receiving a bortezomib-containing combination regimen. Study objectives included determination of the maximum tolerated dose (MTD), overall response rate (ORR), clinical benefit rate (CBR), time to progression, time to response, duration of response, progression-free survival and overall survival (OS). Of 38 registered patients, 37 were treated and evaluable for efficacy and safety. Thirty-one carfilzomib-based regimens using 14 different drug combinations were tested. One regimen (carfilzomib (45 mg/m(2)), ascorbic acid (1000 mg) and cyclophosphamide (2.2 mg/kg)) reached MTD. ORR and CBR were 43.2 and 62.2%, respectively. Median progression-free survival, time to progression and OS were 8.3, 9.9 and 15.8 months, respectively. Hematologic adverse events (AEs; ⩾grade 3) included lymphopenia (35.1%), thrombocytopenia (24.3%), anemia (10.8%) and neutropenia (10.8%). Nonhematologic AEs (⩾grade 3) included fever (5.4%) and hypokalemia (5.4%). These results demonstrate that replacing bortezomib with carfilzomib is safe and can be effective for MM patients failing bortezomib-containing combination regimens. This trial was registered at http://www.clinicaltrials.gov (#NCT01365559).
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35
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Mateos MV, Ocio EM, San Miguel JF. Novel Generation of Agents With Proven Clinical Activity in Multiple Myeloma. Semin Oncol 2013; 40:618-33. [DOI: 10.1053/j.seminoncol.2013.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Kukreti V, Masih-Khan E, Young T, Chu CM, Jiang H, Trudel S, Chen C, Jimenez-Zepeda V, Reece DE. Efficacy of thalidomide-based therapy following lenalidomide plus dexamethasone in patients with relapsed/refractory multiple myeloma. Am J Hematol 2013; 88:337-8. [PMID: 23494911 DOI: 10.1002/ajh.23394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 01/02/2013] [Accepted: 01/08/2013] [Indexed: 11/12/2022]
Affiliation(s)
- Vishal Kukreti
- Department of Medical Oncology and Hematology; Princess Margaret Cancer Centre; Toronto Ontario Canada
| | - Esther Masih-Khan
- Department of Medical Oncology and Hematology; Princess Margaret Cancer Centre; Toronto Ontario Canada
| | - Trieu Young
- Department of Medical Oncology and Hematology; Princess Margaret Cancer Centre; Toronto Ontario Canada
| | - Chia-Min Chu
- Department of Medical Oncology and Hematology; Princess Margaret Cancer Centre; Toronto Ontario Canada
| | - Haiyun Jiang
- Department of Biostatistics; Princess Margaret Cancer Centre; Toronto Ontario Canada
| | - Suzanne Trudel
- Department of Medical Oncology and Hematology; Princess Margaret Cancer Centre; Toronto Ontario Canada
| | - Christine Chen
- Department of Medical Oncology and Hematology; Princess Margaret Cancer Centre; Toronto Ontario Canada
| | - Victor Jimenez-Zepeda
- Department of Medical Oncology and Hematology; Princess Margaret Cancer Centre; Toronto Ontario Canada
| | - Donna E. Reece
- Department of Medical Oncology and Hematology; Princess Margaret Cancer Centre; Toronto Ontario Canada
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37
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Ludwig H, Sonneveld P. Disease control in patients with relapsed and/or refractory multiple myeloma: what is the optimal duration of therapy? Leuk Res 2013. [PMID: 23176721 DOI: 10.1016/s0145-2126(12)70006-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Novel agents such as thalidomide, bortezomib, and lenalidomide have improved outcomes and extended survival in patients with relapsed and/or refractory multiple myeloma (RRMM). These agents appear to be most effective when used at first relapse rather than later in the treatment sequence; however, the optimal duration of therapy has not been defined. Continuous therapy from relapse to disease progression may be able to maintain suppression of residual disease, thereby extending overall survival. This article reviews the currently available data on treatments, including novel agents for patients with RRMM, focusing on the duration of therapy required to improve clinical outcomes.
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Affiliation(s)
- Heinz Ludwig
- 1st Department of Medicine, Center for Oncology and Haematology, Vienna, Austria.
