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Alwahsh M, Farhat J, Talhouni S, Hamadneh L, Hergenröder R. Bortezomib advanced mechanisms of action in multiple myeloma, solid and liquid tumors along with its novel therapeutic applications. EXCLI JOURNAL 2023; 22:146-168. [PMID: 36998701 PMCID: PMC10043448 DOI: 10.17179/excli2022-5653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/12/2023] [Indexed: 04/01/2023]
Abstract
Bortezomib (BTZ) is a first-in-class reversible and selective proteasome inhibitor. It inhibits the ubiquitin proteasome pathway that leads to the degradation of many intracellular proteins. Initially, BTZ was FDA approved for the treatment of refractory or relapsed multiple myeloma (MM) in 2003. Later, its usage was approved for patients with previously untreated MM. In 2006, BTZ was approved for the treatment of relapsed or refractory Mantle Cell Lymphoma (MCL) and, in 2014, for previously untreated MCL. BTZ has been extensively studied either alone or in combination with other drugs for the treatment of different liquid tumors especially in MM. However, limited data evaluated the efficacy and safety of using BTZ in patients with solid tumors. In this review, we will discuss the advanced and novel mechanisms of action of BTZ documented in MM, solid tumors and liquid tumors. Moreover, we will shed the light on the newly discovered pharmacological effects of BTZ in other prevalent diseases.
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Affiliation(s)
- Mohammad Alwahsh
- Department of Pharmacy, Faculty of Pharmacy, Al-Zaytoonah University of Jordan, P.O. Box 130, Amman, 11733, Jordan
- Leibniz-Institut für Analytische Wissenschaften-ISAS-e.V., 44139 Dortmund, Germany
- Institute of Pathology and Medical Research Center (ZMF), University Medical Center Mannheim, Heidelberg University, 68167 Mannheim, Germany
- *To whom correspondence should be addressed: Mohammad Alwahsh, Department of Pharmacy, Faculty of Pharmacy, Al-Zaytoonah University of Jordan, P.O. Box 130, Amman, 11733, Jordan, E-mail:
| | - Joviana Farhat
- Department of Epidemiology and Population Health, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, PO Box 127788, United Arab Emirates
| | - Shahd Talhouni
- Department of Pharmacy, Faculty of Pharmacy, Al-Zaytoonah University of Jordan, P.O. Box 130, Amman, 11733, Jordan
| | - Lama Hamadneh
- Department of Pharmacy, Faculty of Pharmacy, Al-Zaytoonah University of Jordan, P.O. Box 130, Amman, 11733, Jordan
| | - Roland Hergenröder
- Leibniz-Institut für Analytische Wissenschaften-ISAS-e.V., 44139 Dortmund, Germany
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Yang G, Geng C, Jian Y, Zhou H, Chen W. Triplet RVd Induction for Transplant-Eligible Newly Diagnosed Multiple Myeloma: A Systematic Review and Meta-Analysis. Adv Ther 2022; 39:3799-3834. [PMID: 35771352 DOI: 10.1007/s12325-022-02195-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/12/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION The combination of lenalidomide, bortezomib, and dexamethasone (RVd) has become standard of care for transplant-eligible patients with newly diagnosed MM (NDMM). This study aimed to determine the efficacy of RVd as induction therapy in terms of response rates and survival outcomes of transplant-eligible patients with NDMM. METHODS The databases of Medline, Embase, and Cochrane Library were searched until February 1, 2021. Both randomized controlled trials (RCT) and non-RCTs from the available literature were extracted as one-arm data to assess the efficacy of each triplet regimen for the target patients in terms of response rates and survival rates for transplant-eligible patients with NDMM. Data was summarized as estimated pooled value regarding each evaluated index. Risk of bias of studies was assessed with standard methods. RESULTS The findings of 71 studies published from 2008 to 2020 were analyzed. For RVd induction, the overall response rate (ORR), very good partial response or better (≥ VGPR) rate, and complete response or better (≥ CR) rate after induction were 0.91 (95% CI 0.86-0.95), 0.23 (95% CI 0.17-0.29), and 0.56 (95% CI 0.51-0.61), respectively. Indirect comparisons in efficacy were made between RVd and other traditional triplet regimens. RVd induction led to a better ≥ CR rate than bortezomib, cyclophosphamide, and dexamethasone (VCd) regimen in both postinduction and post-ASCT phase, ≥ CR rate 0.11 (95% CI 0.08-0.15) and 0.21 (95% CI 0.12-0.32), respectively. The 1-year overall survival (OS) rate and 3-year OS rate of RVd regimen were longer than that of bortezomib, thalidomide, and dexamethasone (VTd), 0.97 (95% CI 0.94-0.98) vs 0.71 (95% CI 0.61-0.80), and 0.90 (95% CI 0.79-0.98) vs 0.70 (95% CI 0.64-0.75), respectively. CONCLUSIONS The RVd induction demonstrated confident response rates and survival benefits for transplant-eligible patients with NDMM.
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Affiliation(s)
- Guangzhong Yang
- Department of Hematology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Chuanying Geng
- Department of Hematology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Yuan Jian
- Department of Hematology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Huixing Zhou
- Department of Hematology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Wenming Chen
- Department of Hematology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China.
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Liu Y, Zhou J, Li Q, Li L, Jia Y, Geng F, Zhou J, Yin T. Tumor microenvironment remodeling-based penetration strategies to amplify nanodrug accessibility to tumor parenchyma. Adv Drug Deliv Rev 2021; 172:80-103. [PMID: 33705874 DOI: 10.1016/j.addr.2021.02.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/05/2021] [Accepted: 02/23/2021] [Indexed: 12/12/2022]
Abstract
Remarkable advances in nano delivery systems have provided new hope for tumor prevention, diagnosis and treatment. However, only limited clinical therapeutic effects against solid tumors were achieved. One of the main reasons is the presence of abundant physiological and pathological barriers in vivo that impair tumoral penetration and distribution of the nanodrugs. These barriers are related to the components of tumor microenvironment (TME) including abnormal tumor vasculature, rich composition of the extracellular matrix (ECM), and abundant stroma cells. Herein, we review the advanced strategies of TME remodeling to overcome these biological obstacles against nanodrug delivery. This review aims to offer a perspective guideline for the implementation of promising approaches to facilitate intratumoral permeation of nanodrugs through alleviation of biological barriers. At the same time, we analyze the advantages and disadvantages of the corresponding methods and put forward possible directions for the future researches.
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Affiliation(s)
- Yanhong Liu
- Department of Pharmaceutics, China Pharmaceutical University, 639 Longmian Avenue, Nanjing 211198, China
| | - Jiyuan Zhou
- Department of Pharmaceutics, China Pharmaceutical University, 639 Longmian Avenue, Nanjing 211198, China
| | - Qiang Li
- Department of Pharmaceutics, China Pharmaceutical University, 639 Longmian Avenue, Nanjing 211198, China
| | - Lingchao Li
- Department of Pharmaceutics, China Pharmaceutical University, 639 Longmian Avenue, Nanjing 211198, China
| | - Yue Jia
- Department of Pharmaceutics, China Pharmaceutical University, 639 Longmian Avenue, Nanjing 211198, China
| | - Feiyang Geng
- Department of Pharmaceutics, China Pharmaceutical University, 639 Longmian Avenue, Nanjing 211198, China
| | - Jianping Zhou
- Department of Pharmaceutics, China Pharmaceutical University, 639 Longmian Avenue, Nanjing 211198, China.
| | - Tingjie Yin
- Department of Pharmaceutics, China Pharmaceutical University, 639 Longmian Avenue, Nanjing 211198, China.
