1
|
Mohyuddin GR, Goodman AM. Overtreatment of multiple myeloma and its precursor states: de-escalation is an urgent need in clinical practice and trials. Nat Rev Clin Oncol 2024; 21:561-562. [PMID: 38649423 DOI: 10.1038/s41571-024-00895-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Affiliation(s)
- Ghulam Rehman Mohyuddin
- Division of Hematology and Hematologic Malignancies, Department of Medicine, University of Utah, Salt Lake City, UT, USA.
| | - Aaron M Goodman
- Division of Blood and Marrow Transplantation, Department of Medicine, University of California San Diego, San Diego, CA, USA
| |
Collapse
|
2
|
Rees MJ, Kumar S. High-risk multiple myeloma: Redefining genetic, clinical, and functional high-risk disease in the era of molecular medicine and immunotherapy. Am J Hematol 2024; 99:1560-1575. [PMID: 38613829 DOI: 10.1002/ajh.27327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/22/2024] [Accepted: 04/02/2024] [Indexed: 04/15/2024]
Abstract
Multiple myeloma (MM) exhibits significant heterogeneity in its presentation, genetics, and treatment response. Despite therapeutic advances, some patients continue to relapse early (ER, <18-months) and rapidly cycle through therapies. Myriad prognostic factors have been identified and incorporated into risk stratification models; however, these produce discordant, often three-tiered outputs that fail to identify many patients destined for ER. Treatment strategies are increasingly focused on disease biology and trials enriched for high-risk (HR)MM, but consensus on the minimum required testing and a succinct, specific, and clinically meaningful definition for HRMM remains elusive. We review the risk-factors, definitions, and future directions for HRMM.
Collapse
Affiliation(s)
- Matthew J Rees
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
3
|
Landgren O, Prior TJ, Masterson T, Heuck C, Bueno OF, Dash AB, Einsele H, Goldschmidt H, Knop S, Li C, Mellqvist UH, McFadden I, Oprea C, Ross JA, Talpes M, Hydren JR, Ahlstrom JM, Kazandjian D, Weinhold N, Zhang R, Stetler-Stevenson M, Marti G, Devlin SM. EVIDENCE meta-analysis: evaluating minimal residual disease as an intermediate clinical end point for multiple myeloma. Blood 2024; 144:359-367. [PMID: 38768337 DOI: 10.1182/blood.2024024371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/23/2024] [Accepted: 05/10/2024] [Indexed: 05/22/2024] Open
Abstract
ABSTRACT Estimating progression-free survival (PFS) and overall survival superiority during clinical trials of multiple myeloma (MM) has become increasingly challenging as novel therapeutics have improved patient outcomes. Thus, it is imperative to identify earlier end point surrogates that are predictive of long-term clinical benefit. Minimal residual disease (MRD)-negativity is a common intermediate end point that has shown prognostic value for clinical benefit in MM. This meta-analysis was based on the US Food and Drug Administration guidance for considerations for a meta-analysis of MRD as a clinical end point and evaluates MRD-negativity as an early end point reasonably likely to predict long-term clinical benefit. Eligible studies were phase 2 or 3 randomized controlled clinical trials measuring MRD-negativity as an end point in patients with MM, with follow-up of ≥6 months following an a priori-defined time point of 12 ± 3 months after randomization. Eight newly diagnosed MM studies evaluating 4907 patients were included. Trial-level associations between MRD-negativity and PFS were R2WLSiv, 0.67 (95% confidence interval [CI], 0.43-0.91) and R2copula 0.84 (0.64 to >0.99) at the 12-month time point. The individual-level association between 12-month MRD-negativity and PFS resulted in a global odds ratio (OR) of 4.02 (95% CI, 2.57-5.46). For relapse/refractory MM, there were 4 studies included, and the individual-level association between 12-month MRD-negativity and PFS resulted in a global OR of 7.67 (4.24-11.10). A clinical trial demonstrating a treatment effect on MRD is reasonably likely to eventually demonstrate a treatment effect on PFS, suggesting that MRD may be an early clinical end point reasonably likely to predict clinical benefit in MM, that may be used to support accelerated approval and thereby, expedite the availability of new drugs to patients with MM.
Collapse
Affiliation(s)
- Ola Landgren
- Division of Myeloma, Department of Medicine, Sylvester Myeloma Research Institute, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
| | | | | | | | | | | | - Hermann Einsele
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Hartmut Goldschmidt
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Knop
- Nuremberg General Hospital and Paracelsus Medical School, Nuremberg, Germany
| | | | | | | | | | | | | | | | | | - Dickran Kazandjian
- Division of Myeloma, Department of Medicine, Sylvester Myeloma Research Institute, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
| | - Niels Weinhold
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | | | | | - Gerald Marti
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Sean M Devlin
- Memorial Sloan Kettering Cancer Center, New York, NY
| |
Collapse
|
4
|
Bommier C, Maurer MJ, Lambert J. What clinicians should know about surrogate end points in hematologic malignancies. Blood 2024; 144:11-20. [PMID: 38603637 DOI: 10.1182/blood.2023022269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 03/14/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024] Open
Abstract
ABSTRACT Use of surrogates as primary end points is commonplace in hematology/oncology clinical trials. As opposed to prognostic markers, surrogates are end points that can be measured early and yet can still capture the full effect of treatment, because it would be captured by the true outcome (eg, overall survival). We discuss the level of evidence of the most commonly used end points in hematology and share recommendations on how to apply and evaluate surrogate end points in research and clinical practice. Based on the statistical literature, this clinician-friendly review intends to build a bridge between clinicians and surrogacy specialists.
Collapse
Affiliation(s)
- Côme Bommier
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
- Epidemiology and Clinical Statistics for Tumor, Respiratory, and Resuscitation Assessments Team, INSERM, U1153, Assistance Publique-Hôpitaux de Paris Hôpital St Louis, Université Paris Cité, Paris, France
| | - Matthew John Maurer
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Jerome Lambert
- Epidemiology and Clinical Statistics for Tumor, Respiratory, and Resuscitation Assessments Team, INSERM, U1153, Assistance Publique-Hôpitaux de Paris Hôpital St Louis, Université Paris Cité, Paris, France
| |
Collapse
|
5
|
Szalat R, Anderson K, Munshi N. Role of minimal residual disease assessment in multiple myeloma. Haematologica 2024; 109:2049-2059. [PMID: 38328864 PMCID: PMC11215375 DOI: 10.3324/haematol.2023.284662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/31/2024] [Indexed: 02/09/2024] Open
Abstract
Multiple myeloma (MM) is a hematologic malignancy characterized by clonal proliferation of plasma cells. MM is a heterogeneous disease, featured by various molecular subtypes with different outcomes. With the advent of very efficient therapies including monoclonal antibodies, bispecific T-cell engagers and chimeric antigen receptor T cells (CAR T cells), most MM patients now have a prolonged survival. However, the disease remains incurable, and a subgroup of high-risk patients continue to have early relapse and short survival. Novel and highly sensitive methods have been developed allowing the detection of minimal residual disease (MRD) during or after treatment. Achievement of MRD negativity is a strong and independent prognostic factor in both prospective randomized clinical trials and in the real-world setting. While MRD assessment is now a validated endpoint in clinical trials, its incorporation in clinical practice is not yet established and its potential impact on guiding therapy remains under in-depth evaluation. Here we discuss the different methods available for MRD assessment and the role of MRD evaluation in MM management.
Collapse
Affiliation(s)
- Raphael Szalat
- Section of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA.
| | - Kenneth Anderson
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Nikhil Munshi
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA
| |
Collapse
|
6
|
Rajkumar SV. Multiple myeloma: 2024 update on diagnosis, risk-stratification, and management. Am J Hematol 2024. [PMID: 38943315 DOI: 10.1002/ajh.27422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Accepted: 06/11/2024] [Indexed: 07/01/2024]
Abstract
DISEASE OVERVIEW Multiple myeloma accounts for approximately 10% of hematologic malignancies. DIAGNOSIS The diagnosis requires ≥10% clonal bone marrow plasma cells or a biopsy proven plasmacytoma plus evidence of one or more multiple myeloma defining events (MDE): CRAB (hypercalcemia, renal failure, anemia, or lytic bone lesions) attributable to the plasma cell disorder, bone marrow clonal plasmacytosis ≥60%, serum involved/uninvolved free light chain (FLC) ratio ≥100 (provided involved FLC is ≥100 mg/L and urine monoclonal protein is ≥200 mg/24 h), or >1 focal lesion on magnetic resonance imaging. RISK STRATIFICATION The presence of del(17p), t(4;14), t(14;16), t(14;20), gain 1q, del 1p, or p53 mutation is considered high-risk multiple myeloma. Presence of any two high risk factors is considered double-hit myeloma; three or more high risk factors is triple-hit myeloma. RISK-ADAPTED INITIAL THERAPY In patients who are candidates for autologous stem cell transplantation, induction therapy consists of anti-CD38 monoclonal antibody plus bortezomib, lenalidomide, dexamethasone (VRd) followed by autologous stem cell transplantation (ASCT). Selected standard risk patients can delay transplant until first relapse. Frail patients who not candidates for transplant are treated with VRd for approximately 8-12 cycles followed by maintenance or alternatively with daratumumab, lenalidomide, dexamethasone (DRd) until progression. MAINTENANCE THERAPY Standard risk patients need lenalidomide maintenance, while bortezomib plus lenalidomide maintenance is needed for high-risk myeloma. MANAGEMENT OF RELAPSED DISEASE A triplet regimen is usually needed at relapse, with the choice of regimen varying with each successive relapse. Chimeric antigen receptor T (CAR-T) cell therapy and bispecific antibodies are additional options.
Collapse
|
7
|
Morè S, Corvatta L, Manieri VM, Morsia E, Offidani M. The Challenging Approach to Multiple Myeloma: From Disease Diagnosis and Monitoring to Complications Management. Cancers (Basel) 2024; 16:2263. [PMID: 38927968 PMCID: PMC11202048 DOI: 10.3390/cancers16122263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/12/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
The outcome of multiple myeloma (MM) has significantly improved in the last few decades due to several factors such as new biological discoveries allowing to better stratify disease risk, development of more effective therapies and better management of side effects related to them. However, handling all these aspects requires an interdisciplinary approach involving multiple knowledge and collaboration of different specialists. The hematologist, faced with a patient with MM, must not only choose a treatment according to patient and disease characteristics but must also know when therapy needs to be started and how to monitor it during and after treatment. Moreover, he must deal not only with organ issues related to MM such as bone disease, renal failure or neurological disease but also with adverse events, often very serious, related to novel therapies, particularly new generation immunotherapies such as CAR T cell therapy and bispecific antibodies. In this review, we provide an overview on the newer MM diagnostic and monitoring strategies and on the main side effects of MM therapies, focusing on adverse events occurring during treatment with CAR T cells and bispecific antibodies.
Collapse
Affiliation(s)
- Sonia Morè
- Clinica di Ematologia Azienda Ospedaliero, Universitaria delle Marche, 60126 Ancona, Italy; (S.M.); (V.M.M.); (E.M.)
| | - Laura Corvatta
- U.O.C. Medicina, Ospedale Profili, 60044 Fabriano, Italy;
| | - Valentina Maria Manieri
- Clinica di Ematologia Azienda Ospedaliero, Universitaria delle Marche, 60126 Ancona, Italy; (S.M.); (V.M.M.); (E.M.)
| | - Erika Morsia
- Clinica di Ematologia Azienda Ospedaliero, Universitaria delle Marche, 60126 Ancona, Italy; (S.M.); (V.M.M.); (E.M.)
| | - Massimo Offidani
- Clinica di Ematologia Azienda Ospedaliero, Universitaria delle Marche, 60126 Ancona, Italy; (S.M.); (V.M.M.); (E.M.)
| |
Collapse
|
8
|
Szlasa W, Dybko J. Current status of bispecific antibodies and CAR-T therapies in multiple myeloma. Int Immunopharmacol 2024; 134:112043. [PMID: 38733817 DOI: 10.1016/j.intimp.2024.112043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/28/2024] [Accepted: 04/05/2024] [Indexed: 05/13/2024]
Abstract
Multiple myeloma (MM), a malignancy of plasma cells, is an incurable disease that is characterized by the neoplastic proliferation of plasma cells leading to extensive skeletal destruction. This includes osteolytic lesions, osteopenia, and pathologic fractures. MM is clinically manifested through bone pain, renal insufficiency, hypercalcemia, anemia, and recurrent infections. Its prevalence and the need for effective treatment underscore the importance of this research. Recent advancements in MM therapy have been significant, particularly with the integration of daratumumab into first-line treatments. The use of daratumumab in regimens such as DRD (Daratumumab, Revlimid, Dexamethasone) and D-RVd (Daratumumab, Lenalidomide, Bortezomib, Dexamethasone) represents a paradigm shift in the treatment landscape. GRIFFIN and CASSIOPEIA trials have highlighted the efficacy of these regimens, particularly in prolonging progression-free survival and deepening patient responses. The shift from older regimens like MPV (Melphalan, Prednisone, Velcade) to more effective ones like DRD and RVD has been pivotal in treatment strategies. This review also focuses on the potential of Chimeric Antigen Receptor T-cell therapy and bispecific antibodies in MM. CAR-T therapy, which has shown success in other hematological malignancies, is being explored for its ability to specifically target MM cells. The latest clinical trials and research findings are analyzed to evaluate the efficacy and challenges of CAR-T therapy in MM. Additionally, the role of bispecific antibodies, which are designed to bind both cancer cells and T cells, is explored. These antibodies offer a unique mechanism that could complement the effects of CAR-T therapy.
Collapse
Affiliation(s)
- Wojciech Szlasa
- Lower Silesia Centre for Oncology, Pulmonology and Hematology in Wrocław, 53-439 Wroclaw, Poland; Medical University Hospital, Borowska 213, 50-556, Wrocław, Poland; Department of Molecular and Cellular Biology, Faculty of Pharmacy, Wroclaw Medical University, Wroclaw, Poland
| | - Jarosław Dybko
- Lower Silesia Centre for Oncology, Pulmonology and Hematology in Wrocław, 53-439 Wroclaw, Poland; Department of Oncology and Hematology, Wroclaw University of Science and Technology, 50-370 Wrocław, Poland.
| |
Collapse
|
9
|
Zanwar S, Sidana S, Shune L, Puglianini OC, Pasvolsky O, Gonzalez R, Dima D, Afrough A, Kaur G, Davis JA, Herr M, Hashmi H, Forsberg P, Sborov D, Anderson LD, McGuirk JP, Wagner C, Lieberman-Cribbin A, Rossi A, Freeman CL, Locke FL, Richard S, Khouri J, Lin Y, Patel KK, Kumar SK, Hansen DK. Impact of extramedullary multiple myeloma on outcomes with idecabtagene vicleucel. J Hematol Oncol 2024; 17:42. [PMID: 38845015 PMCID: PMC11157748 DOI: 10.1186/s13045-024-01555-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 05/06/2024] [Indexed: 06/09/2024] Open
Abstract
Idecabtagene vicleucel (Ide-cel) has demonstrated excellent efficacy and durable responses in patients with relapsed/refractory multiple myeloma (RRMM). However, the outcomes with ide-cel in patients with extramedullary disease (EMD) remain incompletely characterized. We included patients with RRMM treated with ide-cel between May 2021 and April 2023 across 11 US academic institutions. Visceral or soft tissue lesions non-contiguous from bone was classified as EMD. Time-to-event analyses were performed from date of ide-cel infusion. Among 351 patients, 84 (24%) had EMD prior to infusion. The median follow-up from ide-cel infusion was 18.2 months (95% CI: 17-19.3). The day 90 overall response rates (ORR) were 52% vs. 82% for the EMD and non-EMD cohorts, respectively (p < 0.001). The median progression-free survival (PFS) was 5.3 months (95% CI: 4.1-6.9) for the EMD cohort vs. 11.1 months (95% CI: 9.2-12.6; p < 0.0001) for the non-EMD cohort. In a multivariable analysis, EMD was an independent predictor of inferior PFS [hazard ratio 1.5 (1.1-2.2), p = 0.02]. The median overall survival was 14.8 months [95% CI: 9-Not reached (NR)] vs. 26.9 months (26.3 vs. NR, p = 0.006) for the EMD and non-EMD cohorts, respectively. Extramedullary disease represents an independent predictor of inferior day 90 ORR and PFS among patients treated with ide-cel.