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Thalidomide-analogue biology: immunological, molecular and epigenetic targets in cancer therapy. Oncogene 2013; 32:4191-202. [PMID: 23318436 DOI: 10.1038/onc.2012.599] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 11/04/2012] [Accepted: 11/05/2012] [Indexed: 11/08/2022]
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Reece D, Kouroukis CT, LeBlanc R, Sebag M, Song K, Ashkenas J. Practical approaches to the use of lenalidomide in multiple myeloma: a canadian consensus. Adv Hematol 2012; 2012:621958. [PMID: 23097669 PMCID: PMC3477526 DOI: 10.1155/2012/621958] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 08/14/2012] [Indexed: 01/06/2023] Open
Abstract
In Canada, lenalidomide combined with dexamethasone (Len/Dex) is approved for use in relapsed or refractory multiple myeloma (RRMM). Our expert panel sought to provide an up-to-date practical guide on the use of lenalidomide in the managing RRMM within the Canadian clinical setting, including management of common adverse events (AEs). The panel concluded that safe, effective administration of Len/Dex treatment involves the following steps: (1) lenalidomide dose adjustment based on creatinine clearance and the extent of neutropenia or thrombocytopenia, (2) dexamethasone administered at 20-40 mg/week, and (3) continuation of treatment until disease progression or until toxicity persists despite dose reduction. Based on available evidence, the following precautions should reduce the risk of common Len/Dex AEs: (1) all patients treated with Len/Dex should receive thromboprophylaxis, (2) erythropoiesis-stimulating agents (ESAs) should be used cautiously, and (3) females of child-bearing potential and males in contact with such females must use multiple contraception methods. Finally, while Len/Dex can be administered irrespective of prior therapy and in all prognostic subsets, patients with chromosomal deletion 17(p13) have less favorable outcomes with all treatments, including Len/Dex. New directions for the use of lenalidomide in RRMM are also considered.
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Affiliation(s)
- Donna Reece
- Princess Margaret Hospital, University Health Network, 610 University Avenue, Toronto, ON, Canada M5G 2M9
| | - C. Tom Kouroukis
- Department of Oncology, Juravinski Cancer Centre, 699 Concession Street, Hamilton, ON, Canada L8V 5C2
| | - Richard LeBlanc
- Hôpital Maisonneuve-Rosemont, University of Montreal, Montreal, QC, Canada H1T 2M4
| | - Michael Sebag
- McGill University Health Centre, McGill University, Montreal, QC, Canada H3A 1A1
| | - Kevin Song
- Leukemia/BMT Program of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada V5Z 1M9
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40
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Zhu YX, Kortuem KM, Stewart AK. Molecular mechanism of action of immune-modulatory drugs thalidomide, lenalidomide and pomalidomide in multiple myeloma. Leuk Lymphoma 2012; 54:683-7. [PMID: 22966948 DOI: 10.3109/10428194.2012.728597] [Citation(s) in RCA: 208] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Although several mechanisms have been proposed to explain the activity of thalidomide, lenalidomide and pomalidomide in multiple myeloma (MM), including demonstrable anti-angiogenic, anti-proliferative and immunomodulatory effects, the precise cellular targets and molecular mechanisms have only recently become clear. A landmark study recently identified cereblon (CRBN) as a primary target of thalidomide teratogenicity. Subsequently it was demonstrated that CRBN is also required for the anti-myeloma activity of thalidomide and related drugs, the so-called immune-modulatory drugs (IMiDs). Low CRBN expression was found to correlate with drug resistance in MM cell lines and primary MM cells. One of the downstream targets of CRBN identified is interferon regulatory factor 4 (IRF4), which is critical for myeloma cell survival and is down-regulated by IMiD treatment. CRBN is also implicated in several effects of IMiDs, such as down-regulation of tumor necrosis factor-α (TNF-α) and T cell immunomodulatory activity, demonstrating that the pleotropic actions of the IMiDs are initiated by binding to CRBN. Future dissection of CRBN downstream signaling will help to delineate the underlying mechanisms for IMiD action and eventually lead to development of new drugs with more specific anti-myeloma activities. It may also provide a biomarker to predict IMiD response and resistance.