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4
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Zhai Y, Yuan D, Ge X, Hu S, Li P, Fang X, Li Y, Zhou X, Wang X. Pegylated Liposomal Doxorubicin in Vindesine-Based and Bortezomib-Based Regimens for Patients With Newly Diagnosed Multiple Myeloma: A Retrospective Study of Efficacy and Safety. Front Oncol 2021; 11:597453. [PMID: 33842312 PMCID: PMC8030239 DOI: 10.3389/fonc.2021.597453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/18/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose Although pegylated liposomal doxorubicin (PLD) has been approved in combination with bortezomib for relapsed/refractory multiple myeloma (MM), the antitumor efficacy and tolerability of PLD in different regimens for patients with newly diagnosed MM (NDMM) have not been fully defined. Methods A total of 249 NDMM patients diagnosed between January 2008 and October 2019 were included in this retrospective study. Among them, 112 patients received vindesine-based chemotherapy (35 vDD and 77 vAD) and 137 received bortezomib-based chemotherapy (58 VDD and 79 VD). Results In bortezomib-containing regimens, the complete response rate (48.3 vs. 30.4%, p = 0.033) and very good partial response or better rate (74.1 vs. 57.0%, p = 0.038) of VDD were significantly higher than those of VD subgroup. While no superior survival was found between VDD and VD subgroup. In vindesine-containing regimens, no statistical significance was identified between vDD and vAD in terms of response rate and survival. The occurrence rates of all cardiac AEs were similar between VDD and VD. Conclusions The vDD regimen was similar with vAD in the aspect of response rate, survival, and toxicity in NDMM patients. The addition of PLD to VD brought deeper response without increased toxicity, while no superior survival was found.
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Affiliation(s)
- Yujia Zhai
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,School of Medicine, Shandong University, Jinan, China
| | - Dai Yuan
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,School of Medicine, Shandong University, Jinan, China.,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China.,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China
| | - Xueling Ge
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,School of Medicine, Shandong University, Jinan, China.,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China.,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China
| | - Shunfeng Hu
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,School of Medicine, Shandong University, Jinan, China
| | - Peipei Li
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,School of Medicine, Shandong University, Jinan, China.,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China.,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China
| | - Xiaosheng Fang
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,School of Medicine, Shandong University, Jinan, China.,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China.,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China
| | - Ying Li
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,School of Medicine, Shandong University, Jinan, China.,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China.,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China.,National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiangxiang Zhou
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,School of Medicine, Shandong University, Jinan, China.,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China.,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China.,National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xin Wang
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,School of Medicine, Shandong University, Jinan, China.,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China.,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China.,National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
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5
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Kumar SK, Laubach JP, Giove TJ, Quick M, Neuwirth R, Yung G, Rajkumar SV, Richardson PG. Impact of concomitant dexamethasone dosing schedule on bortezomib-induced peripheral neuropathy in multiple myeloma. Br J Haematol 2017; 178:756-763. [DOI: 10.1111/bjh.14754] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 03/29/2017] [Indexed: 11/27/2022]
Affiliation(s)
| | | | | | | | | | - Godwin Yung
- Millennium Pharmaceuticals, Inc.; Cambridge MA USA
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Voorhees PM, Gasparetto C, Moore DT, Winans D, Orlowski RZ, Hurd DD. Final Results of a Phase 1 Study of Vorinostat, Pegylated Liposomal Doxorubicin, and Bortezomib in Relapsed or Refractory Multiple Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17:424-432. [PMID: 28655599 DOI: 10.1016/j.clml.2017.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 03/07/2017] [Accepted: 05/04/2017] [Indexed: 11/17/2022]
Abstract
INTRODUCTION/BACKGROUND Deacetylase inhibitors have synergistic activity in combination with proteasome inhibitors and anthracyclines in preclinical models of multiple myeloma (MM). We therefore evaluated the safety and efficacy of the deacetylase inhibitor vorinostat in combination with pegylated liposomal doxorubicin (PLD) and bortezomib in relapsed/refractory MM. PATIENTS AND METHODS Thirty-two patients were treated with PLD and bortezomib in combination with escalating doses of vorinostat on days 4 to 11 or 1 to 14. RESULTS The maximum tolerated dose of vorinostat was 400 mg on days 4 to 11. Neutropenia and thrombocytopenia attributable to protocol therapy were seen in 59% and 94% of patients, of which 37% and 47% were of grade 3 or higher severity, respectively. Constitutional and gastrointestinal adverse events of all grades were common, the majority of which were less than grade 3 in severity. The overall response rate (partial response rate or better) was 65% and the clinical benefit rate (minimal response rate or better) 74%. The overall response rate was 83%, 71%, and 45% for patients with bortezomib-naive, -sensitive, and -refractory MM, respectively. The median progression-free survival was 13.9 months and the 3-year overall survival 77%. Whole blood proteasome activity assays demonstrated a potential impact of vorinostat on the chymotryptic-like activity of the proteasome. CONCLUSION Further evaluation of PLD, bortezomib, and deacetylase inhibitor combinations is warranted, with special attention directed toward strategies to improve tolerability.
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Affiliation(s)
- Peter M Voorhees
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC.
| | - Cristina Gasparetto
- Division of Hematological Malignancies and Cellular Therapy, Duke University Medical Center, Durham, NC
| | - Dominic T Moore
- Division of Hematology-Oncology, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Diane Winans
- Division of Hematology-Oncology, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Robert Z Orlowski
- Department of Lymphoma/Myeloma, University of Texas MD Anderson Cancer Center, Houston, TX
| | - David D Hurd
- Section on Hematology and Oncology, Department of Internal Medicine, Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC
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7
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Dingli D, Ailawadhi S, Bergsagel PL, Buadi FK, Dispenzieri A, Fonseca R, Gertz MA, Gonsalves WI, Hayman SR, Kapoor P, Kourelis T, Kumar SK, Kyle RA, Lacy MQ, Leung N, Lin Y, Lust JA, Mikhael JR, Reeder CB, Roy V, Russell SJ, Sher T, Stewart AK, Warsame R, Zeldenrust SR, Rajkumar SV, Chanan Khan AA. Therapy for Relapsed Multiple Myeloma: Guidelines From the Mayo Stratification for Myeloma and Risk-Adapted Therapy. Mayo Clin Proc 2017; 92:578-598. [PMID: 28291589 PMCID: PMC5554888 DOI: 10.1016/j.mayocp.2017.01.003] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 12/12/2016] [Accepted: 01/04/2017] [Indexed: 12/13/2022]
Abstract
Life expectancy in patients with multiple myeloma is increasing because of the availability of an increasing number of novel agents with various mechanisms of action against the disease. However, the disease remains incurable in most patients because of the emergence of resistant clones, leading to repeated relapses of the disease. In 2015, 5 novel agents were approved for therapy for relapsed multiple myeloma. This surfeit of novel agents renders management of relapsed multiple myeloma more complex because of the occurrence of multiple relapses, the risk of cumulative and emergent toxicity from previous therapies, as well as evolution of the disease during therapy. A group of physicians at Mayo Clinic with expertise in the care of patients with multiple myeloma regularly evaluates the evolving literature on the biology and therapy for multiple myeloma and issues guidelines on the optimal care of patients with this disease. In this article, the latest recommendations on the diagnostic evaluation of relapsed multiple myeloma and decision trees on how to treat patients at various stages of their relapse (off study) are provided together with the evidence to support them.