Collapse
Affiliation(s)
- Saurabh Zanwar
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Surbhi Sidana
- Stanford University School of Medicine, Stanford, CA, USA
| | - Leyla Shune
- The University of Kansas Medical Center, Kansas City, KS, USA
| | - Omar Castaneda Puglianini
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Oren Pasvolsky
- Department of Lymphoma/Myeloma, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebecca Gonzalez
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Danai Dima
- Cleveland Clinic Taussig Cancer Center, Cleveland, OH, USA
| | - Aimaz Afrough
- UT Southwestern Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, USA
| | - Gurbakhash Kaur
- UT Southwestern Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, USA
| | - James A Davis
- Medical University of South Carolina, Charleston, SC, USA
| | - Megan Herr
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Hamza Hashmi
- Medical University of South Carolina, Charleston, SC, USA
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter Forsberg
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Douglas Sborov
- The University of Utah Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Larry D Anderson
- UT Southwestern Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, USA
| | | | - Charlotte Wagner
- The University of Utah Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Alex Lieberman-Cribbin
- Department of Medicine, Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Adriana Rossi
- Department of Medicine, Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ciara L Freeman
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Frederick L Locke
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Shambavi Richard
- Department of Medicine, Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jack Khouri
- Cleveland Clinic Taussig Cancer Center, Cleveland, OH, USA
| | - Yi Lin
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Krina K Patel
- Department of Lymphoma/Myeloma, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Shaji K Kumar
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
| | - Doris K Hansen
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL, USA.
| |
Collapse
|
10
|
Meseha M, Hoffman J, Kazandjian D, Landgren O, Diamond B. Minimal Residual Disease-Adapted Therapy in Multiple Myeloma: Current Evidence and Opinions. Curr Oncol Rep 2024; 26:679-690. [PMID: 38676789 PMCID: PMC11169024 DOI: 10.1007/s11912-024-01537-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2024] [Indexed: 04/29/2024]
Abstract
PURPOSE OF REVIEW Multiple myeloma (MM) is a biologically heterogeneous malignancy with relatively uniform treatment paradigms. This review aims to assess the growing role of Minimal Residual Disease (MRD) assessment in facilitating response-adapted therapeutic decision making to individualize therapy in MM. RECENT FINDINGS MRD has been repeatedly demonstrated to provide strong prognostic information, superseding traditional IMWG response criteria. The use of MRD to modulate therapy remains controversial. Here, we review the existing landscape of MRD-adapted trial designs in both induction/consolidation and maintenance settings, including recent data from influential studies and retrospective analyses. We navigate existing data, leverage the increased resolution of longitudinal MRD assessments, and comment on trials in progress to explain our current utilization of MRD in the clinic. MRD transcends traditional response assessments by providing a window into disease-treatment interaction over time. As a strong patient-level surrogate, MRD has limited current use in individualizing treatment, but is poised to comprehensively shape treatment strategies at many key points in a patient's MM course.
Collapse
Affiliation(s)
- Mina Meseha
- Myeloma Institute, Sylvester Comprehensive Cancer Center, University of Miami, 1120 NW 14th Street, Clinical Research Building, Miami, FL, 33136, USA
| | - James Hoffman
- Myeloma Institute, Sylvester Comprehensive Cancer Center, University of Miami, 1120 NW 14th Street, Clinical Research Building, Miami, FL, 33136, USA
| | - Dickran Kazandjian
- Myeloma Institute, Sylvester Comprehensive Cancer Center, University of Miami, 1120 NW 14th Street, Clinical Research Building, Miami, FL, 33136, USA
| | - Ola Landgren
- Myeloma Institute, Sylvester Comprehensive Cancer Center, University of Miami, 1120 NW 14th Street, Clinical Research Building, Miami, FL, 33136, USA
| | - Benjamin Diamond
- Myeloma Institute, Sylvester Comprehensive Cancer Center, University of Miami, 1120 NW 14th Street, Clinical Research Building, Miami, FL, 33136, USA.
| |
Collapse
|
11
|
Quivoron C, Michot JM, Danu A, Lecourt H, Saada V, Saleh K, Vergé V, Cotteret S, Bernard OA, Ribrag V. Sensitivity, specificity, and accuracy of molecular profiling on circulating cell-free DNA in refractory or relapsed multiple myeloma patients, results of MM-EP1 study. Leuk Lymphoma 2024; 65:789-799. [PMID: 38433500 DOI: 10.1080/10428194.2024.2320258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/13/2024] [Indexed: 03/05/2024]
Abstract
As a promising alternative to bone marrow aspiration (BMA), mutational profiling on blood-derived circulating cell-free tumor DNA (cfDNA) is a harmless and simple technique to monitor molecular response and treatment resistance of patients with refractory/relapsed multiple myeloma (R/R MM). We evaluated the sensitivity and specificity of cfDNA compared to BMA CD138 positive myeloma plasma cells (PCs) in a series of 45 R/R MM patients using the 29-gene targeted panel (AmpliSeq) NGS. KRAS, NRAS, FAM46C, DIS3, and TP53 were the most frequently mutated genes. The average sensitivity and specificity of cfDNA detection were 65% and 97%, respectively. The concordance per gene between the two samples was good to excellent according to Cohen's κ coefficients interpretation. An increased number of mutations detected in cfDNA were associated with a decreased overall survival. In conclusion, we demonstrated cfDNA NGS analysis feasibility and accuracy in R/R MM patients who may benefit from early phase clinical trial.
Collapse
Affiliation(s)
- C Quivoron
- Translational Hematology Laboratory, AMMICa, INSERM US23/CNRS UAR3655, Gustave Roussy Cancer Campus, Villejuif, France
- INSERM U1170, Université Paris-Saclay, Gustave Roussy Cancer Campus, Villejuif, France
| | - J-M Michot
- INSERM U1170, Université Paris-Saclay, Gustave Roussy Cancer Campus, Villejuif, France
- Drug Development Department: Département d'Innovation Thérapeutique et d'Essais Précoces (DITEP), Gustave Roussy, Villejuif, France
| | - A Danu
- Hematology Department, Gustave Roussy, Villejuif, France
| | - H Lecourt
- Translational Hematology Laboratory, AMMICa, INSERM US23/CNRS UAR3655, Gustave Roussy Cancer Campus, Villejuif, France
| | - V Saada
- Department of Medical Biology and Pathology, Gustave Roussy, Villejuif, France
| | - K Saleh
- Hematology Department, Gustave Roussy, Villejuif, France
| | - V Vergé
- Department of Medical Biology and Pathology, Gustave Roussy, Villejuif, France
| | - S Cotteret
- Department of Medical Biology and Pathology, Gustave Roussy, Villejuif, France
| | - O A Bernard
- INSERM U1170, Université Paris-Saclay, Gustave Roussy Cancer Campus, Villejuif, France
| | - V Ribrag
- Translational Hematology Laboratory, AMMICa, INSERM US23/CNRS UAR3655, Gustave Roussy Cancer Campus, Villejuif, France
- INSERM U1170, Université Paris-Saclay, Gustave Roussy Cancer Campus, Villejuif, France
- Drug Development Department: Département d'Innovation Thérapeutique et d'Essais Précoces (DITEP), Gustave Roussy, Villejuif, France
- Hematology Department, Gustave Roussy, Villejuif, France
| |
Collapse
|
12
|
Rees MJ, D'Agostino M, Leypoldt LB, Kumar S, Weisel KC, Gay F. Navigating High-Risk and Ultrahigh-Risk Multiple Myeloma: Challenges and Emerging Strategies. Am Soc Clin Oncol Educ Book 2024; 44:e433520. [PMID: 38772002 DOI: 10.1200/edbk_433520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
Despite significant improvement in the outcomes of patients with newly diagnosed multiple myeloma (NDMM) with novel therapies, there is still an underserved high-risk (HR) population that experiences early disease progression and death. With the median survival crossing 10 years, we defined ultrahigh-risk (uHR)MM as MM leading to death within 24-36 months of diagnosis and HRMM as MM leading to death within 36-60 months. Several features have emerged as markers of uHRMM: the co-occurrence of two or more high-risk cytogenetic abnormalities, extramedullary disease, plasma cell leukemia and a high-risk gene expression profiling signature. The heterogeneous risk definition across trials, the few trials available designed for HR patients, and the small HR subgroups in all-comers trials make it difficult to generate recommendations with high levels of evidence. Nevertheless, regardless of treatment administered, several studies consistently showed that achieving and maintaining measurable residual disease negativity is now considered the main factor able to mitigate the adverse prognosis related to baseline features. For fit patients with HR transplant-eligible (TE) NDMM, quadruplet induction/consolidation treatment with anti-CD38 monoclonal antibodies, immunomodulatory agents, proteasome inhibitors and dexamethasone, and autologous stem-cell transplant and maintenance with, if available, at least a doublet combination could be considered the option of choice. For non-TE NDMM, considering the recent data generated and carefully reviewing those upcoming, quadruplet treatment consisting of anti-CD38 monoclonal antibodies, immunomodulatory agents, proteasome inhibitors, and dexamethasone should also be considered. Future trials integrating BCMA-directed novel generation immunotherapies hold great potential for further advancing the treatment landscape in all NDMM patients with HR disease.
Collapse
Affiliation(s)
| | - Mattia D'Agostino
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, AOU Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Lisa B Leypoldt
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Katja C Weisel
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Francesca Gay
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, AOU Città della Salute e della Scienza, University of Torino, Torino, Italy
| |
Collapse
|
13
|
Fonseca R, Rossi A, Medhekar R, Voelker J, Homan T, Wilcock J, Karakusevic A, Cochrane J, Bridge D, Perry R, Kaila S, Davies FE. Clinical consensus on treatments for transplant-ineligible newly diagnosed multiple myeloma: double-blinded Delphi panel. Future Oncol 2024:1-12. [PMID: 38861282 DOI: 10.1080/14796694.2024.2342228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 04/09/2024] [Indexed: 06/12/2024] Open
Abstract
Aim: Obtain clinical consensus on factors impacting first-line prescribing for transplant-ineligible (TIE) patients with newly diagnosed multiple myeloma (NDMM). Materials & methods: A double-blinded, modified Delphi panel was employed. USA-based hematologists/oncologists who treat TIE patients with NDMM were selected as expert panelists. Results: Consensus was reached that patient frailty, performance status, comorbidities, treatment efficacy, and adverse event profile affect first-line prescribing. All panelists agreed it is important to use the most efficacious treatment first; 88% of panelists considered daratumumab-containing regimens the most efficacious. Panelists agreed treatment should be continued until progression while benefits outweigh risk. Conclusion: Findings reinforce the importance of using the most efficacious regimen upfront for TIE NDMM, and nearly all panelists considered daratumumab-containing regimens the most efficacious treatment.
Collapse
Affiliation(s)
- Rafael Fonseca
- Division of Hematology and Medical Oncology, Mayo Clinic in Arizona, Phoenix, AZ, USA
| | - Adriana Rossi
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | | | | | | | | | | | - Faith E Davies
- Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| |
Collapse
|
14
|
Heestermans R, Schots R, De Becker A, Van Riet I. Liquid Biopsies as Non-Invasive Tools for Mutation Profiling in Multiple Myeloma: Application Potential, Challenges, and Opportunities. Int J Mol Sci 2024; 25:5208. [PMID: 38791247 PMCID: PMC11121516 DOI: 10.3390/ijms25105208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Over the last decades, the survival of multiple myeloma (MM) patients has considerably improved. However, despite the availability of new treatments, most patients still relapse and become therapy-resistant at some point in the disease evolution. The mutation profile has an impact on MM patients' outcome, while typically evolving over time. Because of the patchy bone marrow (BM) infiltration pattern, the analysis of a single bone marrow sample can lead to an underestimation of the known genetic heterogeneity in MM. As a result, interest is shifting towards blood-derived liquid biopsies, which allow for a more comprehensive and non-invasive genetic interrogation without the discomfort of repeated BM aspirations. In this review, we compare the application potential for mutation profiling in MM of circulating-tumor-cell-derived DNA, cell-free DNA and extracellular-vesicle-derived DNA, while also addressing the challenges associated with their use.
Collapse
Affiliation(s)
- Robbe Heestermans
- Department of Clinical Biology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium
- Department of Hematology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium
- Translational Oncology Research Center (Team Hematology and Immunology), Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Rik Schots
- Department of Hematology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium
- Translational Oncology Research Center (Team Hematology and Immunology), Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Ann De Becker
- Department of Hematology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium
- Translational Oncology Research Center (Team Hematology and Immunology), Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Ivan Van Riet
- Department of Hematology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium
- Translational Oncology Research Center (Team Hematology and Immunology), Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
| |
Collapse
|
15
|
Pereira R, Bergantim R. An Assessment of the Effectiveness and Safety of Chimeric Antigen Receptor T-Cell Therapy in Multiple Myeloma Patients with Relapsed or Refractory Disease: A Systematic Review and Meta-Analysis. Int J Mol Sci 2024; 25:4996. [PMID: 38732213 PMCID: PMC11084236 DOI: 10.3390/ijms25094996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 04/30/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
Multiple myeloma (MM), the second most common hematologic malignancy, remains incurable, and its incidence is rising. Chimeric Antigen Receptor T-cell (CAR-T cell) therapy has emerged as a novel treatment, with the potential to improve the survival and quality of life of patients with relapsed/refractory multiple myeloma (rrMM). In this systematic review and meta-analysis, conducted in accordance with PRISMA guidelines, we aim to provide a concise overview of the latest developments in CAR-T therapy, assess their potential implications for clinical practice, and evaluate their efficacy and safety outcomes based on the most up-to-date evidence. A literature search conducted from 1 January 2019 to 12 July 2023 on Medline/PubMed, Scopus, and Web of Science identified 2273 articles, of which 29 fulfilled the specified criteria for inclusion. Our results offer robust evidence supporting CAR-T cell therapy's efficacy in rrMM patients, with an encouraging 83.21% overall response rate (ORR). A generally safe profile was observed, with grade ≥ 3 cytokine release syndrome (CRS) at 7.12% and grade ≥ 3 neurotoxicity at 1.37%. A subgroup analysis revealed a significantly increased ORR in patients with fewer antimyeloma regimens, while grade ≥ 3 CRS was more common in those with a higher proportion of high-risk cytogenetics and prior exposure to BCMA therapy.