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Affiliation(s)
- Yuan Xiao Zhu
- Division of Hematology-Oncology, Mayo Clinic, Scottsdale, AZ 85259, USA
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Ocio EM, Mateos MV, San-Miguel JF. Novel agents derived from the currently approved treatments for MM: novel proteasome inhibitors and novel IMIDs. Expert Opin Investig Drugs 2012; 21:1075-87. [PMID: 22621161 DOI: 10.1517/13543784.2012.691164] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Several novel proteasome inhibitors (PIs) and immunomodulatory agents (IMIDs) with similar, but not exactly the same, mechanisms of action than their predecessors have been developed in the last years with three different aims: to increase the efficacy; to overcome the resistance and to exhibit a better toxicity profile. AREAS COVERED This review summarizes the mechanism of action of novel PIs (carfilzomib, ONX-0912, MLN-9708, marizomib and CEP-18770) and IMIDs (pomalidomide), stressing the similarities and differences with their parental drugs. It also reviews their most updated clinical results. A search of the recent literature in published papers and abstracts from the most important oncology scientific meetings (ASCO and ASH) has been performed. EXPERT OPINION Novel PIs and IMIDs show clinical activity as single agents and in combination with dexamethasone, with similar or even higher efficacy than their predecessors; moreover, they may even overcome resistance to their parental drugs, indicating that there are some differences in their mechanisms of action and resistance. The investigation of these mechanisms of resistance and ways to overcome it would allow the optimization of the sequential use of these agents, and the design of novel therapeutic strategies and more appropriate scientifically based combinations.
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Affiliation(s)
- Enrique M Ocio
- University of Salamanca, University Hospital & Cancer Research Center, Department of Hematology, Salamanca, Spain.
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Ludwig H, Avet-Loiseau H, Bladé J, Boccadoro M, Cavenagh J, Cavo M, Davies F, de la Rubia J, Delimpasi S, Dimopoulos M, Drach J, Einsele H, Facon T, Goldschmidt H, Hess U, Mellqvist UH, Moreau P, San-Miguel J, Sondergeld P, Sonneveld P, Udvardy M, Palumbo A. European perspective on multiple myeloma treatment strategies: update following recent congresses. Oncologist 2012; 17:592-606. [PMID: 22573721 DOI: 10.1634/theoncologist.2011-0391] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The management of multiple myeloma has undergone profound changes over the recent past as a result of advances in our understanding of the disease biology as well as improvements in treatment and supportive care strategies. Notably, recent years have seen a surge in studies incorporating the novel agents thalidomide, bortezomib, and lenalidomide into treatment for different disease stages and across different patient groups. This article presents an update to a previous review of European treatment practices and is based on discussions during an expert meeting that was convened to review novel agent data published or presented at medical meetings until the end of 2011 and to assess their impact on treatment strategies.
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Affiliation(s)
- Heinz Ludwig
- Department of Medicine I, Center of Oncology and Hematology, Wilhelminenspital, Vienna, Austria.
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Treatment strategies in relapsed and refractory multiple myeloma: a focus on drug sequencing and 'retreatment' approaches in the era of novel agents. Leukemia 2011; 26:73-85. [PMID: 22024721 DOI: 10.1038/leu.2011.310] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Treatment of multiple myeloma has evolved over the last decade, most notably with the introduction of highly effective novel agents. It is now possible to aim for deep disease responses in a greater number of patients in an attempt to prolong remission duration and survival. Initially introduced in the relapsed setting, the novel agents, namely thalidomide, bortezomib and lenalidomide, are now being increasingly incorporated into upfront treatment strategies, raising questions about the feasibility of 'retreatment' with such agents. Also, in a disease that is characterized by multiple relapses, the 'sequencing' of the different effective options is an important question. In the frontline setting, the first remission is likely to be the period during which patients will enjoy the best quality of life. Thus, the goal should be to achieve a first remission that is the longest possible by using the most effective treatment upfront. At relapse, the challenge is to select the optimal treatment for each patient while balancing efficacy and toxicity. The decision will depend on both disease- and patient-related factors. This review aimed to assess the available research data addressing 'retreatment' approaches, drug 'sequencing' and the long-term impact of upfront therapy with novel drugs.
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