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Affiliation(s)
- David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
| | | | - P Leif Bergsagel
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ
| | - Francis K Buadi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Angela Dispenzieri
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Rafael Fonseca
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ
| | - Morie A Gertz
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Wilson I Gonsalves
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Susan R Hayman
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Prashant Kapoor
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Taxiarchis Kourelis
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Shaji K Kumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Robert A Kyle
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Martha Q Lacy
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Nelson Leung
- Division of Nephrology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Yi Lin
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - John A Lust
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Joseph R Mikhael
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ
| | - Craig B Reeder
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ
| | - Vivek Roy
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL
| | - Stephen J Russell
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Taimur Sher
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL
| | - A Keith Stewart
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ
| | - Rahma Warsame
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Stephen R Zeldenrust
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - S Vincent Rajkumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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Single Dose Preemptive Plerixafor for Stem Cell Mobilization for ASCT After Lenalidomide Based Therapy in Multiple Myeloma: Impact in Resource Limited Setting. Indian J Hematol Blood Transfus 2017; 33:463-469. [PMID: 29075055 DOI: 10.1007/s12288-017-0798-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 02/21/2017] [Indexed: 12/22/2022] Open
Abstract
Peripheral blood stem cell mobilization with cytokines for autologous stem cell transplant in multiple myeloma is adversely affected by initial induction therapy consisting of either Lenalidomide or cytotoxic drugs, with failure rates of up to 45%. The use of Plerixafor with G-CSF for PBSC mobilisation significantly improves the chances of a successful mobilization. Plerixafor is a costly therapy and increases the overall costs of ASCT which can affect the number of patients being taken up for ASCT in resource limited settings. We prospectively studied the impact of single dose preemptive Plerixafor for PBSC mobilization in patients with prior Lenalidomide exposure. 26 patients who had received Lenalidomide based induction protocol underwent PBSC mobilisation during the study period with G-CSF 10 μg/kg/day SC for 4 days and single dose preemptive Plerixafor 240 μg/kg SC stat 11 h before the scheduled PB stem cell harvest on D5, based on a D4 PB CD34+ counts of <20/μL. A median of 07 cycles of Lenalidomide based combination therapy was used for induction therapy prior to ASCT. 84% patients underwent successful mobilization with one sitting of stem cell harvest post a single dose of Inj Plerixafor. 7.6% patients failed to mobilise the predefined minimum cell dose of CD34 and could not be taken up for ASCT. The median CD34% of the harvest bag sample was 0.33% (0.1-0.97%). Injection site erythema (34%), paresthesia's (34%) and nausea (30%) were the commonest adverse events reported post Inj Plerixafor. We did a real-world cost analysis for a resource limited setting for PBSC mobilization and found significant cost savings for the preemptive Plerixafor group.
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9
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Terragna C, Remondini D, Martello M, Zamagni E, Pantani L, Patriarca F, Pezzi A, Levi G, Offidani M, Proserpio I, De Sabbata G, Tacchetti P, Cangialosi C, Ciambelli F, Viganò CV, Dico FA, Santacroce B, Borsi E, Brioli A, Marzocchi G, Castellani G, Martinelli G, Palumbo A, Cavo M. The genetic and genomic background of multiple myeloma patients achieving complete response after induction therapy with bortezomib, thalidomide and dexamethasone (VTD). Oncotarget 2016; 7:9666-79. [PMID: 26575327 PMCID: PMC4891075 DOI: 10.18632/oncotarget.5718] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/27/2015] [Indexed: 11/25/2022] Open
Abstract
The prime focus of the current therapeutic strategy for Multiple Myeloma (MM) is to obtain an early and deep tumour burden reduction, up to the level of complete response (CR). To date, no description of the characteristics of the plasma cells (PC) prone to achieve CR has been reported. This study aimed at the molecular characterization of PC obtained at baseline from MM patients in CR after bortezomib-thalidomide-dexamethasone (VTD) first line therapy. One hundred and eighteen MM primary tumours obtained from homogeneously treated patients were profiled both for gene expression and for single nucleotide polymorphism genotype. Genomic results were used to obtain a predictor of sensitivity to VTD induction therapy, as well as to describe both the transcription and the genomic profile of PC derived from MM with subsequent optimal response to primary induction therapy. By analysing the gene profiles of CR patients, we identified a 5-gene signature predicting CR with an overall median accuracy of 75% (range: 72%–85%). In addition, we highlighted the differential expression of a series of genes, whose deregulation might explain patients' sensitivity to VTD therapy. We also showed that a small copy number loss, covering 606Kb on chromosome 1p22.1 was the most significantly associated with CR patients.
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Affiliation(s)
- Carolina Terragna
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Daniel Remondini
- Department of Physics and Astronomy (DIFA), Bologna University, Bologna, Italy
| | - Marina Martello
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Elena Zamagni
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Lucia Pantani
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | | | - Annalisa Pezzi
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Giuseppe Levi
- Department of Physics and Astronomy (DIFA), Bologna University, Bologna, Italy
| | - Massimo Offidani
- Clinica di Ematologia, A.O.U. Ospedali Riuniti di Ancona, Ancona, Italy
| | - Ilaria Proserpio
- U.O Oncologia Medica, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | | | - Paola Tacchetti
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Clotilde Cangialosi
- Hematology Division UTMO, Azienda "Ospedali Riuniti Villa Sofia-Cervello" Presidio Ospedaliero V.Cervello, Palermo, Italy
| | | | | | - Flores Angela Dico
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Barbara Santacroce
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Enrica Borsi
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Annamaria Brioli
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Giulia Marzocchi
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Gastone Castellani
- Department of Physics and Astronomy (DIFA), Bologna University, Bologna, Italy
| | - Giovanni Martinelli
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
| | - Antonio Palumbo
- Myeloma Unit, Division of Hematology, University of Torino, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Michele Cavo
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Bologna University School of Medicine, Bologna, Italy
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10
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Orlowski RZ, Nagler A, Sonneveld P, Bladé J, Hajek R, Spencer A, Robak T, Dmoszynska A, Horvath N, Spicka I, Sutherland HJ, Suvorov AN, Xiu L, Cakana A, Parekh T, San-Miguel JF. Final overall survival results of a randomized trial comparing bortezomib plus pegylated liposomal doxorubicin with bortezomib alone in patients with relapsed or refractory multiple myeloma. Cancer 2016; 122:2050-6. [PMID: 27191689 PMCID: PMC5701574 DOI: 10.1002/cncr.30026] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 01/07/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Previous results from an interim analysis of an open-label, randomized, phase 3 study demonstrated that bortezomib combined with pegylated liposomal doxorubicin (PLD) was superior to bortezomib monotherapy in patients with relapsed/refractory multiple myeloma who had previously received one or more lines of therapy. Protocol-defined final survival data from that study are provided here. METHODS Patients were randomized (1:1) to receive either bortezomib alone (1.3 mg/m(2) intravenously on days 1, 4, 8, and 11 of every 21-day cycle) or bortezomib-PLD (bortezomib plus PLD 30 mg/m(2) intravenously on day 4). The primary endpoint was the time to progression. Secondary efficacy endpoints included overall survival (OS), progression-free survival, and the overall response rate. RESULTS In total, 646 patients (bortezomib-PLD, n = 324; bortezomib alone, n = 322) were randomized between December, 2004, and March, 2006. On the clinical cutoff date (May 16, 2014) for the final survival analysis, at a median follow-up of 103 months, 79% of patients had died (bortezomib-PLD group: 253 of 324 patients; 78%; bortezomib alone group: 257 of 322 patients; 80%). The median OS in the bortezomib-PLD group was 33 months (95% confidence interval [CI], 28.9-37.1) versus 30.8 months (95% CI, 25.2-36.5) in the bortezomib alone group (hazard ratio, 1.047; 95% CI, 0.879-1.246; P = .6068). Salvage therapies included conventional and novel drugs, which were well balanced between the two treatment groups. CONCLUSIONS Despite inducing a superior time to progression, long-term follow-up revealed that PLD-bortezomib did not improve OS compared with bortezomib alone in patients with relapsed/refractory multiple myeloma. The inability to sustain the early observed survival advantage may have been caused by the effects of subsequent lines of therapy, and underscores the need for long-term follow-up of phase 3 trials while recognizing the challenge of having adequate power to detect long-term differences in OS. Cancer 2016;122:2050-6. © 2016 American Cancer Society.