Collapse
Affiliation(s)
- Rita Pereira
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal;
| | - Rui Bergantim
- i3S—Instituto de Investigação e Inovação em Saúde, University of Porto, 4200-135 Porto, Portugal
- Cancer Drug Resistance Group, IPATIMUP—Institute of Molecular Pathology and Immunology of the University of Porto, 4200-135 Porto, Portugal
- Clinical Hematology Department, Hospital Center of São João, 4200-319 Porto, Portugal
- Clinical Hematology Department, FMUP—Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal
| |
Collapse
|
16
|
Pasquini MC, Wallace PK, Logan B, Kaur M, Tario JD, Howard A, Zhang Y, Brunstein C, Efebera Y, Geller N, Giralt S, Hari P, Horowitz MM, Koreth J, Krishnan A, Landau H, Somlo G, Shah N, Stadtmauer E, Vogl DT, Vesole DH, McCarthy PL, Hahn T. Minimal Residual Disease Status in Multiple Myeloma 1 Year After Autologous Hematopoietic Cell Transplantation and Lenalidomide Maintenance Are Associated With Long-Term Overall Survival. J Clin Oncol 2024:JCO2300934. [PMID: 38701390 DOI: 10.1200/jco.23.00934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 01/31/2024] [Accepted: 03/01/2024] [Indexed: 05/05/2024] Open
Abstract
PURPOSE Prognostic Immunophenotyping in Myeloma Response (PRIMeR) is an ancillary study of minimal residual disease (MRD) assessment for multiple myeloma by next-generation multiparameter flow cytometry (MFC). Patients were enrolled on a three-arm randomized control trial (Blood and Marrow Transplants Clinical Trials Network 0702 Stem Cell Transplant for Myeloma in Combination of Novel Agents [STaMINA]; ClinicalTrials.gov identifier: NCT01109004). METHODS Four hundred and thirty-five patients consented to the MRD panel, which included 10 monoclonal antibodies measured via six-color MFC. MRD was measured at baseline/preautologous hematopoietic cell transplant (BL/preAutoHCT), premaintenance (PM), and 1 year (Y1) after AutoHCT with a sensitivity of 10-5 to 10-6. The primary objective was to assess MRD-negative (MRDneg) at 1 year after AutoHCT and progression-free survival and overall survival (PFS/OS). RESULTS Similar to the STaMINA results, at a median follow-up of 70 months, there was no significant difference in PFS/OS by treatment arm in the PRIMeR patients. MRDneg at all three time points was associated with significantly improved PFS, and MRDneg at Y1 had significantly longer OS. Multivariate analysis of PFS, adjusting for disease risk and treatment arm, demonstrated hazard ratios (HRs) in MRD-positive patients compared with MRDneg patients at BL, PM, and Y1 of 1.55 (P = .0074), 1.83 (P = .0007), and 3.61 (P < .0001), respectively. Corresponding HRs for OS were 1.19 (P = .48), 0.88 (P = .68), and 3.36 (P < .001). Patients with sustained MRDneg or who converted to MRDneg by Y1 had similar PFS/OS. CONCLUSION To our knowledge, this first, prospective US cooperative group, multicenter study demonstrates that MRDneg at Y1 after AutoHCT with lenalidomide maintenance is prognostic for improved 6-year PFS and OS. Serial MRD measurements may direct trials to test how further therapy may improve long-term PFS and OS.
Collapse
Affiliation(s)
| | | | | | | | | | - Alan Howard
- National Marrow Donor Program, Minneapolis, MN
| | - Yali Zhang
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | - Yvonne Efebera
- OhioHealth, Columbus, OH
- Ohio State University, Columbus, OH
| | - Nancy Geller
- National Heart, Lung and Blood Institute, Bethesda, MD
| | - Sergio Giralt
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | | | - Nina Shah
- University California San Francisco, San Francisco, CA
| | | | - Dan T Vogl
- University of Pennsylvania, Philadelphia, PA
| | | | | | - Theresa Hahn
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| |
Collapse
|
17
|
Pasvolsky O, Pasyar S, Bassett RL, Khan HN, Tanner MR, Bashir Q, Srour S, Saini N, Lin P, Ramdial J, Nieto Y, Lee HC, Patel KK, Kebriaei P, Thomas SK, Weber DM, Orlowski RZ, Shpall EJ, Champlin RE, Qazilbash MH. Impact of pretransplant minimal residual disease in patients with multiple myeloma and a very good partial response or better receiving autologous hematopoietic stem cell transplantation. Cancer 2024; 130:1663-1672. [PMID: 38127583 PMCID: PMC11009063 DOI: 10.1002/cncr.35171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/20/2023] [Accepted: 10/13/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The prognostic significance of minimal residual disease (MRD) status before autologous hematopoietic stem cell transplantation (autoHCT) in patients with multiple myeloma (MM) has not been clearly elucidated. METHODS Retrospective single-center study of adult MM patients who achieved ≥very good partial response (VGPR) after induction therapy from 2015 to 2021 received upfront autoHCT and had available pretransplant MRD status by next-generation flow cytometry. The cohort was divided into pretransplant MRD-negative (MRDneg) and MRD-positive (MRDpos) groups. RESULTS A total of 733 patients were included in our analysis; 425 were MRDneg and 308 MRDpos at autoHCT. In the MRDpos group, more patients had high-risk cytogenetic abnormalities (48% vs. 38%, respectively; p = .025), whereas fewer patients achieved ≥CR before autoHCT (14% vs. 40%; p < .001). At day 100 after autoHCT, 37% of the MRDpos versus 71% of the MRDneg achieved ≥CR, and at best posttransplant response 65% versus 88% achieved ≥CR, respectively. After a median follow-up of 27.6 months (range, 0.7-82.3), the median PFS was significantly shorter for patients in the MRDpos group compared to the MRDneg group: 48.2 months (95% confidence interval [CI], 0.3-80.5) versus 80.1 months (95% CI, 0.5-80.1), respectively (p < .001). There was no significant difference in overall survival between the two groups (p = .41). Pretransplant MRDpos status was predictive of shorter PFS in multivariate analysis (hazard ratio, 1.80; 95% CI, 1.31-2.46; p < .001). The impact of pretransplant MRD status was retained in most of the examined subgroups. CONCLUSIONS In patients achieving ≥VGPR to induction, pretransplant MRDpos status was associated with a lower CR rate after autoHCT and a shorter PFS.
Collapse
Affiliation(s)
- Oren Pasvolsky
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sarah Pasyar
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Roland L. Bassett
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hina N. Khan
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Hematology/Oncology, McGovern Medical School, The University of Texas Health Sciences Center at Houston, Houston, Texas
| | - Mark R. Tanner
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Qaiser Bashir
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Samer Srour
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Neeraj Saini
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul Lin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeremy Ramdial
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yago Nieto
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hans C. Lee
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Krina K. Patel
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sheeba K. Thomas
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Donna M. Weber
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Robert Z. Orlowski
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth J. Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard E. Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Muzaffar H. Qazilbash
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
18
|
Tang HKK, Fung CY, Hwang YY, Lee H, Lau G, Yip SF, Kho B, Lau CK, Leung KH, Au E, Tse E, Sim J, Kwong YL, Chim CS. Prognostic factors in 448 newly diagnosed multiple myeloma receiving bortezomib-based induction: impact of ASCT, transplant refusal and high-risk MM. Bone Marrow Transplant 2024; 59:660-669. [PMID: 38383715 DOI: 10.1038/s41409-024-02227-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 01/18/2024] [Accepted: 01/24/2024] [Indexed: 02/23/2024]
Abstract
In Hong Kong, newly diagnosed multiple myeloma (NDMM) receives bortezomib-based triplet induction. Upfront autologous stem cell transplant (ASCT) is offered to transplant eligible (TE) patients (NDMM ≤ 65 years of age), unless medically unfit (TE-unfit) or refused (TE-refused). Data was retrieved for 448 patients to assess outcomes. For the entire cohort, multivariate analysis showed that male gender (p = 0.006), international staging system (ISS) 3 (p = 0.003), high lactate dehydrogenase (LDH) (p = 7.6 × 10-7) were adverse predictors for overall survival (OS), while complete response/ near complete response (CR/nCR) post-induction (p = 2.7 × 10-5) and ASCT (p = 4.8 × 10-4) were favorable factors for OS. In TE group, upfront ASCT was conducted in 252 (76.1%). Failure to undergo ASCT in TE patients rendered an inferior OS (TE-unfit p = 1.06 × 10-8, TE-refused p = 0.002) and event free survival (EFS) (TE-unfit p = 0.00013, TE-refused p = 0.002). Among TE patients with ASCT, multivariate analysis showed that age ≥ 60 (p = 8.9 × 10-4), ISS 3 (p = 0.019) and high LDH (p = 2.6 × 10-4) were adverse factors for OS. In those with high-risk features (HR cytogenetics, ISS 3, R-ISS 3), ASCT appeared to mitigate their adverse impact. Our data reaffirmed the importance of ASCT. The poor survival inherent with refusal of ASCT should be recognized by clinicians. Finally, improved outcome with ASCT in those with high-risk features warrant further studies.
Collapse
Affiliation(s)
- Hoi Ki Karen Tang
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Chi Yeung Fung
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Yu Yan Hwang
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Harold Lee
- Department of Medicine, Princess Margaret Hospital, Kwai Chung, Hong Kong
| | - Grace Lau
- Department of Medicine, Princess Margaret Hospital, Kwai Chung, Hong Kong
| | - Sze Fai Yip
- Department of Medicine, Tuen Mun Hospital, Tuen Mun, Hong Kong
| | - Bonnie Kho
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Chi Kuen Lau
- Department of Medicine, Tseung Kwan O Hospital, Tseung Kwan O, Hong Kong
| | - Kwan Hung Leung
- Department of Medicine, United Christian Hospital, Kwun Tong, Hong Kong
| | - Elaine Au
- Department of Pathology, Queen Mary Hospital, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Eric Tse
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Joycelyn Sim
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Yok Lam Kwong
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Chor Sang Chim
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pok Fu Lam, Hong Kong.
- Department of Medicine, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong.
| |
Collapse
|
19
|
Haran A, Vaxman I, Gatt ME, Lebel E. Immune Therapies in AL Amyloidosis-A Glimpse to the Future. Cancers (Basel) 2024; 16:1605. [PMID: 38672686 PMCID: PMC11048972 DOI: 10.3390/cancers16081605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/16/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
Light-chain (AL) amyloidosis is a rare plasma cell disorder characterized by the deposition of misfolded immunoglobulin light chains in target organs, leading to multi-organ dysfunction. Treatment approaches have historically mirrored but lagged behind those of multiple myeloma (MM). Recent advancements in MM immunotherapy are gradually being evaluated and adopted in AL amyloidosis. This review explores the current state of immunotherapeutic strategies in AL amyloidosis, including monoclonal antibodies, antibody-drug conjugates, bispecific antibodies, and chimeric antigen receptor T-cell therapy. We discuss the unique challenges and prospects of these therapies in AL amyloidosis, including the exposure of frail AL amyloidosis patients to immune-mediated toxicities such as cytokine release syndrome (CRS) and immune effector-cell-associated neurotoxicity syndrome (ICANS), as well as their efficacy in promoting rapid and deep hematologic responses. Furthermore, we highlight the need for international initiatives and compassionate programs to provide access to these promising therapies and address critical unmet needs in AL amyloidosis management. Finally, we discuss future directions, including optimizing treatment sequencing and mitigating toxicities, to improve outcomes for AL amyloidosis patients.
Collapse
Affiliation(s)
- Arnon Haran
- Department of Hematology, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel; (A.H.); (M.E.G.)
| | - Iuliana Vaxman
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva 49100, Israel;
| | - Moshe E. Gatt
- Department of Hematology, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel; (A.H.); (M.E.G.)
| | - Eyal Lebel
- Department of Hematology, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel; (A.H.); (M.E.G.)
| |
Collapse
|
20
|
Nadeem O, Aranha MP, Redd R, Timonian M, Magidson S, Lightbody ED, Alberge JB, Bertamini L, Dutta AK, El-Khoury H, Bustoros M, Laubach JP, Bianchi G, O'Donnell E, Wu T, Tsuji J, Anderson K, Getz G, Trippa L, Richardson PG, Sklavenitis-Pistofidis R, Ghobrial IM. Long-Term Follow-Up Defines the Population That Benefits from Early Interception in a High-Risk Smoldering Multiple Myeloma Clinical Trial Using the Combination of Ixazomib, Lenalidomide, and Dexamethasone. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.19.24306082. [PMID: 38699307 PMCID: PMC11064995 DOI: 10.1101/2024.04.19.24306082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Background Early therapeutic intervention in high-risk SMM (HR-SMM) has demonstrated benefit in previous studies of lenalidomide with or without dexamethasone. Triplets and quadruplet studies have been examined in this same population. However, to date, none of these studies examined the impact of depth of response on long-term outcomes of participants treated with lenalidomide-based therapy, and whether the use of the 20/2/20 model or the addition of genomic alterations can further define the population that would benefit the most from early therapeutic intervention. Here, we present the results of the phase II study of the combination of ixazomib, lenalidomide, and dexamethasone in patients with HR-SMM with long-term follow-up and baseline single-cell tumor and immune sequencing that help refine the population to be treated for early intervention studies. Methods This is a phase II trial of ixazomib, lenalidomide, and dexamethasone (IRD) in HR-SMM. Patients received 9 cycles of induction therapy with ixazomib 4mg on days 1, 8, and 15; lenalidomide 25mg on days 1-21; and dexamethasone 40mg on days 1, 8, 15, and 22. The induction phase was followed by maintenance with ixazomib 4mg on days 1, 8, and 15; and lenalidomide 15mg d1-21 for 15 cycles for 24 months of treatment. The primary endpoint was progression-free survival after 2 years of therapy. Secondary endpoints included depth of response, biochemical progression, and correlative studies included single-cell RNA sequencing and/or whole-genome sequencing of the tumor and single-cell sequencing of immune cells at baseline. Results Fifty-five patients, with a median age of 64, were enrolled in the study. The overall response rate was 93%, with 31% of patients achieving a complete response and 45% achieving a very good partial response or better. The most common grade 3 or greater treatment-related hematologic toxicities were neutropenia (16 patients; 29%), leukopenia (10 patients; 18%), lymphocytopenia (8 patients; 15%), and thrombocytopenia (4 patients; 7%). Non-hematologic grade 3 or greater toxicities included hypophosphatemia (7 patients; 13%), rash (5 patients; 9%), and hypokalemia (4 patients; 7%). After a median follow-up of 50 months, the median progression-free survival (PFS) was 48.6 months (95% CI: 39.9 - not reached; NR) and median overall survival has not been reached. Patients achieving VGPR or better had a significantly better progression-free survival (p<0.001) compared to those who did not achieve VGPR (median PFS 58.2 months vs. 31.3 months). Biochemical progression preceded or was concurrent with the development of SLiM-CRAB criteria in eight patients during follow-up, indicating that biochemical progression is a meaningful endpoint that correlates with the development of end-organ damage. High-risk 20/2/20 participants had the worst PFS compared to low- and intermediate-risk participants. The use of whole genome or single-cell sequencing of tumor cells identified high-risk aberrations that were not identified by FISH alone and aided in the identification of participants at risk of progression. scRNA-seq analysis revealed a positive correlation between MHC class I expression and response to proteasome inhibition and at the same time a decreased proportion of GZMB+ T cells within the clonally expanded CD8+ T cell population correlated with suboptimal response. Conclusions Ixazomib, lenalidomide and dexamethasone in HR-SMM demonstrates significant clinical activity with an overall favorable safety profile. Achievement of VGPR or greater led to significant improvement in time to progression, suggesting that achieving deep response is beneficial in HR-SMM. Biochemical progression correlates with end-organ damage. Patients with high-risk FISH and lack of deep response had poor outcomes. ClinicalTrials.gov identifier: ( NCT02916771 ).
Collapse
|
21
|
Li X, Yu Y, Yu H, Chen M, Zhang X, Wu Y. Minimal residual disease in systemic light chain amyloidosis: a systematic review and meta-analysis. J Cancer Res Clin Oncol 2024; 150:193. [PMID: 38619663 PMCID: PMC11018658 DOI: 10.1007/s00432-024-05733-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 03/30/2024] [Indexed: 04/16/2024]
Abstract
PURPOSE Minimal residual disease (MRD) is a validated prognostic factor in several hematological malignancies. However, its role in systemic light chain (AL) amyloidosis remains controversial, and this systematic review and meta-analysis aims to fill this gap. METHODS We searched for relevant studies on Pubmed, Embase, and Cochrane Controlled Register of Trials, nine studies involving 451 patients were included and meta-analyzed. This systematic review has been registered in PROSPERO (CRD42023494169). RESULTS Our study found that in the group of patients who achieved very good partial response (VGPR) or better, MRD negativity was correlated with higher cardiac and renal response rates [pooled risk ratio (RR) = 0.74 (95% CI 0.62-0.89), 0.74 (95% CI 0.64-0.87), respectively]. Patients with MRD positivity had a higher hematologic progression rate within two years after MRD detection [pooled RR = 10.31 (95% CI 2.02-52.68)]; and a higher risk of hematologic + organ progression in the first year [pooled RR = 12.57 (95% CI 1.73-91.04)]. Moreover, MRD negativity was correlated with a better progression-free survival (PFS) [pooled hazard ratio (HR) = 0.27 (95% CI 0.17-0.45)]; but it did not significantly improve the overall survival (OS) [pooled HR = 0.34 (95% CI 0.11-1.07)]. CONCLUSION In AL amyloidosis, our study supports that MRD negativity correlates with higher cardiac or renal response rates and indicates a better PFS in the follow-up. However, the correlation between OS and the status of MRD is not significant.