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Affiliation(s)
- Robert Z. Orlowski
- Department of Lymphoma/Myeloma, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Arnon Nagler
- Division of Hematology, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Pieter Sonneveld
- Department of Hematology, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Joan Bladé
- Department of Clinical Hematology, August Pi I Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain
| | - Roman Hajek
- Department of Hemato-Oncology, University Hospital and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Andrew Spencer
- Malignant Hematology and Stem Cell Transplantation Service, The Alfred Hospital, Melbourne, Australia
| | - Tadeusz Robak
- Department of Hematology, Medical University of Łødź, Łødź, Poland
| | - Anna Dmoszynska
- Hematology and Bone Marrow Transplant Department, Medical University of Lublin, Lublin, Poland
| | - Noemi Horvath
- Department of Hematology, Royal Adelaide Hospital, West Australia, Australia
| | - Ivan Spicka
- Department of Internal Medicine, Charles University General Faculty Hospital, Prague, Czech Republic
| | - Heather J. Sutherland
- Division of Hematology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexander N. Suvorov
- Department of Hematology, First Republican Clinical Hospital of the Ministry of Healthcare of the Udmurt Republic, Izhevsk, Russia
| | - Liang Xiu
- Janssen Research & Development, LLC, Raritan, New Jersey
| | - Andrew Cakana
- Janssen Research & Development, LLC, Raritan, New Jersey
| | - Trilok Parekh
- Janssen Research & Development, LLC, Raritan, New Jersey
| | - Jesús F. San-Miguel
- Center for Applied Medical Research, August Pi I Sunyer Biomedical Research Institute, University of Navarra, Pamplona, Spain
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11
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Luo W, Johnson CS, Trump DL. Vitamin D Signaling Modulators in Cancer Therapy. VITAMINS AND HORMONES 2016; 100:433-72. [PMID: 26827962 DOI: 10.1016/bs.vh.2015.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The antiproliferative and pro-apoptotic effects of 1α,25-dihydroxycholecalciferol (1,25(OH)2D3, 1,25D3, calcitriol) have been demonstrated in various tumor model systems in vitro and in vivo. However, limited antitumor effects of 1,25D3 have been observed in clinical trials. This may be attributed to a variety of factors including overexpression of the primary 1,25D3 degrading enzyme, CYP24A1, in tumors, which would lead to rapid local inactivation of 1,25D3. An alternative strategy for improving the antitumor activity of 1,25D3 involves the combination with a selective CYP24A1 inhibitor. The validity of this approach is supported by numerous preclinical investigations, which demonstrate that CYP24A1 inhibitors suppress 1,25D3 catabolism in tumor cells and increase the effects of 1,25D3 on gene expression and cell growth. Studies are now required to determine whether selective CYP24A1 inhibitors+1,25D3 can be used safely and effectively in patients. CYP24A1 inhibitors plus 1,25D3 can cause dose-limiting toxicity of vitamin D (hypercalcemia) in some patients. Dexamethasone significantly reduces 1,25D3-mediated hypercalcemia and enhances the antitumor activity of 1,25D3, increases VDR-ligand binding, and increases VDR protein expression. Efforts to dissect the mechanisms responsible for CYP24A1 overexpression and combinational effect of 1,25D3/dexamethasone in tumors are underway. Understanding the cross talk between vitamin D receptor (VDR) and glucocorticoid receptor (GR) signaling axes is of crucial importance to the design of new therapies that include 1,25D3 and dexamethasone. Insights gained from these studies are expected to yield novel strategies to improve the efficacy of 1,25D3 treatment.
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Affiliation(s)
- Wei Luo
- Department of Pharmacology and Therapeutics, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Candace S Johnson
- Department of Pharmacology and Therapeutics, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Donald L Trump
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York, USA; Inova Dwight and Martha Schar Cancer Institute, Falls Church, Virginia, USA.
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12
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Liu J, Li J, Zheng D. [Bortezomib-based four-drug combination regimen improved the efficacy of multiple myeloma patients receiving previous doublet or triplet regimens containing Bortezomib]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2015; 36:793-5. [PMID: 26462785 PMCID: PMC7342697 DOI: 10.3760/cma.j.issn.0253-2727.2015.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Junru Liu
- Department of Hematology, The First Affiliated Hospital, Sun Yat- sen University, Guangzhou 510080, China
| | - Juan Li
- Department of Hematology, The First Affiliated Hospital, Sun Yat- sen University, Guangzhou 510080, China
| | - Dong Zheng
- Department of Hematology, The First Affiliated Hospital, Sun Yat- sen University, Guangzhou 510080, China
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13
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Larsen JT, Kumar S. Evolving Paradigms in the Management of Multiple Myeloma: Novel Agents and Targeted Therapies. ACTA ACUST UNITED AC 2015; 3:47-68. [PMID: 27182478 PMCID: PMC4837942 DOI: 10.1007/s40487-015-0009-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Indexed: 12/22/2022]
Abstract
Multiple myeloma (MM) is a clonal plasma cell disorder defined by bone marrow infiltration and osteolytic bone lesions and is the second most common hematologic malignancy after non-Hodgkin lymphoma. The landscape of MM treatment was transformed at the dawn of the twenty-first century by the introduction of novel agents including proteasome inhibitors (bortezomib) and immunomodulatory drugs (thalidomide, lenalidomide), which have prolonged the survival of MM patients. The recently revised International Myeloma Working Group diagnostic criteria for MM added validated biomarkers (clonal bone marrow plasma cell ≥60%, involved:uninvolved serum free light chain ratio ≥100, or >1 focal lesion on magnetic resonance imaging) to identify near inevitable progression to symptomatic MM requiring therapy. In addition, the definition of myeloma-defining CRAB features (hypercalcemia, renal failure, anemia, and bone lesions) has been refined based on advances in imaging and laboratory techniques since the 2003 IMWG consensus. Despite expanded treatment options, MM remains an incurable disease. Drug resistance and clonal evolution remain problematic, and novel therapeutic agents are needed. New approaches to myeloma treatment include anti-CD38 antibodies, next generation proteasome inhibitors, epigenetic modulation with histone deacetylase inhibitors, and targeting the tumor microenvironment. In this article, the diagnosis, staging, and prognostic stratification of newly diagnosed MM will be reviewed. Clinical data pertaining to the emerging targeted agents will be discussed, and a suggested framework for integration of these new therapeutic options will be provided.
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Affiliation(s)
- Jeremy T Larsen
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN USA
| | - Shaji Kumar
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN USA
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14
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Voorhees PM, Orlowski RZ, Mulkey F, Watson P, Geyer S, Sanford BL, Bennett E, Chanan-Khan AA, Bloomfield CD, Larson RA. Long-term outcomes for newly-diagnosed multiple myeloma patients treated with pegylated liposomal doxorubicin and bortezomib: final results of CALGB (Alliance) 10301, a multicentre phase II study. Br J Haematol 2015. [PMID: 26202857 DOI: 10.1111/bjh.13592] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Long-term outcomes and updated clinical efficacy and safety data were evaluated for newly-diagnosed multiple myeloma patients treated on a phase II study of bortezomib and pegylated liposomal doxorubicin (PegLD). Out of 61 patients, the overall response rate was 57% and the near-complete/complete response rate was 7%. Patients aged ≥65 years old had a higher incidence of treatment-related ≥Grade 3 non-haematological toxicity (80% vs. 51%, P = 0·020). Median overall survival was 5·6 years and negatively impacted by the presence of International Staging System stage III disease, underscoring the need for novel treatment strategies for this group of patients.