Collapse
Affiliation(s)
- Xuefeng Li
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Yu
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hongbin Yu
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Mengran Chen
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xin Zhang
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yu Wu
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| |
Collapse
|
22
|
Tao Y, Jin S, Yang D, Pan M, Ouyang W, Liu Y, Wang Y, Zhang W, Mi J. Real-world advantage and challenge of post-autologous stem cell transplantation MRD negativity in high-risk patients with double-hit multiple myeloma. BMC Cancer 2024; 24:406. [PMID: 38565996 PMCID: PMC10985970 DOI: 10.1186/s12885-024-12077-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/03/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Autologous stem-cell transplantation (ASCT) remains a beneficial approach for patients with newly diagnosed multiple myeloma (NDMM) in the age of novel therapeutic agents. Nevertheless, limited real-world data is available to establish criteria for identifying high-risk ASCT patients. METHODS We analyzed outcomes for 168 NDMM patients who underwent ASCT at our center from December 2015 to December 2022. We investigated the impact of the number of high-risk cytogenetics (HRCA), defined as t(4;14), t(14;16), 1q21 gain/amplification, and del(17p), as well as the post-ASCT minimal residual disease (MRD) status as prognostic indicators. We assessed progression-free survival (PFS) and overall survival (OS), and focused on identifying risk factors. RESULTS The cohort included 42% of patients (n = 71) with 0 HRCA, 42% (n = 71) with 1 HRCA, and 16% (n = 26) with ≥ 2 HRCA. After a median follow-up of 31 months, the median PFS was 53 months (95% CI, 37-69), and OS was not reached for the entire cohort. Despite similar rates of MRD-negativity post-ASCT, patients with ≥ 2 HRCA, termed "double hit" (DH), had a significantly higher risk of progression/mortality than those with 0 or 1 HRCA. Multivariate analysis highlighted DH (HR 4.103, 95% CI, 2.046-8.231) and MRD positivity post-ASCT (HR 6.557, 95% CI, 3.217-13.366) as adverse prognostic factors for PFS, with DH also linked to inferior OS. As anticipated, DH patients with post-ASCT MRD positivity displayed the poorest prognosis, with a median PFS of 7 months post-ASCT. Meanwhile, DH patients with MRD negativity post-ASCT showed improved prognosis, akin to MRD-negative non-DH patients. It is noteworthy to exercise caution, as DH patients who initially achieved MRD negativity experienced a 41% cumulative loss of that status within one year. CONCLUSIONS This study strongly advocates integrating DH genetic assessments for eligible ASCT patients and emphasizes the importance of ongoing MRD monitoring, as well as considering MRD-based treatment adaptation for those patients in real-world settings.
Collapse
Affiliation(s)
- Yi Tao
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Department of Hematology, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200025, Shanghai, China
| | - Shiwei Jin
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Department of Hematology, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200025, Shanghai, China
| | - Dan Yang
- Department of Hematology, Lu Daopei Hospital, 200025, Shanghai, China
| | - Mengmeng Pan
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Department of Hematology, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200025, Shanghai, China
| | - Wanyan Ouyang
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Department of Hematology, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200025, Shanghai, China
| | - Yuanfang Liu
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Department of Hematology, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200025, Shanghai, China
| | - Yan Wang
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Department of Hematology, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200025, Shanghai, China
| | - Weiping Zhang
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Department of Hematology, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200025, Shanghai, China.
| | - Jianqing Mi
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Department of Hematology, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 200025, Shanghai, China.
| |
Collapse
|
23
|
Derman BA, Fonseca R. Measurable Residual Disease and Decision-Making in Multiple Myeloma. Hematol Oncol Clin North Am 2024; 38:477-495. [PMID: 38184470 DOI: 10.1016/j.hoc.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2024]
Abstract
Measurable (minimal) residual disease (MRD) has already proven to be one of the most important prognostic factors in multiple myeloma (MM). Each improvement in the depth of MRD testing has led to superior discrimination of outcomes, and sustained MRD negativity seems to be paramount to durable responses. Peripheral blood assays to assess for MRD are still under investigation but hold promise as complementary tools to bone marrow MRD assays such as next-generation sequencing and flow cytometry. Herein, the authors explore the evidence and potential benefits and drawbacks of MRD-adapted clinical decision-making in MM.
Collapse
Affiliation(s)
- Benjamin A Derman
- Section of Hematology/Oncology, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
| | - Rafael Fonseca
- Division of Hematology and Medical Oncology, Mayo Clinic in Arizona, 13400 East Shea Boulevard, MCCRB 3-001, Phoenix, AZ 85259, USA
| |
Collapse
|
24
|
de Tute R, Counsell N, Clifton-Hadley L, D'Sa S, Pratt G, Campbell G, Campbell L, Sadler R, Townsend W, Popova B, Smith P, Schofield O, Owen R, Auer R. Long-term outcomes by bone marrow B-cell depletion from the R2W trial of bortezomib with cyclophosphamide and rituximab in Waldenstrőm macroglobulinaemia. Leukemia 2024; 38:822-828. [PMID: 38409530 DOI: 10.1038/s41375-024-02162-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 01/16/2024] [Accepted: 01/19/2024] [Indexed: 02/28/2024]
Abstract
There remains a lack of consensus as to the most appropriate primary therapy in Waldenstrőm macroglobulinemia (WM). We evaluated a novel bortezomib-based combination and developed a sensitive WM-specific flow cytometry assay (limit of detection 0.004% of leucocytes) to assess bone marrow (BM) response. Sixty treatment-naïve WM patients were enroled into this phase II trial and randomised (2:1) to receive cyclophosphamide and rituximab with either bortezomib (BRC) or fludarabine (FCR). The primary objective was to assess the overall response rate (ORR) in eligible patients receiving BRC (N = 41). An ORR of 97.6% (95%CI:87.1-99.9) was observed; 27 (65.9%) patients remain alive without progression after 62.6 months median follow-up, with 2-, 3- and 5-year progression-free survival (PFS) rates of 92.7% (95%CI:79.0-97.6), 80.5% (95%CI:64.8-89.7) and 65.5% (95%CI:48.8-77.9). Persistent WM B-cells were demonstrable in 19/38 patients at the end of treatment (median 0.24%, range 0.02-11.2%). PFS was markedly longer in patients with BM B-cell depletion (<0.004%) compared to those who had persistent BM B-cells detectable at end of treatment (HR = 0.06, 95%CI:0.01-0.47, p < 0.001), and remained independently associated after adjusting for baseline risk stratification or investigator-assessed response. BRC is a tolerable, highly efficacious regimen for treatment-naïve WM patients. BM B-cell depletion is independently associated with patient outcomes.
Collapse
Affiliation(s)
| | | | | | | | - Guy Pratt
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Lauren Campbell
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ross Sadler
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - Paul Smith
- CR UK and UCL Cancer Trials Centre, London, UK
| | | | - Roger Owen
- St James's University Hospital, Leeds, UK
| | | |
Collapse
|
25
|
Hwang A, Hayden P, Pawlyn C, McLornan D, Garderet L. The role of maintenance therapy following autologous stem cell transplantation in newly diagnosed multiple myeloma: Considerations on behalf of the Chronic Malignancies Working Party of the EBMT. Br J Haematol 2024; 204:1159-1175. [PMID: 38390784 DOI: 10.1111/bjh.19353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/22/2024] [Accepted: 02/12/2024] [Indexed: 02/24/2024]
Abstract
Recent treatment advancements in multiple myeloma have led to significant improvements in patient outcomes. Maintenance therapy following autologous haematopoietic stem cell transplantation (AHCT) is now standard of care and has been demonstrated to prolong and deepen treatment responses. Currently, lenalidomide remains the single agent that has been approved for maintenance post-AHCT in Europe and the USA which, if tolerated, is continued until disease progression. The treatment landscape is rapidly expanding however, and the optimal personalised maintenance approach for a patient is becoming more complex. Treatment outcomes for patients with high-risk disease remain poor and choice of maintenance in this population also remains unclear. This review article evaluates up-to-date literature regarding established maintenance approaches. It further analyses ongoing studies exploring maintenance regimens using combination and novel agents, approaches to maintenance in patients with cytogenetic high-risk disease and minimal residual disease response-adapted strategies that reflect the current evolving treatment paradigm.
Collapse
Affiliation(s)
- Angela Hwang
- Department of Haematology, University College London Hospital NHS Foundation Trust, London, UK
| | - Patrick Hayden
- Department of Haematology, St James's Hospital, Dublin, Ireland
| | | | - Donal McLornan
- Department of Haematology, University College London Hospital NHS Foundation Trust, London, UK
| | - Laurent Garderet
- Département d'Hématologie, Hôpital Pitié Salpêtrière, AP-HP, Paris, France
| |
Collapse
|
26
|
Zhou M, Chen Y, Gong Y, Zhu M, Cen J, Pan J, Yan L, Shang J, Jin S, Shi X, Yao W, Yan S, Wu D, Chen S, Fu C, Yao L. Evaluation of next-generation sequencing versus next-generation flow cytometry for minimal-residual-disease detection in Chinese patients with multiple myeloma. Discov Oncol 2024; 15:78. [PMID: 38502423 PMCID: PMC10951185 DOI: 10.1007/s12672-024-00938-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/15/2024] [Indexed: 03/21/2024] Open
Abstract
PURPOSE To evaluate the efficacy of next-generation sequencing (NGS) in minimal-residual-disease (MRD) monitoring in Chinese patients with multiple myeloma (MM). METHODS This study analyzed 60 Chinese MM patients. During MRD monitoring in these patients' post-therapy, clonal immunoglobulin heavy chain (IGH) rearrangements were detected via NGS using LymphoTrack assays. MRD monitoring was performed using NGS or next-generation flow cytometry (NGF), and the results were compared. Additionally, the sensitivity and reproducibility of the NGS method were assessed. RESULTS The MRD detection range of the NGS method was 10-6-10-1, which suggested good linearity, with a Pearson correlation coefficient of 0.985 and a limit of detection of 10-6. Intra- and inter-assay reproducibility analyses showed that NGS exhibited 100% reproducibility with low variability in clonal cells. At diagnosis, unique clones were found in 42 patients (70.0%) with clonal IGH rearrangements, which were used as clonality markers for MRD monitoring post-therapy. Comparison of NGS and NGF for MRD monitoring showed 79.1% concordance. No samples that tested MRD-positive via NGF were found negative via NGS, indicating the higher sensitivity of NGS. MRD could be detected using NGS in 6 of 7 samples before autologous hematopoietic stem-cell transplantation, and 5 of them tested negative post-transplantation. In contrast, the NGF method could detect MRD in only 1 sample pre-transplantation. CONCLUSION Compared with NGF, NGS exhibits higher sensitivity and reproducibility in MRD detection and can be an effective strategy for MRD monitoring in Chinese MM patients.
Collapse
Affiliation(s)
- Mo Zhou
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Soochow University, 188 Shizi Street, Suzhou, 215006, People's Republic of China
- Hematology Department, Yancheng Third People's Hospital, Yancheng, People's Republic of China
| | - Yan Chen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Soochow University, 188 Shizi Street, Suzhou, 215006, People's Republic of China
| | - Yanlei Gong
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Soochow University, 188 Shizi Street, Suzhou, 215006, People's Republic of China
| | - Mingqing Zhu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Soochow University, 188 Shizi Street, Suzhou, 215006, People's Republic of China
| | - Jiannong Cen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Soochow University, 188 Shizi Street, Suzhou, 215006, People's Republic of China
| | - Jinlan Pan
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Soochow University, 188 Shizi Street, Suzhou, 215006, People's Republic of China
| | - Lingzhi Yan
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Soochow University, 188 Shizi Street, Suzhou, 215006, People's Republic of China
| | - Jingjing Shang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Soochow University, 188 Shizi Street, Suzhou, 215006, People's Republic of China
| | - Song Jin
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Soochow University, 188 Shizi Street, Suzhou, 215006, People's Republic of China
| | - Xiaolan Shi
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Soochow University, 188 Shizi Street, Suzhou, 215006, People's Republic of China
| | - Weiqin Yao
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Soochow University, 188 Shizi Street, Suzhou, 215006, People's Republic of China
| | - Shuang Yan
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Soochow University, 188 Shizi Street, Suzhou, 215006, People's Republic of China
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Soochow University, 188 Shizi Street, Suzhou, 215006, People's Republic of China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, People's Republic of China
| | - Suning Chen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Soochow University, 188 Shizi Street, Suzhou, 215006, People's Republic of China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, People's Republic of China
| | - Chengcheng Fu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Soochow University, 188 Shizi Street, Suzhou, 215006, People's Republic of China
| | - Li Yao
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Soochow University, 188 Shizi Street, Suzhou, 215006, People's Republic of China.
| |
Collapse
|
27
|
Giles HV, Drayson MT, Kishore B, Pawlyn C, Kaiser M, Cook G, de Tute R, Owen RG, Cairns D, Menzies T, Davies FE, Morgan GJ, Pratt G, Jackson GH. Progression free survival of myeloma patients who become IFE-negative correlates with the detection of residual monoclonal free light chain (FLC) by mass spectrometry. Blood Cancer J 2024; 14:50. [PMID: 38499538 PMCID: PMC10948753 DOI: 10.1038/s41408-024-00995-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 01/17/2024] [Accepted: 01/22/2024] [Indexed: 03/20/2024] Open
Abstract
Deeper responses are associated with improved survival in patients being treated for myeloma. However, the sensitivity of the current blood-based assays is limited. Historical studies suggested that normalisation of the serum free light chain (FLC) ratio in patients who were negative by immunofixation electrophoresis (IFE) was associated with improved outcomes. However, recently this has been called into question. Mass spectrometry (MS)-based FLC assessments may offer a superior methodology for the detection of monoclonal FLC due to greater sensitivity. To test this hypothesis, all available samples from patients who were IFE negative after treatment with carfilzomib and lenalidomide-based induction and autologous stem cell transplantation (ASCT) in the Myeloma XI trial underwent FLC-MS testing. FLC-MS response assessments from post-induction, day+100 post-ASCT and six months post-maintenance randomisation were compared to serum FLC assay results. Almost 40% of patients had discordant results and 28.7% of patients with a normal FLC ratio had residual monoclonal FLC detectable by FLC-MS. FLC-MS positivity was associated with reduced progression-free survival (PFS) but an abnormal FLC ratio was not. This study demonstrates that FLC-MS provides a superior methodology for the detection of residual monoclonal FLC with FLC-MS positivity identifying IFE-negative patients who are at higher risk of early progression.
Collapse
Affiliation(s)
- H V Giles
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
- University of Birmingham, Birmingham, UK.
| | | | - B Kishore
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - C Pawlyn
- The Institute of Cancer Research, London and The Royal Marsden Hospital, London, UK
| | - M Kaiser
- The Institute of Cancer Research, London and The Royal Marsden Hospital, London, UK
| | - G Cook
- Leeds Cancer Research UK Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - R de Tute
- Haematological Malignancy Diagnostic Service, Leeds Teaching Hospitals Trust, Leeds, UK
| | - R G Owen
- Haematological Malignancy Diagnostic Service, Leeds Teaching Hospitals Trust, Leeds, UK
| | - D Cairns
- Leeds Cancer Research UK Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - T Menzies
- Leeds Cancer Research UK Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - F E Davies
- Myeloma Research Program, Perlmutter Cancer, NYU Langone Health, New York, USA
| | - G J Morgan
- Myeloma Research Program, Perlmutter Cancer, NYU Langone Health, New York, USA
| | - G Pratt
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - G H Jackson
- Department of Haematology, University of Newcastle, Newcastle upon Tyne, UK
| |
Collapse
|
28
|
Fan H, Wang B, Shi L, Pan N, Yan W, Xu J, Gong L, Li L, Liu Y, Du C, Cui J, Zhu G, Deng S, Sui W, Xu Y, Yi S, Hao M, Zou D, Chen X, Qiu L, An G. Monitoring Minimal Residual Disease in Patients with Multiple Myeloma by Targeted Tracking Serum M-Protein Using Mass Spectrometry (EasyM). Clin Cancer Res 2024; 30:1131-1142. [PMID: 38170583 PMCID: PMC10940853 DOI: 10.1158/1078-0432.ccr-23-2767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/10/2023] [Accepted: 12/29/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE We investigated both the clinical utilities and the prognostic impacts of the clonotypic peptide mass spectrometry (MS)-EasyM, a blood-based minimal residual disease (MRD) monitoring protocol in multiple myeloma. EXPERIMENTAL DESIGN A total of 447 sequential serum samples from 56 patients with multiple myeloma were analyzed using EasyM. Patient-specific M-protein peptides were sequenced from diagnostic samples; sequential samples were quantified by EasyM to monitor the M-protein. The performance of EasyM was compared with serum immunofixation electrophoresis (IFE), bone marrow multiparameter flow cytometry (MFC), and next-generation flow cytometry (NGF) detection. The optimal balance of EasyM sensitivity/specificity versus NGF (10-5 sensitivity) was determined and the prognostic impact of MS-MRD status was investigated. RESULTS Of the 447 serum samples detected and measured by EasyM, 397, 126, and 92 had time-matching results for comparison with serum IFE, MFC-MRD, and NGF-MRD, respectively. Using a dotp >0.9 as the MS-MRD positive, sensitivity was 99.6% versus IFE and 100.0% versus MFC and NGF. Using an MS negative cutoff informed by ROC analysis (<1.86% of that at diagnosis), EasyM sensitivity remained high versus IFE (88.3%), MFC (85.1%), and NGF (93.2%), whereas specificity increased to 90.4%, 55.8%, and 93.2%, respectively. In the multivariate analysis, older diagnostic age was an independent predictor for progression-free survival [PFS; high risk (HR), 3.15; 1.26-7.86], the best MS-MRD status (MS-MRD negative) was independent predictor for both PFS (HR, 0.25; 0.12-0.52) and overall survival (HR, 0.16; 0.06-0.40). CONCLUSIONS EasyM is a highly sensitive and minimal invasive method of MRD monitoring in multiple myeloma; MS-MRD had significant predictive ability for survival outcomes.
Collapse
Affiliation(s)
- Huishou Fan
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Department of Hematology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Bing Wang
- Shanghai Kuaixu Biotechnology Co., Ltd., Shanghai, China
| | - Lihui Shi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Ni Pan
- Shanghai Kuaixu Biotechnology Co., Ltd., Shanghai, China
| | - Wenqiang Yan
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Jingyu Xu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Lixin Gong
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Lingna Li
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yuntong Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Chenxing Du
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Jian Cui
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Guoqing Zhu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Shuhui Deng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Weiwei Sui
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yan Xu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Shuhua Yi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Mu Hao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Dehui Zou
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Xiequn Chen
- Department of Hematology, Affiliated Hospital of Northwest University, Institute of Hematology, Northwest University, Xian, Shaanxi, China
| | - Lugui Qiu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Gang An
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| |
Collapse
|
29
|
Thorlund K, Shephard C, Machado L, Bourgouin T, Hudson L, Ting E, Dempster W, Bick R. Adapting Health Technology Assessment agency standards for surrogate outcomes in early stage cancer trials: what needs to happen? Expert Rev Pharmacoecon Outcomes Res 2024; 24:331-342. [PMID: 38189086 DOI: 10.1080/14737167.2024.2302431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/03/2024] [Indexed: 01/09/2024]
Abstract
INTRODUCTION An avalanche of early stage cancer clinical trials is coming. The majority of these solely use surrogate outcomes that have not been validated against a target outcome of interest (e.g. overall survival). Current HTA guidance on surrogate outcome validation are not methodologically or practically conducive to this scenario. AREAS COVERED We provide a high-level overview of methods, approaches, and conceptual thinking for making better use of limited evidence within early stage cancer HTA submissions. We outline regulatory and HTA issues and emphasize how evidence transitions from one to another, what major gaps currently exist, and how these may be bridged. We summarize current methodologies and practices, their pros and cons. We outline how complementary measurements strengthen evaluations and address fallacies and biases of conventional statistical methods for surrogate outcomes validation. The value of real-world data to support some of the necessary validity components is discussed. Lastly, we address the importance of the patient voice for better understanding which surrogate outcomes may appropriately inform HTA. EXPERT OPINION Conventional surrogate outcome validation represents a fraught and sub-optimal framework for HTA purposes, particularly for early stage cancer. Tools for optimizing use of limited evidence exist. Education of stakeholders is highly needed.
Collapse
Affiliation(s)
- Kristian Thorlund
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Cal Shephard
- AstraZeneca Canada, Mississauga, Ontario, Canada
| | | | | | | | - Eon Ting
- AstraZeneca Canada, Mississauga, Ontario, Canada
| | | | - Robert Bick
- The CanCertainty Coalition, Toronto, Ontario, Canada
| |
Collapse
|
30
|
Gupta R, Jevremovic D, Mathew SJ, Kumar S. Multiparametric Flow Cytometry in the Evaluation of Plasma Cell Proliferative Disorders: Current Paradigms for Clinical Practice. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:e88-e95. [PMID: 38142203 DOI: 10.1016/j.clml.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/25/2023]
Abstract
Diagnosis of plasma cell proliferative disorders (PCPDs) is primarily based on the demonstration of monoclonal protein (M-Protein) in blood and/ or urine which often precedes clinical manifestations of the disease. The basic pathophysiology behind the M-protein presence is the proliferation of clonal plasma cells (PCs) in bone marrow or extramedullary sites and is assessed using cytomorphology and immunophenotyping. The role of multiparametric flow cytometry (MFC) for PC identification is technically the most valuable tool in this context as it characterizes as well as quantifies the clonal PCs based on differential expression of various immunophenotypic (IPT) markers. From a diagnostic perspective, MFC is critical in the definite identification of the clonal PCs and delineates benign and borderline entities at one end of the spectrum (MGUS, SMM) with lower clonal PC% and, malignant diseases at the other end (MM and PCL) with higher clonal PC fraction. The role of MFC in assessment of measurable residual disease (MRD) and monitoring of progression in MM and various PCPDs has been validated in multiple clinical studies and is probably one of the most promising tools for predicting treatment outcomes. Furthermore, MFC also plays a crucial role in disease prognostication based on specific IPT profiles. An additional role of MFC in the current clinical scenario is the evaluation of tumor microenvironment based on immune cell repertoire, which is reflecting encouraging results across. Thus, in the current review we concisely describe the role of MFC as a reliable and essential modality in PCPDs, from diagnosis to prediction of treatment outcome and disease monitoring.
Collapse
Affiliation(s)
- Ritu Gupta
- Department of Laboratory Oncology, Dr. BRAIRCH, AIIMS, New Delhi, India; Department of Hematology, Mayo Clinic, Rochester, MN.
| | - Dragan Jevremovic
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN
| | | | - Shaji Kumar
- Department of Hematology, Mayo Clinic, Rochester, MN
| |
Collapse
|
31
|
Wang J, Li J, Zhang R, Li J, Chen L, Jin Y. Real-world prognostic significance of attaining minimal residual disease negativity in newly diagnosed multiple myeloma. Discov Oncol 2024; 15:38. [PMID: 38367151 PMCID: PMC10874347 DOI: 10.1007/s12672-024-00891-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 02/11/2024] [Indexed: 02/19/2024] Open
Abstract
The aim of the study was to evaluate the prognostic impact of minimal residual disease (MRD) in the real-world setting and the interaction between MRD and molecular risk, clinical response and autologous stem-cell transplant (ASCT). A retrospective analysis of 275 newly diagnosed multiple myeloma (NDMM) patients who achieved very good partial remission (VGPR) or better before maintenance were involved. We examined MRD status by multiparameter flow cytometry (MFC). At a median follow-up of 37 months (4-88 months), In patients who achieved ≥ VGPR, those with MRD negativity had significantly longer PFS (51 vs. 26 months; P < 0.001) and OS (Not reached: NR vs. 62 months, P < 0.001) than those with MRD positivity. MRD positivity was the independent prognostic factor for PFS with hazard ratios of 2.650 (95% CI 1.755-4.033, P < 0.001) and OS with hazard ratios of 2.122 (95% CI 1.155-3.899, P = 0.015). Achieving MRD negativity was able to ameliorate a poor prognosis associated with genetic high risk. MRD negativity was associated with better PFS regardless of ASCT treatment. MRD status was more predictable for clinical outcome than conventional clinical responses. Moreover, Sustained MRD negativity ≥ 12 or ≥ 24 months improved both PFS and OS. Patients with NDMM who achieved MRD-negative status or sustained MRD negativity had deep remission and improved clinical outcomes regardless of high-risk cytogenetics, ASCT and clinical responses in a real-world setting.
Collapse
Affiliation(s)
- Jing Wang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, No. 300 Guangzhou Road, Nanjing, 210029, China
| | - Jing Li
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, No. 300 Guangzhou Road, Nanjing, 210029, China
| | - Run Zhang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, No. 300 Guangzhou Road, Nanjing, 210029, China
| | - Jianyong Li
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, No. 300 Guangzhou Road, Nanjing, 210029, China
| | - Lijuan Chen
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, No. 300 Guangzhou Road, Nanjing, 210029, China.
| | - Yuanyuan Jin
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, No. 300 Guangzhou Road, Nanjing, 210029, China.
| |
Collapse
|
32
|
Guerrero C, Puig N, Cedena MT, Calasanz MJ, Gutierrez NC, Fernandez M, Oriol A, Ríos-Tamayo R, Hernandez MT, Martínez-Martínez R, Bargay J, de Arriba F, Palomera L, Gonzalez-Rodriguez AP, Gonzalez Perez MS, Orfao A, Mateos MV, Martinez-Lopez J, Rosiñol L, Bladé J, Lahuerta JJ, San-Miguel JF, Paiva B. Predictors of unsustained measurable residual disease negativity in transplant-eligible patients with multiple myeloma. Blood 2024; 143:597-603. [PMID: 38048552 DOI: 10.1182/blood.2023022083] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 12/06/2023] Open
Abstract
ABSTRACT The role of measurable residual disease (MRD) negativity as a biomarker to stop treatment is being investigated in transplant-eligible patients with multiple myeloma (MM). Thus, it is important to identify risk factors of MRD resurgence and/or progressive disease (PD) among patients achieving undetectable MRD to avoid undertreating them. Here, we studied 267 newly diagnosed transplant-eligible patients with MM enrolled in the GEM2012MENOS65 and GEM2014MAIN clinical trials who achieved MRD negativity by next-generation flow cytometry. After a median follow-up of 73 months since the first MRD negative assessment, 111 of the 267 (42%) patients showed MRD resurgence and/or PD. The only prognostic factors at diagnosis that predicted MRD resurgence and/or PD were an International Staging System (ISS) 3 and the presence of ≥0.01% circulating tumor cells (CTCs). Failure to achieve MRD negativity after induction also predicted higher risk of MRD resurgence and/or PD. Patients having 0 vs 1 vs ≥2 risk factors (ISS 3, ≥0.01% CTCs, and late MRD negativity) showed 5-year rates of MRD resurgence and/or PD of 16%, 33%, and 57%, respectively (P < .001). Thus, these easily measurable risk factors could help refine the selection of patients for whom treatment cessation after MRD negativity is being investigated in clinical trials. This trial was registered at www.clinicaltrials.gov as NCT01916252 and NCT02406144.
Collapse
Affiliation(s)
- Camila Guerrero
- Cancer Center Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Instituto de Investigación Sanitaria de Navarra, Centro de Investigación Biomédica en Red de Cáncer (CIBER-ONC) number CB16/12/00369, Pamplona, Spain
| | - Noemi Puig
- Department of Hematology, Hospital Universitario de Salamanca Hematología, Instituto de investigación Biomédica de Salamanca, Salamanca, Spain
| | - María-Teresa Cedena
- Department of Hematology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - María-José Calasanz
- Cancer Center Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Instituto de Investigación Sanitaria de Navarra, Centro de Investigación Biomédica en Red de Cáncer (CIBER-ONC) number CB16/12/00369, Pamplona, Spain
| | - Norma C Gutierrez
- Department of Hematology, Hospital Universitario de Salamanca Hematología, Instituto de investigación Biomédica de Salamanca, Salamanca, Spain
| | - Manuela Fernandez
- Department of Hematology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Albert Oriol
- Department of Hematology, Institut Català d'Oncologia L'Hospitalet, Barcelona, Spain
| | - Rafael Ríos-Tamayo
- Department of Hematology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | | | - Joan Bargay
- Department of Hematology, Hospital Universitario Son Llatzer, Institut d'Investigacio Illes Balears, Palma de Mallorca, Spain
| | - Felipe de Arriba
- Department of Hematology, Hospital Morales Meseguer, Instituto Murciano de Investigación Biosanitaria-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
| | - Luis Palomera
- Department of Hematology, Hospital Clínico Lozano Blesa, Zaragoza, Spain
| | | | - Marta-Sonia Gonzalez Perez
- Department of Hematology, Complejo Hospitalario Universitario de Santiago de Compostela, Servizio Galego de Saúde, Compostela, Spain
| | - Alberto Orfao
- Department of Hematology, Hospital Universitario de Salamanca Hematología, Instituto de investigación Biomédica de Salamanca, Salamanca, Spain
| | - María-Victoria Mateos
- Department of Hematology, Hospital Universitario de Salamanca Hematología, Instituto de investigación Biomédica de Salamanca, Salamanca, Spain
| | | | - Laura Rosiñol
- Department of Hematology, Hospital Clínic, Institut de Recerca Biomedica August Pi i Suñer, Barcelona, Spain
| | - Joan Bladé
- Department of Hematology, Hospital Clínic, Institut de Recerca Biomedica August Pi i Suñer, Barcelona, Spain
| | - Juan-Jose Lahuerta
- Department of Hematology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Jesus F San-Miguel
- Cancer Center Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Instituto de Investigación Sanitaria de Navarra, Centro de Investigación Biomédica en Red de Cáncer (CIBER-ONC) number CB16/12/00369, Pamplona, Spain
| | - Bruno Paiva
- Cancer Center Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Instituto de Investigación Sanitaria de Navarra, Centro de Investigación Biomédica en Red de Cáncer (CIBER-ONC) number CB16/12/00369, Pamplona, Spain
| |
Collapse
|
33
|
Al Hadidi S, Ababneh OE, Schinke CD, Thanendrarajan S, Bailey C, Smith R, Panozzo S, Alapat D, Cottler-Fox M, Tricot G, Shaughnessy JD, Zhan F, Sawyer J, Barlogie B, Zangari M, van Rhee F. Three years of maintenance with VRD in multiple myeloma: results of total therapy IIIB with a 15-year follow-up. Blood Adv 2024; 8:703-707. [PMID: 38052037 PMCID: PMC10845028 DOI: 10.1182/bloodadvances.2023011601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/27/2023] [Accepted: 11/21/2023] [Indexed: 12/07/2023] Open
Abstract
ABSTRACT The total therapy (TT) IIIB phase 2 study incorporated bortezomib into tandem melphalan-based hematopoietic stem cell transplantation with dexamethasone, thalidomide, cisplatin, doxorubicin, cyclophosphamide, and etoposide for induction/consolidation and bortezomib, lenalidomide, and dexamethasone (VRD) for maintenance in patients with newly diagnosed multiple myeloma (MM). This updated analysis presents a 15.4-year median follow-up. Of 177 patients, 21% patients had gene expression profile (GEP)-defined high-risk MM. 15-year progression free survival (PFS) was 27.9%. Median PFS was better in GEP-defined low-risk patients at 7.8 years and in International Staging System stage 1 patients at 8.7 years. Overall, median OS was 9.1 years, and 15-year overall survival (OS) was 35.9%. GEP-defined low-risk patients' median OS was 11.2 years, and that of GEP-defined high-risk patients was 2.8 years. There was no difference in OS between TT IIIB and TT IIIA. This study includes the longest follow-up of patients treated with maintenance VRD reported to date. In patients with GEP-defined low-risk, nearly half and one-third of patients without ongoing treatment showed no signs of progression at 10 and 15 years, respectively. One-third of patients survived more than 15 years, but 3 years of VRD maintenance did not improve outcomes for patients with GEP-defined high-risk MM. The study was registered on www.clinicaltrials.gov as #NCT00572169.