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Affiliation(s)
- Peter M Voorhees
- Division of Hematology-Oncology, the University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Robert Z Orlowski
- Department of Lymphoma/Myeloma, the University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Flora Mulkey
- Alliance Statistics and Data Center, Duke University Medical Center, Durham, NC, USA
| | - Peter Watson
- Department of Oncology, Kinston Medical Specialists, P.A., Kinston, NC, USA
| | - Susan Geyer
- Health Informatics Institute, University of South Florida, Tampa, FL, USA
| | - Ben L Sanford
- Alliance Statistics and Data Center, Duke University Medical Center, Durham, NC, USA
| | - Elizabeth Bennett
- Alliance Statistics and Data Center, Duke University Medical Center, Durham, NC, USA
| | | | - Clara D Bloomfield
- Division of Hematology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Richard A Larson
- Department of Medicine, University of Chicago Comprehensive Cancer Center, Chicago, IL, USA
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15
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Mateos MV, Ocio EM, Paiva B, Rosiñol L, Martínez-López J, Bladé J, Lahuerta JJ, García-Sanz R, San Miguel JF. Treatment for patients with newly diagnosed multiple myeloma in 2015. Blood Rev 2015; 29:387-403. [PMID: 26094881 DOI: 10.1016/j.blre.2015.06.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 06/05/2015] [Accepted: 06/08/2015] [Indexed: 10/23/2022]
Abstract
Multiple myeloma is the second most frequent haematological disease. The introduction of high-dose melphalan followed by autologous haematopoietic cell transplant (HDT/ASCT) for young patients and the availability of novel agents for young and elderly patients with multiple myeloma have dramatically changed the perspective of treatment. However, further research is necessary if we want to definitively cure the disease. Treatment goals for transplant-eligible and non-transplant-eligible patients should be to prolong survival by achieving the best possible response, while ensuring quality of life. The treatment should be individualized on the basis of host and disease features and better monitoring of the response upon use of high-sensitivity techniques for evaluating residual disease. For young patients, HDT/ASCT is a standard of care for treatment and its efficacy has been enhanced and challenged by the new drugs. For elderly patients, treatment options were limited to alkylators, but new upfront treatment combinations based on novel agents (proteasome inhibitors and immunomodulatory drugs) combined or not with alkylators have significantly improved outcomes.Extended treatment for young and elderly patients improves the quality and duration of clinical responses; however,the optimal scheme, appropriate doses and duration of long-term therapy have not yet been fully determined.This review summarises the progress in the treatment of patients with newly diagnosed multiple myeloma, addressing critical questions such as the optimal induction, early versus late ASCT, consolidation and/or maintenance for young patients, and how we can choose the best option for non-transplant-eligible patients.
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Affiliation(s)
| | - Enrique M Ocio
- Hospital Universitario de Salamanca-IBSAL, IBMCC-CSIC, Salamanca, Spain
| | - Bruno Paiva
- Clínica Universidad de Navarra/Centro de Investigación Médica Aplicada (CIMA), Spain
| | - Laura Rosiñol
- Hospital Clínic i Provincial de Barcelona, Institut d'Investigacions Biomédiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Joan Bladé
- Hospital Clínic i Provincial de Barcelona, Institut d'Investigacions Biomédiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Ramón García-Sanz
- Hospital Universitario de Salamanca-IBSAL, IBMCC-CSIC, Salamanca, Spain
| | - Jesús F San Miguel
- Clínica Universidad de Navarra/Centro de Investigación Médica Aplicada (CIMA), Spain
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16
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Dytfeld D, Rosebeck S, Kandarpa M, Mayampurath A, Mellacheruvu D, Alonge MM, Ngoka L, Jasielec J, Richardson PG, Volchenboum S, Nesvizhskii AI, Sreekumar A, Jakubowiak AJ. Proteomic profiling of naïve multiple myeloma patient plasma cells identifies pathways associated with favourable response to bortezomib-based treatment regimens. Br J Haematol 2015; 170:66-79. [DOI: 10.1111/bjh.13394] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 02/04/2015] [Indexed: 01/08/2023]
Affiliation(s)
- Dominik Dytfeld
- University of Chicago; Chicago IL USA
- Karol Marcinkowski University of Medical Sciences; Poznan Poland
| | | | - Malathi Kandarpa
- Hematology/Oncology; University of Michigan Comprehensive Cancer Center; Ann Arbor MI USA
| | - Anoop Mayampurath
- Center for Research Informatics; Computation Institute and Department of Pediatrics; University of Chicago; Chicago IL USA
| | - Dattatreya Mellacheruvu
- Department of Pathology; University of Michigan; Ann Arbor MI USA
- Department of Computational Medicine & Bioinformatics; Ann Arbor MI USA
| | | | | | | | | | - Samuel Volchenboum
- Center for Research Informatics; Computation Institute and Department of Pediatrics; University of Chicago; Chicago IL USA
| | | | - Arun Sreekumar
- Department of Pathology; University of Michigan; Ann Arbor MI USA
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17
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Nishihori T, Baz R, Shain K, Kim J, Ochoa-Bayona JL, Yue B, Sullivan D, Dalton W, Alsina M. An open-label phase I/II study of cyclophosphamide, bortezomib, pegylated liposomal doxorubicin, and dexamethasone in newly diagnosed myeloma. Eur J Haematol 2015; 95:426-35. [PMID: 25600676 DOI: 10.1111/ejh.12509] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2014] [Indexed: 01/09/2023]
Abstract
We conducted a phase 1/2 trial evaluating the combination of cyclophosphamide, bortezomib, pegylated liposomal doxorubicin, and dexamethasone (CVDD) for newly diagnosed multiple myeloma (MM). The primary objective of the phase 1 was to evaluate the safety and tolerability of maximum planned dose (MPD) and the phase 2 was to assess the overall response rate. Patients received 6-8 cycles of CVDD at four dose levels. There were no dose-limiting toxicities. The MPD was cyclophosphamide 750 mg/m(2) IV on day 1, bortezomib 1.3 mg/m(2) IV on days 1, 4, 8, 11, pegylated liposomal doxorubicin 30 mg/m(2) IV on day 4, and dexamethasone 20 mg orally on the day of and after bortezomib (21-d cycle). Forty-nine patients were treated at the MPD of which 22% had high-risk myeloma. The most common grade ≥3 toxicities included myelosuppression, infection, and fatigue. Overall response and complete response rates were 91% and 26% in standard-risk, and 100% and 58% in high-risk cohort, respectively. After a median follow-up of 34 months, the median progression-free survival was 31.3 months. The 2-yr overall survival was 91.1% in the standard-risk and 88.9% in the high-risk cohort, respectively. CVDD regimen was well tolerated and was highly active in newly diagnosed MM.