Collapse
Affiliation(s)
- Samer Al Hadidi
- Myeloma Institute, The Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Obada Ehab Ababneh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Carolina D. Schinke
- Myeloma Institute, The Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Sharmilan Thanendrarajan
- Myeloma Institute, The Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Clyde Bailey
- Myeloma Institute, The Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Robert Smith
- Myeloma Institute, The Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Susan Panozzo
- Myeloma Institute, The Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Daisy Alapat
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Michele Cottler-Fox
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Guido Tricot
- Myeloma Institute, The Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - John D. Shaughnessy
- Myeloma Institute, The Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Fenghuang Zhan
- Myeloma Institute, The Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Jeffrey Sawyer
- Myeloma Institute, The Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Bart Barlogie
- Myeloma Institute, The Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Maurizio Zangari
- Myeloma Institute, The Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Frits van Rhee
- Myeloma Institute, The Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR
| |
Collapse
|
34
|
Cheong CS, Aziz TAHTK, Anuar NA, Bee PC, Chin EFM, Khairullah S, Liong CC, Zamri Y, Gan GG. Treatment Pattern and Outcome of Newly Diagnosed Multiple Myeloma Patients in a Resource-Limited Setting. Asian Pac J Cancer Prev 2024; 25:595-601. [PMID: 38415546 PMCID: PMC11077109 DOI: 10.31557/apjcp.2024.25.2.595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/22/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Multiple myeloma is the third most common hematologic malignancy in Malaysia. The introduction of novel agents over the past decades has improved patient outcome and survival substantially. However, these agents incur significant economic burden, thus leading to limited use in less developed countries. This study aims to report on the real-world treatment pattern and outcome of newly diagnosed multiple myeloma (NDMM) patients from a resource-constraint setting. METHODS This is a retrospective study on NDMM patients diagnosed between 1 January 2008 and 31 December 2022 in a single academic center. Patients' demographic and treatment details were included for analysis of progression free survival (PFS) and overall survival (OS). RESULTS One hundred and thirty-six NDMM patients with a median age of 64.0 years (ranged from 38 to 87 years old) were included. Bortezomib-containing regimens were the most commonly used induction agent, followed by thalidomide. Almost half of the patients (47.1%) achieved very good partial response (VGPR) or complete remission (CR), while 31.6% achieved partial response (PR). Bortezomib containing regimen was associated with significantly deeper and more rapid response, (p=0.001 and p=0.017, respectively) when compared to other agents. Only 22.8% of these patients proceeded to upfront autologous haematopoietic stem cell transplantation. The median OS and PFS were 60.0 months and 25.0 months, respectively. Best initial response and upfront autologous stem cell transplantation (ASCT) were significantly associated with better PFS. CONCLUSION Achieving at least a VGPR significantly associated with better outcome in NDMM patients. In a resource constrain country, we recommend incorporating bortezomib in the induction therapy followed with an upfront ASCT.
Collapse
Affiliation(s)
- Chin Sum Cheong
- Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
| | | | - Nur Adila Anuar
- KPJ Ampang Puteri Specialist Hospital, Ampang, Selangor, Malaysia.
| | - Ping Chong Bee
- Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
| | - Edmund Fui Min Chin
- Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
| | - Shasha Khairullah
- Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
| | - Chee Chiat Liong
- Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
| | - Yazid Zamri
- Universiti Malaya Medical Center, Kuala Lumpur, Malaysia.
| | - Gin Gin Gan
- Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
| |
Collapse
|
35
|
Paiva B, Zherniakova A, Nuñez-Córdoba JM, Rodriguez-Otero P, Shi Q, Munshi NC, Durie BGM, San-Miguel J. Impact of treatment effect on MRD and PFS: an aggregate data analysis from randomized clinical trials in multiple myeloma. Blood Adv 2024; 8:219-223. [PMID: 37639322 PMCID: PMC10805640 DOI: 10.1182/bloodadvances.2023010821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/09/2023] [Accepted: 08/13/2023] [Indexed: 08/31/2023] Open
Affiliation(s)
- Bruno Paiva
- Cancer Center Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada, Instituto de Investigacion Sanitaria de Navarra, Cedars-Sinai Medical Center CB16/12/00369, Pamplona, Spain
| | - Anastasiia Zherniakova
- Cancer Center Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada, Instituto de Investigacion Sanitaria de Navarra, Cedars-Sinai Medical Center CB16/12/00369, Pamplona, Spain
| | - Jorge M. Nuñez-Córdoba
- Cancer Center Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada, Instituto de Investigacion Sanitaria de Navarra, Cedars-Sinai Medical Center CB16/12/00369, Pamplona, Spain
| | - Paula Rodriguez-Otero
- Cancer Center Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada, Instituto de Investigacion Sanitaria de Navarra, Cedars-Sinai Medical Center CB16/12/00369, Pamplona, Spain
| | - Qian Shi
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Nikhil C. Munshi
- Dana-Farber Cancer Institute and Boston VA Healthcare System, Boston, MA
| | | | - Jesus San-Miguel
- Cancer Center Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada, Instituto de Investigacion Sanitaria de Navarra, Cedars-Sinai Medical Center CB16/12/00369, Pamplona, Spain
| |
Collapse
|
36
|
Suzuki K, Gunji T, Kawashima M, Uryu H, Nagao R, Momoki M, Yokoyama H, Ishii H, Tanoue S, Saito T, Nishiwaki K, Yano S. Contribution of post-transplantation therapy to sustained MRD negativity in multiple myeloma: a retrospective analysis. Int J Hematol 2024; 119:39-49. [PMID: 38103160 DOI: 10.1007/s12185-023-03682-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/07/2023] [Accepted: 11/16/2023] [Indexed: 12/17/2023]
Abstract
Post-transplantation therapy is commonly performed in patients with myeloma and can prolong progression-free survival (PFS). However, whether post-transplantation therapy contributes to achieving and continuing MRD-negativity remains controversial. This retrospective analysis aimed to evaluate the clinical impact of post-transplantation therapy, including tandem autologous stem cell transplantation (ASCT), in myeloma patients. The subjects were 79 patients (median age: 62 years) who received induction therapy, including bortezomib and/or lenalidomide, of whom 58 underwent post-transplantation therapy. At the median follow-up time of 50 months, the 4-year PFS rate was significantly higher in patients who underwent post-transplantation therapy than those who did not (60.6% vs. 28.6%, P = 0.012). Multivariate analysis revealed post-transplantation therapy to be a significant prognostic factor for long PFS. Tandem ASCT followed by consolidation and/or maintenance therapies improved PFS and OS. The minimal residual disease (MRD)-negative rate was significantly higher in patients who underwent post-transplantation therapy than those who did not (50.9% vs. 16.7%, P = 0.006). Post-transplantation therapy contributed to sustained MRD-negativity, which predicted long PFS and overall survival. Patients frequently discontinued post-transplantation therapy due to adverse events within 4 months. In conclusion, post-transplantation therapy improved PFS and contributed to sustained MRD-negativity in myeloma patients.
Collapse
Affiliation(s)
- Kazuhito Suzuki
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-0003, Japan.
| | - Tadahiro Gunji
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-0003, Japan
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University Daisan Hospital, Komoe, Japan
| | - Masaharu Kawashima
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-0003, Japan
| | - Hideki Uryu
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-0003, Japan
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University Daisan Hospital, Komoe, Japan
| | - Riku Nagao
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-0003, Japan
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University Kashiwa Hospital, Kashiwa, Japan
| | - Mamiko Momoki
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-0003, Japan
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University Kashiwa Hospital, Kashiwa, Japan
| | - Hiroki Yokoyama
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-0003, Japan
| | - Hiroto Ishii
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-0003, Japan
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University Kashiwa Hospital, Kashiwa, Japan
| | - Susumu Tanoue
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-0003, Japan
| | - Takeshi Saito
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-0003, Japan
| | - Kaichi Nishiwaki
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-0003, Japan
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University Kashiwa Hospital, Kashiwa, Japan
| | - Shingo Yano
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-0003, Japan
| |
Collapse
|
37
|
Leypoldt LB, Tichy D, Besemer B, Hänel M, Raab MS, Mann C, Munder M, Reinhardt HC, Nogai A, Görner M, Ko YD, de Wit M, Salwender H, Scheid C, Graeven U, Peceny R, Staib P, Dieing A, Einsele H, Jauch A, Hundemer M, Zago M, Požek E, Benner A, Bokemeyer C, Goldschmidt H, Weisel KC. Isatuximab, Carfilzomib, Lenalidomide, and Dexamethasone for the Treatment of High-Risk Newly Diagnosed Multiple Myeloma. J Clin Oncol 2024; 42:26-37. [PMID: 37753960 PMCID: PMC10730063 DOI: 10.1200/jco.23.01696] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 08/24/2023] [Accepted: 08/31/2023] [Indexed: 09/28/2023] Open
Abstract
PURPOSE The GMMG-CONCEPT trial investigated isatuximab, carfilzomib, lenalidomide, and dexamethasone (Isa-KRd) in transplant-eligible (TE) and transplant-noneligible (TNE) patients with newly diagnosed multiple myeloma (NDMM) with exclusively high-risk disease for whom prospective trials are limited, aiming to induce minimal residual disease (MRD) negativity. METHODS This academic, investigator-initiated, multicenter, phase II trial enrolled patients with high-risk NDMM (HRNDMM) defined by mandatory International Staging System stage II/III combined with del17p, t(4;14), t(14;16), or more than three 1q21 copies as high-risk cytogenetic aberrations (HRCAs). Patients received Isa-KRd induction/consolidation and Isa-KR maintenance. TE patients received high-dose melphalan. TNE patients received two additional Isa-KRd cycles postinduction. This prespecified interim analysis (IA) reports the primary end point, MRD negativity (<10-5, next-generation flow), at the end of consolidation. The secondary end point was progression-free survival (PFS). RESULTS Among 125 patients with HRNDMM (TE-intention-to-treat [ITT]-IA, 99; TNE-ITT, 26) of the IA population for the primary end point, the median age was 58 (TE-ITT-IA) and 74 (TNE-ITT) years. Del17p was the most common HRCA (TE, 44.4%; TNE, 42.3%); about one third of evaluable TE/TNE patients presented two or more HRCAs, respectively. The trial met its primary end point with MRD negativity rates after consolidation of 67.7% (TE) and 54.2% (TNE) of patients. Eighty-one of 99 TE-ITT-IA patients reached MRD negativity at any time point (81.8%). MRD negativity was sustained for ≥1 year in 62.6% of patients. With a median follow-up of 44 (TE) and 33 (TNE) months, median PFS was not reached in either arm. CONCLUSION Isa-KRd effectively induces high rates of sustainable MRD negativity in the difficult-to-treat HRNDMM population, regardless of transplant status, translating into a median PFS that was not yet reached after 44/33 months.
Collapse
Affiliation(s)
- Lisa B. Leypoldt
- Department of Hematology, Oncology and Bone Marrow Transplantation With Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Diana Tichy
- Division of Biostatistics, German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany
| | - Britta Besemer
- Department of Hematology, Oncology, Immunology and Rheumatology, University Hospital of Tuebingen, Tuebingen, Germany
| | - Mathias Hänel
- Department of Hematology, Oncology and Bone Marrow Transplantation, Klinikum Chemnitz, Chemnitz, Germany
| | - Marc S. Raab
- Internal Medicine V and National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph Mann
- Department of Hematology, Oncology and Immunology, University Hospital of Gießen and Marburg, Marburg, Germany
| | - Markus Munder
- Department of Internal Medicine III, University Medical Center Mainz, Mainz, Germany
| | - Hans Christian Reinhardt
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University Duisburg-Essen, German Cancer Consortium (DKTK partner site Essen), Essen, Germany
| | - Axel Nogai
- Department of Internal Medicine, Charité—University Medicine Berlin, Berlin, Germany
| | - Martin Görner
- Department of Hematology, Oncology and Palliative Care, Klinikum Bielefeld Mitte, Bielefeld, Germany
| | - Yon-Dschun Ko
- Department of Internal Medicine, Hematology and Oncology, Johanniter Krankenhaus Bonn, Bonn, Germany
| | - Maike de Wit
- Department of Internal Medicine, Hematology, Oncology and Palliative Medicine, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Hans Salwender
- Asklepios Tumorzentrum Hamburg, AK Altona and AK St Georg, Hamburg, Germany
| | - Christof Scheid
- Department of Internal Medicine I, University Hospital Cologne, Cologne, Germany
| | - Ullrich Graeven
- Department of Hematology, Oncology and Gastroenterology, Kliniken Maria Hilf, Mönchengladbach, Germany
| | - Rudolf Peceny
- Department of Oncology, Hematology and Stem Cell Transplantation, Klinikum Osnabrück, Osnabrück, Germany
| | - Peter Staib
- Department of Hematology and Oncology, St Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Annette Dieing
- Department of Hematology and Oncology, Vivantes Klinikum am Urban, Berlin, Germany
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Anna Jauch
- Institute of Human Genetics, University of Heidelberg, Heidelberg, Germany
| | - Michael Hundemer
- Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Manola Zago
- Center for Clinical Trials, University Hospital of Tuebingen, Tuebingen, Germany
| | - Ema Požek
- Division of Biostatistics, German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany
| | - Axel Benner
- Division of Biostatistics, German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany
| | - Carsten Bokemeyer
- Department of Hematology, Oncology and Bone Marrow Transplantation With Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hartmut Goldschmidt
- Internal Medicine V, GMMG-Studygroup at University Hospital Heidelberg, Heidelberg, Germany
| | - Katja C. Weisel
- Department of Hematology, Oncology and Bone Marrow Transplantation With Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
38
|
Alnasser SM, Alharbi KS, Almutairy AF, Almutairi SM, Alolayan AM. Autologous Stem Cell Transplant in Hodgkin's and Non-Hodgkin's Lymphoma, Multiple Myeloma, and AL Amyloidosis. Cells 2023; 12:2855. [PMID: 38132175 PMCID: PMC10741865 DOI: 10.3390/cells12242855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 11/30/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
Human body cells are stem cell (SC) derivatives originating from bone marrow. Their special characteristics include their capacity to support the formation and self-repair of the cells. Cancer cells multiply uncontrollably and invade healthy tissues, making stem cell transplants a viable option for cancer patients undergoing high-dose chemotherapy (HDC). When chemotherapy is used at very high doses to eradicate all cancer cells from aggressive tumors, blood-forming cells and leukocytes are either completely or partially destroyed. Autologous stem cell transplantation (ASCT) is necessary for patients in those circumstances. The patients who undergo autologous transplants receive their own stem cells (SCs). The transplanted stem cells first come into contact with the bone marrow and then undergo engraftment, before differentiating into blood cells. ASCT is one of the most significant and innovative strategies for treating diseases. Here we focus on the treatment of Hodgkin's lymphoma, non-Hodgkin's lymphoma, multiple myeloma, and AL amyloidosis, using ASCT. This review provides a comprehensive picture of the effectiveness and the safety of ASCT as a therapeutic approach for these diseases, based on the currently available evidence.
Collapse
Affiliation(s)
- Sulaiman Mohammed Alnasser
- Department of Pharmacology and Toxicology, Unaizah College of Pharmacy, Qassim University, Buraydah 51452, Saudi Arabia; (K.S.A.); (A.F.A.)
| | - Khalid Saad Alharbi
- Department of Pharmacology and Toxicology, Unaizah College of Pharmacy, Qassim University, Buraydah 51452, Saudi Arabia; (K.S.A.); (A.F.A.)
| | - Ali F. Almutairy
- Department of Pharmacology and Toxicology, Unaizah College of Pharmacy, Qassim University, Buraydah 51452, Saudi Arabia; (K.S.A.); (A.F.A.)
| | | | | |
Collapse
|
39
|
Laane E, Salek S, Oliva EN, Bennink C, Clavreul S, Richardson PG, Scheid C, Weisel K, Ionova T. Guidelines for the Use and Reporting of Patient-Reported Outcomes in Multiple Myeloma Clinical Trials. Cancers (Basel) 2023; 15:5764. [PMID: 38136310 PMCID: PMC10741926 DOI: 10.3390/cancers15245764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 11/28/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
In the era of personalized medicine there is an increasing need for the assessment of patient-reported outcomes (PROs) to become a standard of patient care. Patient-reported outcome measures (PROM) are important in assessing significant and meaningful changes as a result of an intervention based on a patient's own perspective. It is well established that active multiple myeloma (MM) can be characterized by a high burden of disease and treatment-related symptoms, with considerable worsening of quality of life (QoL). In general, and over the past decade, the focus has shifted to obtaining the most durable remissions with the best QoL as primary goals for MM treatment. Patients place considerable value on their QoL and communicating about QoL data prior to treatment decisions allows them to make informed treatment choices. Consequently, optimization of QoL of patients with MM is an important therapeutic goal and the incorporation of PROs into clinical trials has the potential of improving treatment outcomes. In this regard, guidance for the use and reporting of PROMs in MM in clinical trials is warranted. Under the auspices of the European Hematology Association, evidence-based guidelines for the use and reporting of PROs in patients with MM have been developed according to the EHA's core Guidelines Development Methodology. This document provides general considerations for the choice of PROMs in MM clinical trials as well as a series of recommendations covering a selection of PROMs in MM clinical trials; the mode of administration; timing of assessments; strategies to minimize missing data; sample size calculation; reporting of results; and interpretation of results.
Collapse
Affiliation(s)
- Edward Laane
- Hematology-Oncology Clinic, Tartu University, 50406 Tartu, Estonia
| | - Sam Salek
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK;
| | - Esther Natalie Oliva
- U.O.C. Ematologia, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, 89124 Reggio di Calabria, Italy;
| | - Christine Bennink
- Department of Hematology, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | | | - Paul G Richardson
- Jerome Lipper Multiple Myeloma Center, Dana Farber Cancer Institute, Boston, MA 02215, USA;
| | - Christof Scheid
- Department of Internal Medicine I, University of Cologne, 50923 Cologne, Germany;
| | - Katja Weisel
- Department of Hematology, Oncology and Bone Marrow Transplantation with Section of Pneumology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Tatyana Ionova
- Quality of Life Unit, Saint Petersburg State University Hospital, 190103 Saint Petersburg, Russia;
| |
Collapse
|
40
|
Mo CC, Hartley-Brown MA, Midha S, Richardson PG. Upfront or Deferred Autologous Stem Cell Transplantation for Newly Diagnosed Multiple Myeloma in the Era of Triplet and Quadruplet Induction and Minimal Residual Disease/Risk-Adapted Therapy. Cancers (Basel) 2023; 15:5709. [PMID: 38136255 PMCID: PMC10741557 DOI: 10.3390/cancers15245709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/23/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023] Open
Abstract
The standards of care for the initial treatment of patients with newly diagnosed multiple myeloma (NDMM) who are eligible for high-dose melphalan and autologous stem cell transplantation (HDM-ASCT) include highly active triplet and quadruplet regimens based on proteasome inhibitors, immunomodulatory drugs, and monoclonal antibodies. These regimens are resulting in improved outcomes and increasingly high rates of minimal residual disease (MRD)-negative responses without HDM-ASCT as part of the upfront therapy. Furthermore, recent randomized studies have shown that, while transplant-based approaches as a frontline therapy result in significantly longer progression-free survival compared to non-transplant approaches, this has not translated into an overall survival benefit. Given these developments, and in the context of the treatment burden of undergoing HDM-ASCT, in addition to the acute toxicities and long-term sequelae of HDM, which are associated with the genotoxicity of melphalan, there is an increasing rationale for considering deferring upfront HDM-ASCT in select transplant-eligible patients and saving it as a treatment option for later salvage therapy. Here, we review the latest clinical trial data on upfront or deferred HDM-ASCT and on the activity of quadruplet induction regimens, including rates of MRD-negative responses, and summarize emerging treatment approaches in the upfront setting such as the use of MRD-directed therapy and alternatives to HDM-ASCT.
Collapse
Affiliation(s)
| | | | | | - Paul G. Richardson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Jerome Lipper Center for Multiple Myeloma Research, Harvard Medical School, 450 Brookline Avenue, Dana 1B02, Boston, MA 02115, USA; (C.C.M.); (M.A.H.-B.); (S.M.)
| |
Collapse
|
41
|
Óskarsson JÞ, Rögnvaldsson S, Thorsteinsdottir S, Aspelund T, Gunnarsson SB, Hákonardóttir GK, Sigurðardóttir GÁ, Þórðardóttir ÁR, Gíslason GK, Ólafsson A, Sigurðsson JK, Eyþórsson E, Jónsson Á, Viðarsson B, Önundarson PT, Agnarsson BA, Pálmason R, Sigurðardóttir M, Þorsteinsdóttir I, Ólafsson Í, Harding S, Flores-Montero J, Orfao A, Durie BGM, Love TJ, Kristinsson SY. Determining hemodilution in diagnostic bone marrow aspirated samples in plasma cell disorders by next-generation flow cytometry: Proposal for a bone marrow quality index. Blood Cancer J 2023; 13:177. [PMID: 38040702 PMCID: PMC10692231 DOI: 10.1038/s41408-023-00951-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 12/03/2023] Open
Abstract
Hemodilution of bone marrow (BM) aspirates is a limitation of multiparameter flow cytometry (MFC) in plasma cell disorders. There is a need for a validated approach for assessing sample quality and the distribution of non-plasma cell BM populations by MFC could provide a solution. We evaluated BM-associated cell populations, assessed by next-generation flow cytometry (NGF) and white blood cell (WBC) count in 351 BM aspirated samples from 219 participants with plasma cell disorders in the Iceland Screens, Treats, or Prevents MM study (iStopMM), as markers of hemodilution by their discriminatory ability between first and (generally more hemodiluted) second pull BM aspirated samples. The most discriminating markers were used to derive a novel BM quality index (BMQI). Nucleated red blood cells and myeloid precursors provided the greatest discriminatory ability between first vs second pull samples (area under the curve (AUC): 0.87 and 0.85, respectively), significantly better than B cell precursors (AUC = 0.64; p < 0.001), mast cells (AUC = 0.65; p < 0.001), and the BM WBC count (AUC = 0.77; p < 0.05). We generated a novel BMQI that is intrinsic to current NGF protocols, for evaluating quality of diagnostic BM samples and suggest the use of a BMQI scoring system for interpreting results and guiding appropriate actions.
Collapse
Affiliation(s)
| | - Sæmundur Rögnvaldsson
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland
- Landspítali University Hospital, Reykjavík, Iceland
| | - Sigrun Thorsteinsdottir
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
| | - Thor Aspelund
- Public Health Sciences, University of Iceland, Reykjavík, Iceland
| | | | | | | | | | | | - Andri Ólafsson
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | | | | | | | | | | | | | - Róbert Pálmason
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland
- Landspítali University Hospital, Reykjavík, Iceland
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | | | | | | | | | - Juan Flores-Montero
- Cancer Research Center (IBMCC, USAL-CSIC), Department of Medicine and Cytometry Service (NUCLEUS), University of Salamanca; Biomedical Research Institute of Salamanca (IBSAL) and CIBERONC, Salamanca, Spain
| | - Alberto Orfao
- Cancer Research Center (IBMCC, USAL-CSIC), Department of Medicine and Cytometry Service (NUCLEUS), University of Salamanca; Biomedical Research Institute of Salamanca (IBSAL) and CIBERONC, Salamanca, Spain
| | - Brian G M Durie
- Cedars-Sinai Samuel Oschin Cancer Center, Los Angeles, CA, USA
| | - Thorvardur Jon Love
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland
- Landspítali University Hospital, Reykjavík, Iceland
| | - Sigurdur Yngvi Kristinsson
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland
- Landspítali University Hospital, Reykjavík, Iceland
| |
Collapse
|
42
|
Cárdenas MC, García-Sanz R, Puig N, Pérez-Surribas D, Flores-Montero J, Ortiz-Espejo M, de la Rubia J, Cruz-Iglesias E. Recommendations for the study of monoclonal gammopathies in the clinical laboratory. A consensus of the Spanish Society of Laboratory Medicine and the Spanish Society of Hematology and Hemotherapy. Part I: Update on laboratory tests for the study of monoclonal gammopathies. Clin Chem Lab Med 2023; 61:2115-2130. [PMID: 37477188 DOI: 10.1515/cclm-2023-0326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/29/2023] [Indexed: 07/22/2023]
Abstract
Monoclonal gammopathies (MG) are characterized by the proliferation of plasma cells that produce identical abnormal immunoglobulins (intact or some of their subunits). This abnormal immunoglobulin component is called monoclonal protein (M-protein), and is considered a biomarker of proliferative activity. The identification, characterization and measurement of M-protein is essential for the management of MG. We conducted a systematic review of the different tests and measurement methods used in the clinical laboratory for the study of M-protein in serum and urine, the biochemistry and hematology tests necessary for clinical evaluation, and studies in bone marrow, peripheral blood and other tissues. This review included literature published between 2009 and 2022. The paper discusses the main methodological characteristics and limitations, as well as the purpose and clinical value of the different tests used in the diagnosis, prognosis, monitoring and assessment of treatment response in MG. Included are methods for the study of M-protein, namely electrophoresis, measurement of immunoglobulin levels, serum free light chains, immunoglobulin heavy chain/light chain pairs, and mass spectrometry, and for the bone marrow examination, morphological analysis, cytogenetics, molecular techniques, and multiparameter flow cytometry.
Collapse
Affiliation(s)
- María C Cárdenas
- Department of Clinical Analysis, Hospital Clinico San Carlos, Madrid, Spain
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Ramón García-Sanz
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - Noemí Puig
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - David Pérez-Surribas
- Laboratori Pasteur, Andorra La Vella, Andorra
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Juan Flores-Montero
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - María Ortiz-Espejo
- Department of Clinical Analysis, Hospital Universitario Marqués de Valdecilla, Santander, Spain
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Javier de la Rubia
- Hematology Department, Hospital Universitario y Politécnico La Fe & Universidad Católica de Valencia, Instituto de Investigación Sanitaria La Fe Centro de Investigación Biomédica en Red de Cáncer, CIBERONC CB16/12/00284, Instituto de Salud Carlos III, Valencia, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - Elena Cruz-Iglesias
- Department of Laboratory Medicine, Osakidetza Basque Health Service, Basurto University Hospital, Bilbao, Spain
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| |
Collapse
|
43
|
Mian H, Wildes TM, Venner CP, Fonseca R. MRD negativity: considerations for older adults with multiple myeloma. Blood Cancer J 2023; 13:166. [PMID: 37938551 PMCID: PMC10632351 DOI: 10.1038/s41408-023-00939-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/10/2023] [Accepted: 10/27/2023] [Indexed: 11/09/2023] Open
Affiliation(s)
- Hira Mian
- Department of Oncology, McMaster University, Hamilton, ON, Canada.
| | - Tanya M Wildes
- Department of Hematology/Oncology, University of Nebraska Medical Center/Nebraska Medicine, Omaha, NE, USA
| | - Christopher P Venner
- Department of Medical Oncology, Centre for Lymphoid Cancers, University of British Columbia, Vancouver, BC, Canada
| | - Rafael Fonseca
- Division of Hematology and Medical Oncology, Mayo Clinic in Arizona, Phoenix, AZ, USA
| |
Collapse
|
44
|
Raab MS, Zamagni E, Manier S, Rodriguez‐Otero P, Schjesvold F, Broijl A. Difficult-to-treat patients with relapsed/refractory multiple myeloma: A review of clinical trial results. EJHAEM 2023; 4:1117-1131. [PMID: 38024633 PMCID: PMC10660429 DOI: 10.1002/jha2.743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/31/2023] [Accepted: 06/13/2023] [Indexed: 12/01/2023]
Abstract
Overall outcomes for multiple myeloma have improved due to the availability of new therapies, but patients with relapsed/refractory multiple myeloma harbouring certain factors continue to pose a therapeutic challenge. These challenging features include high-risk cytogenetics, renal impairment, patient characteristics such as age and frailty, and extramedullary disease. Prior refractory status and number of prior lines add further complexity to the treatment of these patients. While newer regimens are available and have suggested efficacy in these patient populations through subgroup analyses, differences in trial definitions and cut-offs make meaningful comparisons difficult. This review aims to examine the available clinical trial data for patients with high-risk cytogenetics, renal impairment, age and frailty and extramedullary disease.
Collapse
Affiliation(s)
- Marc S. Raab
- Heidelberg Myeloma Center, Department of Medicine VUniversity HospitalHeidelbergGermany
| | - Elena Zamagni
- Seragnoli Institute of HematologyBologna University School of MedicineBolognaItaly
| | - Salomon Manier
- Department of HematologyUniversity Hospital Center of LilleLilleFrance
| | | | - Fredrik Schjesvold
- Oslo Myeloma Center, Department of HaematologyOslo University Hospital, Oslo, Norway, and KG Jebsen Center for B Cell MalignanciesUniversity of OsloOsloNorway
| | - Annemiek Broijl
- Department of HematologyErasmus MC Cancer InstituteRotterdamThe Netherlands
| |
Collapse
|
45
|
Wijnands C, Noori S, Donk NWCJVD, VanDuijn MM, Jacobs JFM. Advances in minimal residual disease monitoring in multiple myeloma. Crit Rev Clin Lab Sci 2023; 60:518-534. [PMID: 37232394 DOI: 10.1080/10408363.2023.2209652] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/07/2023] [Accepted: 04/28/2023] [Indexed: 05/27/2023]
Abstract
Multiple myeloma (MM) is characterized by the clonal expansion of plasma cells and the excretion of a monoclonal immunoglobulin (M-protein), or fragments thereof. This biomarker plays a key role in the diagnosis and monitoring of MM. Although there is currently no cure for MM, novel treatment modalities such as bispecific antibodies and CAR T-cell therapies have led to substantial improvement in survival. With the introduction of several classes of effective drugs, an increasing percentage of patients achieve a complete response. This poses new challenges to traditional electrophoretic and immunochemical M-protein diagnostics because these methods lack sensitivity to monitor minimal residual disease (MRD). In 2016, the International Myeloma Working Group (IMWG) expanded their disease response criteria with bone marrow-based MRD assessment using flow cytometry or next-generation sequencing in combination with imaging-based disease monitoring of extramedullary disease. MRD status is an important independent prognostic marker and its potential as a surrogate endpoint for progression-free survival is currently being studied. In addition, numerous clinical trials are investigating the added clinical value of MRD-guided therapy decisions in individual patients. Because of these novel clinical applications, repeated MRD evaluation is becoming common practice in clinical trials as well as in the management of patients outside clinical trials. In response to this, novel mass spectrometric methods that have been developed for blood-based MRD monitoring represent attractive minimally invasive alternatives to bone marrow-based MRD evaluation. This paves the way for dynamic MRD monitoring to allow the detection of early disease relapse, which may prove to be a crucial factor in facilitating future clinical implementation of MRD-guided therapy. This review provides an overview of state-of-the-art of MRD monitoring, describes new developments and applications of blood-based MRD monitoring, and suggests future directions for its successful integration into the clinical management of MM patients.