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Affiliation(s)
- Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Rachid Baz
- Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kenneth Shain
- Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jongphil Kim
- Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Biostatistics core, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jose L Ochoa-Bayona
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Binglin Yue
- Biostatistics core, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Daniel Sullivan
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - William Dalton
- Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Melissa Alsina
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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18
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Turner JG, Dawson J, Cubitt CL, Baz R, Sullivan DM. Inhibition of CRM1-dependent nuclear export sensitizes malignant cells to cytotoxic and targeted agents. Semin Cancer Biol 2014; 27:62-73. [PMID: 24631834 PMCID: PMC4108511 DOI: 10.1016/j.semcancer.2014.03.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 02/25/2014] [Accepted: 03/01/2014] [Indexed: 10/25/2022]
Abstract
Nuclear-cytoplasmic trafficking of proteins is a significant factor in the development of cancer and drug resistance. Subcellular localization of exported proteins linked to cancer development include those involved in cell growth and proliferation, apoptosis, cell cycle regulation, transformation, angiogenesis, cell adhesion, invasion, and metastasis. Here, we examined the basic mechanisms involved in the export of proteins from the nucleus to the cytoplasm. All proteins over 40kDa use the nuclear pore complex to gain entry or exit from the nucleus, with the primary nuclear export molecule involved in these processes being chromosome region maintenance 1 (CRM1, exportin 1 or XPO1). Proteins exported from the nucleus must possess a hydrophobic nuclear export signal (NES) peptide that binds to a hydrophobic groove containing an active-site Cys528 in the CRM1 protein. CRM1 inhibitors function largely by covalent modification of the active site Cys528 and prevent binding to the cargo protein NES. In the absence of a CRM1 inhibitor, CRM1 binds cooperatively to the NES of the cargo protein and RanGTP, forming a trimer that is actively transported out of the nucleus by facilitated diffusion. Nuclear export can be blocked by CRM1 inhibitors, NES peptide inhibitors or by preventing post-translational modification of cargo proteins. Clinical trials using the classic CRM1 inhibitor leptomycin B proved too toxic for patients; however, a new generation of less toxic small molecule inhibitors is being used in clinical trials in patients with both hematological malignancies and solid tumors. Additional trials are being initiated using small-molecule CRM1 inhibitors in combination with chemotherapeutics such as pegylated liposomal doxorubicin. In this review, we present evidence that combining the new CRM1 inhibitors with other classes of therapeutics may prove effective in the treatment of cancer. Potential combinatorial therapies discussed include the use of CRM1 inhibitors and the addition of alkylating agents (melphalan), anthracyclines (doxorubicin and daunomycin), BRAF inhibitors, platinum drugs (cisplatin and oxaliplatin), proteosome inhibitors (bortezomib and carfilzomib), or tyrosine-kinase inhibitors (imatinib). Also, the sequence of treatment may be important for combination therapy. We found that the most effective treatment regimen involved first priming the cancer cells with the CRM1 inhibitor followed by doxorubicin, bortezomib, carfilzomib, or melphalan. This order sensitized both de novo and acquired drug-resistant cancer cell lines.
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Affiliation(s)
- Joel G Turner
- Department of Blood and Marrow Transplantation and Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Jana Dawson
- Department of Blood and Marrow Transplantation and Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Christopher L Cubitt
- Translational Research Core Laboratory, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Rachid Baz
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Daniel M Sullivan
- Department of Blood and Marrow Transplantation and Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA.
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19
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Ria R, Reale A, Vacca A. Novel agents and new therapeutic approaches for treatment of multiple myeloma. World J Methodol 2014; 4:73-90. [PMID: 25332907 PMCID: PMC4202483 DOI: 10.5662/wjm.v4.i2.73] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Revised: 01/28/2014] [Accepted: 04/17/2014] [Indexed: 02/06/2023] Open
Abstract
This review summarizes the therapeutic strategies and the drugs actually in development for the management of myeloma patients. Multiple myeloma is caused by the expansion of monoclonal plasma cells and secretion of M-protein (immunoglobulins, Bence Jones protein and free light chains). Multiple myeloma still remains an incurable disease with a high incidence rate in the elderly, despite the introduction of several new therapeutic agents (bortezomib, lenalidomide and thalidomide) which have changed its natural history. The high heterogeneity of this disease leads to large differences in clinical responses to treatments. Thus, the choice of the best treatment is a difficult issue. However, the introduction of new drugs has made it possible to achieve high response rates and good quality responses with long-term disease control. Interactions between tumor cells and their bone marrow microenvironment play a pivotal role in the development, maintenance, and progression of myeloma, inducing also drug resistance. These knowledges have improved treatment options, leading to the approval of new drugs which not only target the malignant cell itself, but also its microenvironment. These agents are in preclinical/early clinical evaluation and they appear to further improve disease control, but their use is still not approved outside of clinical trials.
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20
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In vivo models of multiple myeloma (MM). Biochem Pharmacol 2014; 89:313-20. [DOI: 10.1016/j.bcp.2014.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 03/25/2014] [Accepted: 03/25/2014] [Indexed: 11/22/2022]
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21
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Xiao Y, Yin J, Wei J, Shang Z. Incidence and risk of cardiotoxicity associated with bortezomib in the treatment of cancer: a systematic review and meta-analysis. PLoS One 2014; 9:e87671. [PMID: 24489948 PMCID: PMC3906186 DOI: 10.1371/journal.pone.0087671] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 12/29/2013] [Indexed: 01/30/2023] Open
Abstract
Background We conducted a systematic review and meta-analysis to clarify the incidence and risk of cardiotoxicity associated with bortezomib in cancer patients. Methods Databases from PubMed, Web of Science and abstracts presented at ASCO meeting up to July 31, 2013 were searched to identify relevant studies. Eligible studies included prospective phase II and III trials evaluating bortezomib in cancer patients with adequate data on cardiotoxicity. Statistical analyses were conducted to calculate the summary incidence, odds ratio (OR) and 95% confidence intervals (CIs) by using either random effects or fixed effect models according to the heterogeneity of included studies. Results A total of 5718 patients with a variety of malignancies from 25 clinical trials were included in our analysis. The incidence of all-grade and high-grade cardiotoxicity associated with bortezomib was 3.8% (95%CI: 2.6–5.6%) and 2.3% (1.6–3.5%), with a mortality of 3.0% (1.4–6.5%). Patients treated with bortezomib did not significantly increase the risk of all-grade (OR 1.15, 95%CI: 0.82–1.62, p = 0.41) and high-grade (OR 1.13, 95%CI: 0.58–2.24, p = 0.72) cardiotoxicity compared with patients treated with control medication. Sub-group analysis showed that the incidence of cardiotoxicity varied with tumor types, treatment regimens and phases of trials. No evidence of publication bias was observed. Conclusions The use of bortezomib does not significantly increase the risk of cardiotoxicity compared to control patients. Further studies are recommended to investigate this association and risk differences among different tumor types, treatment regimens and phases of trials.
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Affiliation(s)
- Yi Xiao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- * E-mail:
| | - Jin Yin
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jia Wei
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhen Shang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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de la Rubia J, Roig M. Bortezomib for previously untreated multiple myeloma. Expert Rev Hematol 2014; 4:381-98. [DOI: 10.1586/ehm.11.38] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Rosiñol L, Kumar S, Moreau P, Cavo M. Initial treatment of transplant-eligible patients in multiple myeloma. Expert Rev Hematol 2014; 7:43-53. [PMID: 24392968 DOI: 10.1586/17474086.2014.871200] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Induction therapy followed by intensification with ASCT is the standard of care in younger patients with multiple myeloma. Three-drug induction regimens combining novel agents (VTD, VRD, VCD, PAD) have shown a high CR rate both, pretransplant and posttransplant. Patients with high-risk cytogenetics continues to have an inferior outcome even when treated with novel agents. The role of tandem autologous stem cell transplant (ASCT) is not well established, although some studies show a better outcome with tandem ASCT as compared to single auto. The high response rate obtained with novel agents also raises the question if autologous transplant has a role in front-line therapy or if it should be used as savage therapy after relapse.
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Affiliation(s)
- Laura Rosiñol
- Hematology Department, Hospital Clínic, IDIBAPS, Barcelona, Spain
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Dou QP, Zonder JA. Overview of proteasome inhibitor-based anti-cancer therapies: perspective on bortezomib and second generation proteasome inhibitors versus future generation inhibitors of ubiquitin-proteasome system. Curr Cancer Drug Targets 2014; 14:517-36. [PMID: 25092212 PMCID: PMC4279864 DOI: 10.2174/1568009614666140804154511] [Citation(s) in RCA: 207] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 06/16/2014] [Accepted: 07/11/2014] [Indexed: 02/07/2023]
Abstract
Over the past ten years, proteasome inhibition has emerged as an effective therapeutic strategy for treating multiple myeloma (MM) and some lymphomas. In 2003, Bortezomib (BTZ) became the first proteasome inhibitor approved by the U.S. Food and Drug Administration (FDA). BTZ-based therapies have become a staple for the treatment of MM at all stages of the disease. The survival rate of MM patients has improved significantly since clinical introduction of BTZ and other immunomodulatory drugs. However, BTZ has several limitations. Not all patients respond to BTZ based therapies and relapse occurs in many patients who initially responded. Solid tumors, in particular, are often resistant to BTZ. Furthermore, BTZ can induce dose-limiting peripheral neuropathy (PN). The second generation proteasome inhibitor Carfizomib (CFZ; U.S. FDA approved in August 2012) induces responses in a minority of MM patients relapsed from or refractory to BTZ. There is less PN compared to BTZ. Four other second-generation proteasome inhibitors (Ixazomib, Delanzomib, Oprozomib and Marizomib) with different pharmacologic properties and broader anticancer activities, have also shown some clinical activity in bortezomib-resistant cancers. While the mechanism of resistance to bortezomib in human cancers still remains to be fully understood, targeting the immunoproteasome, ubiquitin E3 ligases, the 19S proteasome and deubiquitinases in pre-clinical studies represents possible directions for future generation inhibitors of ubiquitin-proteasome system in the treatment of MM and other cancers.
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Affiliation(s)
| | - Jeffrey A Zonder
- Barbara Ann Karmanos Cancer Institute and Department of Oncology, Wayne State University School of Medicine, 540.1 HWCRC, 4100 John R Road, Detroit, MI 48201.
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Giralt S, Costa L, Schriber J, Dipersio J, Maziarz R, McCarty J, Shaughnessy P, Snyder E, Bensinger W, Copelan E, Hosing C, Negrin R, Petersen FB, Rondelli D, Soiffer R, Leather H, Pazzalia A, Devine S. Optimizing autologous stem cell mobilization strategies to improve patient outcomes: consensus guidelines and recommendations. Biol Blood Marrow Transplant 2013; 20:295-308. [PMID: 24141007 DOI: 10.1016/j.bbmt.2013.10.013] [Citation(s) in RCA: 257] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 10/10/2013] [Indexed: 12/13/2022]
Abstract
Autologous hematopoietic stem cell transplantation (aHSCT) is a well-established treatment for malignancies such as multiple myeloma (MM) and lymphomas. Various changes in the field over the past decade, including the frequent use of tandem aHSCT in MM, the advent of novel therapies for the treatment of MM and lymphoma, and the addition of new stem cell mobilization techniques, have led to the need to reassess current stem cell mobilization strategies. Mobilization failures with traditional strategies are common and result in delays in treatment and increased cost and resource utilization. Recently, plerixafor-containing strategies have been shown to significantly reduce mobilization failure rates, but the ideal method to maximize stem cell yields and minimize costs associated with collection has not yet been determined. A panel of experts convened to discuss the currently available data on autologous hematopoietic stem cell mobilization and transplantation and to devise guidelines to optimize mobilization strategies. Herein is a summary of their discussion and consensus.
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Affiliation(s)
- Sergio Giralt
- Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Luciano Costa
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jeffrey Schriber
- Cancer Transplant Institute, Virginia G Piper Cancer Center, Scottsdale, Arizona
| | - John Dipersio
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | | | - John McCarty
- Adult Bone Marrow Transplant, Virginia Commonwealth University, Richmond, Virginia
| | - Paul Shaughnessy
- Adult Bone Marrow Transplant, Texas Transplant Institute, San Antonio, Texas
| | - Edward Snyder
- Yale University Medical School, New Haven, Connecticut
| | | | - Edward Copelan
- Levine Cancer Institute I, Carolinas HealthCare System, Charlotte, North Carolina
| | | | | | - Finn Bo Petersen
- Intermountain Blood and Marrow Transplant Program, Intermountain Healthcare, Salt Lake City, Utah
| | - Damiano Rondelli
- Section of Hematology/Oncology, University of Illinois at Chicago Cancer Center, Chicago, Illinois
| | - Robert Soiffer
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | | | - Amy Pazzalia
- Adult Bone Marrow Transplant, University of Florida, Gainesville, Florida
| | - Steven Devine
- Department of Internal Medicine/Hematology/Oncology, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
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Rosenbaum C, Jasielec J, Laubach J, Paba Prada C, Richardson P, Jakubowiak AJ. Evolving Strategies in the Initial Treatment of Multiple Myeloma. Semin Oncol 2013; 40:592-601. [DOI: 10.1053/j.seminoncol.2013.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Romano A, Conticello C, Di Raimondo F. Bortezomib for the treatment of previously untreated multiple myeloma. Immunotherapy 2013; 5:327-52. [PMID: 23557417 DOI: 10.2217/imt.13.14] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Management of multiple myeloma (MM) has been drastically changed in the last 10 years thanks to the introduction of novel agents, which, combined with the backbone of classical chemotherapy, have led to a significant improvement in disease control. Bortezomib is the first reversible proteasome inhibitor approved for the treatment of MM, with wide synergism in vitro and in vivo with a plethora of drugs active for MM. In patients eligible for autologous stem cell transplantation (ASCT), the achievement of complete response or very good partial response before ASCT is associated with prolonged progression-free and overall survival. Thus, the goal of induction regimens should include, at least for younger patients, a continued improvement of the quality and depth of the achieved response. This article is focused on reviewing the major efforts in frontline therapy for MM, including bortezomib-containing induction regimens in patients either eligible or ineligible for ASCT.
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Affiliation(s)
- Alessandra Romano
- Department of Clinical & Molecular Biomedicine, Section of Hematology, University of Catania, Catania, Italy
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Ajaz B, Akhtar A, Chang CC, Solh M, Tangonan K, Khaled Y. Plasma cell CD20 expression: primary aberrant expression or receptor up-regulation. Leuk Lymphoma 2013; 55:444-6. [PMID: 23662988 DOI: 10.3109/10428194.2013.802782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Bushra Ajaz
- Florida Hospital Cancer Institute , Orlando, FL , USA
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Abstract
Bortezomib was approved for the treatment of multiple myeloma (MM) in 2003. Since then several bortezomib-based combination therapies have emerged. Although some combinations have been preceded by preclinical investigations, most have followed the inevitable process in which active (or potentially active) drugs are combined with each other to create new treatment regimens. Regimens that have combined bortezomib with corticosteroids, alkylating agents, thalidomide, and/or lenalidomide have resulted in high response rates. Despite the higher and often deeper response rates and prolongation of progression-free survival with bortezomib-based multiagent regimens, an overall survival (OS) advantage has not been demonstrated with most combinations compared to the sequential approach of using anti-myeloma agents, particularly in patients less than 65 years of age with newly diagnosed myeloma. The unique properties of some of these regimens can be taken into account when choosing a particular regimen based on the clinical scenario. For example, the combination of bortezomib, thalidomide, and dexamethasone (VTD) has particular value in renal failure since none of the drugs need dose modification. Similarly, the combination chemotherapy regimen VDT-PACE (bortezomib, dexamethasone, thalidomide, cisplatin, doxorubicin, cyclophosphamide, and etoposide) is of particular value in patients presenting with aggressive disease such as extramedullary plasmacytomas or plasma cell leukemia. Ongoing clinical trials are testing combinations of bortezomib with several other classes of agents, including monoclonal antibodies, and inhibitors of deacetylases, heat shock proteins, phosphatidyl inositol 3-kinase/Akt/mammalian target of rapamycin pathway and farnesyl transferase.