Collapse
Affiliation(s)
- Charissa Wijnands
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Somayya Noori
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | | | - Martijn M VanDuijn
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Joannes F M Jacobs
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
46
|
Wellman TJ, Mudd SR, Godby KN, Wooten DW, Ross JA, Bueno OF, Wanik D, Divgi CR, Comley RA, Costa LJ, Hesterman JY. Evaluation of a semi-automated approach for FDG PET image analysis for routine clinical application in patients with multiple myeloma. Transl Oncol 2023; 37:101767. [PMID: 37657154 PMCID: PMC10495672 DOI: 10.1016/j.tranon.2023.101767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND FDG PET/CT is a tool for assessing response to therapy in various cancers, and may provide an earlier biomarker of clinical response. We developed a novel semi-automated approach for analyzing FDG PET/CT images in patients with multiple myeloma (MM) to standardize FDG PET application. METHODS Patients (n = 8) with relapsed/refractory MM from the Phase 2 study (NCT02899052) of venetoclax plus carfilzomib and dexamethasone underwent FDG PET/CT at baseline and up to two timepoints during treatment. Images were processed using an established automated segmentation algorithm, with the modification that a red marrow region in an unaffected lumbar vertebra was used to define background standardized uptake value normalized to lean body mass (SUL) threshold above which uptake was considered disease-specific uptake. This approach was compared to lesion segmentation, and to International Myeloma Working Group (IMWG) response criteria, including minimal residual disease (MRD). RESULTS The two FDG PET analysis techniques agreed on evaluation of patient-level SULpeak for 67% of scans. In the metabolic response assessment per PET Response Criteria in Solid Tumors (PERCIST), the two techniques agreed in 75% of patients. Differences between techniques occurred in low-uptake lesions due to greater reader sensitivity to lesions with uptake marginally above background. PERCIST outcomes were generally in agreement with IMWC and MRD. CONCLUSIONS This semi-automated analysis was in high agreement with standard approaches for detecting response to MM therapy. This proof-of-concept study suggests that larger studies should be conducted to confirm how FDG PET analysis may aid early response detection in MM.
Collapse
Affiliation(s)
- Tyler J Wellman
- Invicro, a Konica Minolta Company, 119 4th Ave, Needham Heights, MA 02494, USA
| | - Sarah R Mudd
- AbbVie, Inc., 1 North Waukegan Rd, North Chicago, IL 60064, USA
| | - Kelly N Godby
- The University of Alabama at Birmingham School of Medicine, 1670 University Blvd, Birmingham, AL 35233, USA
| | - Dustin W Wooten
- AbbVie, Inc., 1 North Waukegan Rd, North Chicago, IL 60064, USA
| | - Jeremy A Ross
- AbbVie, Inc., 1 North Waukegan Rd, North Chicago, IL 60064, USA
| | - Orlando F Bueno
- AbbVie, Inc., 1 North Waukegan Rd, North Chicago, IL 60064, USA
| | - Danielle Wanik
- Invicro, a Konica Minolta Company, 119 4th Ave, Needham Heights, MA 02494, USA
| | - Chaitanya R Divgi
- Invicro, a Konica Minolta Company, 119 4th Ave, Needham Heights, MA 02494, USA
| | - Robert A Comley
- AbbVie, Inc., 1 North Waukegan Rd, North Chicago, IL 60064, USA
| | - Luciano J Costa
- The University of Alabama at Birmingham School of Medicine, 1670 University Blvd, Birmingham, AL 35233, USA
| | - Jacob Y Hesterman
- Invicro, a Konica Minolta Company, 119 4th Ave, Needham Heights, MA 02494, USA.
| |
Collapse
|
47
|
Bar N, Firestone RS, Usmani SZ. Aiming for the cure in myeloma: Putting our best foot forward. Blood Rev 2023; 62:101116. [PMID: 37596172 DOI: 10.1016/j.blre.2023.101116] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 08/20/2023]
Abstract
Frontline therapy for multiple myeloma (MM) is evolving to include novel combinations that can achieve unprecedented deep response rates. Several treatment strategies exist, varying in induction regimen composition, use of transplant and or consolidation and maintenance. In this sea of different treatment permutations, the overarching theme is the powerful prognostic factors of disease risk and achievement of minimal residual disease (MRD) negativity. MM has significant inter-patient variability that requires treatment to be individualized. Risk-adapted and response-adapted strategies which are increasingly being explored to define the extent and duration of therapy, and eventually aim for functional curability. In addition, with T-cell redirection therapies rapidly revolutionizing myeloma treatments, the current standard of care for myeloma will change. This review analyzes the current relevant literature in upfront therapy for fit myeloma patients and provides suggestions for treatment approach while novel clinical trials are maturing.
Collapse
Affiliation(s)
- Noffar Bar
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine University, New Haven, CT, USA.
| | - Ross S Firestone
- Multiple Myeloma Service, Department of medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Saad Z Usmani
- Multiple Myeloma Service, Department of medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
48
|
Costa LJ, Chhabra S, Medvedova E, Dholaria BR, Schmidt TM, Godby KN, Silbermann R, Dhakal B, Bal S, Giri S, D'Souza A, Hall AC, Hardwick P, Omel J, Cornell RF, Hari P, Callander NS. Minimal residual disease response-adapted therapy in newly diagnosed multiple myeloma (MASTER): final report of the multicentre, single-arm, phase 2 trial. Lancet Haematol 2023; 10:e890-e901. [PMID: 37776872 PMCID: PMC10836587 DOI: 10.1016/s2352-3026(23)00236-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/22/2023] [Accepted: 07/27/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND For patients with newly diagnosed multiple myeloma, reaching minimal residual disease (MRD) negativity after treatment is associated with improved outcomes; however, the use of MRD to modulate therapy remains elusive. We present the final analysis of the MASTER trial of daratumumab, carfilzomib, lenalidomide, and dexamethasone (Dara-KRd) therapy in patients with newly diagnosed multiple myeloma, in which MRD status is used to modulate treatment duration and cessation. METHODS MASTER was a multicentre, single-arm, phase 2 trial conducted in five academic medical centres in the USA. Eligible participants were 18 years or older with newly diagnosed multiple myeloma (measurable by serum or urine protein electrophoresis or serum free light chains), a life expectancy of at least 12 months, and an Eastern Cooperative Oncology Group performance status of 0-2, and had received no previous treatment for multiple myeloma except up to one cycle of therapy containing bortezomib, cyclophosphamide, and dexamethasone. The study was enriched for participants with high-risk chromosome abnormalities (HRCAs). During the induction phase, participants received four 28-day cycles of Dara-KRd, each comprising daratumumab (16 mg/kg intravenously on days 1, 8, 15, and 22), carfilzomib (56 mg/m2 intravenously on days 1, 8, and 15), lenalidomide (25 mg orally on days 1-21), and dexamethasone (40 mg orally or intravenously on days 1, 8, 15, and 22); induction was followed by autologous haematopoietic stem-cell transplantation and up to two phases of consolidation with Dara-KRd. We assessed MRD by next-generation sequencing after or during each phase. The primary endpoint was reaching MRD negativity (<10-5). Participants who reached MRD negativity after or during two consecutive phases stopped treatment and began observation with MRD surveillance (MRD-SURE); participants who did not reach two consecutive MRD-negative results received maintenance lenalidomide. Secondary endpoints included progression-free survival and cumulative incidence of progression. All analyses were conducted in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT03224507, and is complete. FINDINGS Between Mar 21, 2018, and Oct 23, 2020, 123 participants were recruited to the study, of whom 70 (57%) were men, 53 (43%) were women, 94 (76%) were non-Hispanic White, 25 (20%) were non-Hispanic Black, and four (3%) were of another race or ethnicity. The median age of participants was 61 years (IQR 55-68), and 24 (20%) were aged 70 years or older. The median duration of follow up was 42·2 months (IQR 34·5-46·0). Of the 123 participants, 53 (43%) had no HRCAs, 46 (37%) had one HRCA, and 24 (20%) had two or more HRCAs. For 118 (96%) of 123 participants, MRD was evaluable by next-generation sequencing; the remaining five had an absence of sufficiently unique clonogenic sequences to enable tracking by the assay. Of these 118 participants, 96 (81%, 95% CI 73-88) reached MRD of less than 10-5 (comprising 39 [78%, 64-88] of 50 participants with no HRCAs, 38 [86%, 73-95] of 44 participants with one HRCA, and 19 [79%, 58-93] of 24 participants with two or more HRCAs) and 84 (71%, 62-79) reached MRD-SURE and treatment cessation. 36-month progression-free survival among all 123 participants was 88% (95% CI 78-95) for participants with no HRCAs, 79% (67-88) for those with one HRCA, and 50% (30-70) for those with two or more HRCAs. For the 84 participants reaching MRD-SURE, the 24-month cumulative incidence of progression from cessation of therapy was 9% (95% CI 1-19) for participants with no HRCAs, 9% (1-18) for those with one HRCA, and 47% (23-72) for those with two or more HRCAs. 61 participants (comprising 52% of 118 MRD-evaluable participants and 73% of 84 participants who reached MRD-SURE) remain free of therapy and MRD-negative as of Feb 7, 2023. The most common grade 3-4 adverse events were neutropenia (43 patients, 35%), lymphopenia (28 patients, 23%), and hypertension (13 patients, 11%). Three treatment-emergent deaths were recorded: two sudden deaths and one due to viral infection, none of which were judged to be treatment-related. INTERPRETATION This approach provided positive outcomes and a pathway for treatment cessation in most patients with newly diagnosed multiple myeloma. Outcomes for patients with ultra-high-risk multiple myeloma, defined as those with two or more HRCAs, remain unsatisfactory, and these patients should be prioritised for trials with early introduction of therapies with novel mechanisms of action. FUNDING Amgen and Janssen Pharmaceuticals.
Collapse
Affiliation(s)
- Luciano J Costa
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Saurabh Chhabra
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Eva Medvedova
- Division of Hematology and Medical Oncology, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Bhagirathbhai R Dholaria
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy M Schmidt
- Division of Hematology, Oncology and Palliative Care, Department of Medicine, University of Wisc onsin, Madison, WI, USA
| | - Kelly N Godby
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rebecca Silbermann
- Division of Hematology and Medical Oncology, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Binod Dhakal
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Susan Bal
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Smith Giri
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Anita D'Souza
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aric C Hall
- Division of Hematology, Oncology and Palliative Care, Department of Medicine, University of Wisc onsin, Madison, WI, USA
| | - Pamela Hardwick
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James Omel
- Academic Consortium to Overcome Multiple Myeloma through Innovative Trials (COMMIT), Omaha, NE, USA
| | - Robert F Cornell
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Parameswaran Hari
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Natalie S Callander
- Division of Hematology, Oncology and Palliative Care, Department of Medicine, University of Wisc onsin, Madison, WI, USA
| |
Collapse
|
49
|
Nahi H, Afram G, Uttervall K, Lockmer S, Tätting L, Gahrton G, Kashif M, Alici E, Stromberg O, Klimkowska M, Lund J. Minimal residual disease status is the prognostic determinant following high-dose treatment for patients with multiple myeloma. Cancer Med 2023; 12:20736-20744. [PMID: 37921243 PMCID: PMC10709722 DOI: 10.1002/cam4.6640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/30/2023] [Accepted: 09/30/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND The presence of minimal residual disease (MRD+) following autologous stem cell transplantation (ASCT) in multiple myeloma represents a poor prognostic factor for progression-free survival (PFS) and overall survival (OS). METHODS At our department, we recommend lenalidomide maintenance for patients who are MRD+ after ASCT, while MRD-negative (MRD-) patients, after information about the national guidelines, were not advised to follow this regimen. RESULTS Out of the total 228 patients, 175 received ASCT following first-line induction (MRD- 92 (53%), MRD+ 83 (47%), at 2 months post-ASCT), while 53 underwent ASCT after second-line treatment (MRD- 27 (51%), MRD+ 26 (49%), at the same time point). Comparatively, MRD- patients who did not receive maintenance demonstrated better OS than MRD+ patients who received upfront ASCT and maintenance treatment (96% vs. 86%, p = 0.030, at 3 years). However, nonsignificant difference was found in PFS (76% vs. 62%, at 3 years). Furthermore, second-line ASCT, MRD- non-maintained patients exhibited significantly better PFS than MRD+ (71% vs. 27%, p > 0.001, at 3 years). However, OS was better but nonsignificant (96% vs. 76%, at 3 years). Fluorescence in situ hybridization (FISH) analysis was performed on 141 out of the 228 patients. Of these, 85 (60%) patients were deemed standard risk (SR), and 56 (40%) were classified as high risk (HR). In the SR cohort, MRD- patients exhibited better PFS and OS than MRD+ patients (71% vs. 59% and 100% vs. 85%, respectively). In the HR cohort, the MRD- patients showed superior PFS but similar OS compared to MRD+ patients (66% vs. 42% and 81% vs. 80%, respectively). CONCLUSIONS Our results indicate that being MRD- is a more crucial prognostic factor for the 3-year PFS and OS than the presence of high-risk cytogenetic markers or undergoing maintenance treatment. The latter appears insufficient, particularly for MRD+ patients following ASCT in the second-line setting, suggesting that these patients may require a more intensive treatment approach.
Collapse
Affiliation(s)
- Hareth Nahi
- Department of MedicineInstitution for biomedicine and clinical scienceLinköpingSweden
- Center for Hematology and Regenerative Medicine, Department of Medicine, HuddingeKarolinska InstitutetStockholmSweden
| | - Gabriel Afram
- Center for Hematology and Regenerative Medicine, Department of Medicine, HuddingeKarolinska InstitutetStockholmSweden
| | - Katarina Uttervall
- Center for Hematology and Regenerative Medicine, Department of Medicine, HuddingeKarolinska InstitutetStockholmSweden
| | - Sandra Lockmer
- Center for Hematology and Regenerative Medicine, Department of Medicine, HuddingeKarolinska InstitutetStockholmSweden
| | - Love Tätting
- Department of MedicineInstitution for biomedicine and clinical scienceLinköpingSweden
| | - Gösta Gahrton
- Center for Hematology and Regenerative Medicine, Department of Medicine, HuddingeKarolinska InstitutetStockholmSweden
| | - Muhammad Kashif
- Center for Hematology and Regenerative Medicine, Department of Medicine, HuddingeKarolinska InstitutetStockholmSweden
| | - Evren Alici
- Center for Hematology and Regenerative Medicine, Department of Medicine, HuddingeKarolinska InstitutetStockholmSweden
| | | | - Monika Klimkowska
- Center for Hematology and Regenerative Medicine, Department of Medicine, HuddingeKarolinska InstitutetStockholmSweden
| | - Johan Lund
- Center for Hematology and Regenerative Medicine, Department of Medicine, HuddingeKarolinska InstitutetStockholmSweden
| |
Collapse
|
50
|
Derman BA. MRD-guided treatment cessation in multiple myeloma. Lancet Haematol 2023; 10:e867-e868. [PMID: 37776871 DOI: 10.1016/s2352-3026(23)00240-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 10/02/2023]
Affiliation(s)
- Benjamin A Derman
- Section of Hematology/Oncology, University of Chicago, Chicago, IL 60637, USA.
| |
Collapse
|