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Affiliation(s)
- Prashant Kapoor
- Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA
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Nishihori T, Ochoa-Bayona JL, Kim J, Pidala J, Shain K, Baz R, Sullivan D, Jim HS, Anasetti C, Alsina M. Allogeneic hematopoietic cell transplantation for consolidation of VGPR or CR for newly diagnosed multiple myeloma. Bone Marrow Transplant 2013; 48:1179-84. [PMID: 23542223 DOI: 10.1038/bmt.2013.37] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 01/30/2013] [Accepted: 02/17/2013] [Indexed: 12/22/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is a potentially curative approach in patients with multiple myeloma, but its use for consolidation of first remission has not yet been fully explored. Twenty-two myeloma patients with very good partial response (VGPR) or CR received allogeneic peripheral blood grafts as consolidation from HLA-matched donors between 2007 and 2012. Conditioning regimens were fludarabine (30 mg/m(2) i.v. if with bortezomib and 40 mg/m(2) i.v. when without bortezomib, × 4 days) plus melphalan (70 mg/m(2) intravenously × 2 days) with (n=13) or without (n=9) bortezomib (1.3 mg/m(2)). The cumulative incidence of grades II - IV acute GVHD at day 100 was 45% (95% CI: 24-65%) and moderate-to-severe chronic GVHD at 2 years was 46% (95% CI: 19-69%). With a median follow-up of 18 (range, 2-61) months, the 2-year PFS estimate is 74.8% (95% CI: 45-90%), which compares favorably with the 52% (95% CI: 35-66%) after autologous HCT for similar patients (a median follow-up of 30 (range, 9-55) months). We are conducting a phase 2 study to assess the efficacy of allogeneic HCT as post-remission therapy.
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Affiliation(s)
- T Nishihori
- Department of Blood and Marrow Transplantation, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
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Painuly U, Kumar S. Efficacy of bortezomib as first-line treatment for patients with multiple myeloma. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2013; 7:53-73. [PMID: 23492937 PMCID: PMC3588852 DOI: 10.4137/cmo.s7764] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Recent years have seen a dramatic change in the approach towards diagnosing and treating Multiple Myeloma. Newer and more target specific approach to treatment has prolonged the survival for patients with multiple myeloma. The proteasome inhibitors make an important class of anti-myeloma drugs that disrupts the proteolytic machinery of the tumor cells preferentially, enhancing their susceptibility to apoptosis. Bortezomib, in particular has shown significant clinical efficacy in myeloma treatment. It is the most commonly used proteasome inhibitor and has been tested to be effective in prolonging the overall survival in several trials. Its combinations with cyclophosphamide and dexamethasone are the treatment of choice for standard risk patients following the mSMART guidelines. The success with its lower dosage in elderly and its proven efficacious subcutaneous usage makes Bortezomib a useful agent for maximizing patient compliance and minimizing therapy related toxicity and costs. This review discusses several trials where Bortezomib has been used as a single/combination agent for front-line treatment of multiple myeloma.
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Affiliation(s)
- Utkarsh Painuly
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA. ; 4th Department of Internal Medicine, University Hospital and Charles University Faculty of Medicine, Hradec Králové, Czech Republic
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Jasielec JK, Jakubowiak AJ. Current approaches to the initial treatment of symptomatic multiple myeloma. Int J Hematol Oncol 2013; 2:10.2217/ijh.13.3. [PMID: 24286003 PMCID: PMC3839860 DOI: 10.2217/ijh.13.3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The treatment of newly diagnosed multiple myeloma has dramatically changed since the emergence of proteasome inhibitors and immunomodulatory drugs. Front-line combination regimens incorporating novel drugs such as thalidomide, bortezomib and lenalidomide, have significantly improved response rates and are the standard of care for induction regimens. Although the timing and role of autologous stem cell transplant are now being questioned, it remains an important part of the treatment paradigm in eligible patients. In addition, the concept of extended sequential therapy has recently emerged, including consolidation and/or maintenance in both the post-transplant setting and in nontransplant candidates. In this article we focus on management strategies in newly diagnosed multiple myeloma, including choice of induction regimens in transplant-eligible and -ineligible patients, as well as the role of autologous stem cell transplant, consolidation therapy and maintenance therapy.
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Affiliation(s)
- Jagoda K Jasielec
- Section of Hematology/Oncology, Department of Medicine & Comprehensive Cancer Center, The University of Chicago, Chicago, IL, USA
| | - Andrzej J Jakubowiak
- Section of Hematology/Oncology, Department of Medicine & Comprehensive Cancer Center, The University of Chicago, Chicago, IL, USA
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Abstract
PURPOSE OF REVIEW Nearly all patients with multiple myeloma will eventually relapse; and, thus, it is critical to identify new treatments that increase therapeutic options for these patients. This review highlights the newest approaches with already approved drugs for treating this common B-cell malignancy. RECENT FINDINGS Most patients with multiple myeloma in both the frontline and relapsed/refractory settings are now treated with a combination of dexamethasone with the proteasome inhibitor bortezomib and/or an immunomodulatory agent thalidomide or lenalidomide. However, alkylating agents including melphalan, cyclophosphamide and most recently bendamustine as well as anthracyclines, especially the pegylated liposomal doxorubicin, have shown high response rates and prolonged remissions when combined with these agents. There are emerging data showing the importance of maintenance therapy especially with lenalidomide. Because of the marked improvement in survival of multiple myeloma during the past decade, there has been a renewed emphasis on developing therapies that are not only effective but also well tolerated. Alternative dosing, scheduling and routes of administration of already approved drugs have proven effective in accomplishing these goals. SUMMARY The availability of drugs with different mechanisms that produce anti-multiple myeloma effects and also show synergistic effects has paved the way for more effective and safer combinations and led to multiple myeloma patients living longer with improved quality of lives.
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Reece D. Update on the initial therapy of multiple myeloma. Am Soc Clin Oncol Educ Book 2013:0011300307. [PMID: 23714532 DOI: 10.14694/edbook_am.2013.33.e307] [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: 06/02/2023]
Abstract
Advances in myeloma biology and the identification of new anti-myeloma agents have resulted in improved management of younger, transplant-eligible, and older patients. The first novel agents-thalidomide, bortezomib, and lenalidomide-have been integrated into induction therapy before autologous stem cell transplant (ASCT) as well as into first-line therapy in elderly individuals; phase III trials have established the superiority of these approaches in terms of better response rates, progression-free survival (PFS), and, in some studies, overall survival. With more experience, improvements in dosing have decreased the toxicity of these regimens. Before ASCT, four phase III studies have shown that bortezomib-based regimens confer better outcomes than older regimens. Posttransplant consolidation and maintenance strategies with novel agents provide additional benefit, particularly in terms of a longer PFS. In the elderly population, novel agents can be combined with melphalan plus prednisone (MP). MP plus thalidomide and MP plus bortezomib are commonly utilized, and the regimen of MP plus lenalidomide with lenalidomide maintenance (MPR + R) produces superior response rates and longer PFS compared with MP alone. Prolonged maintenance with bortezomib plus thalidomide also appears to extend PFS when given following combinations of MP plus bortezomib. Treatment of very elderly patients, however, remains challenging due to comorbidities and side effects. Lenalidomide plus weekly dexamethasone is also effective in elderly patients, and results of a trial comparing this regimen with MP plus thalidomide should be available soon. Finally, better methods of risk stratification and the availability of even newer drugs will allow future refinements in myeloma treatment.
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Affiliation(s)
- Donna Reece
- From the Princess Margaret Hospital, Toronto, Ontario, Canada
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Alexanian R, Delasalle K, Wang M. High frequencies of response after limited primary therapy for multiple myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2012; 13:119-22. [PMID: 23260599 DOI: 10.1016/j.clml.2012.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 11/09/2012] [Accepted: 11/13/2012] [Indexed: 11/24/2022]
Abstract
UNLABELLED In an effort to maintain high primary response rates against multiple myeloma and without serious toxicity, we assessed 3 different bortezomib combinations in small numbers of patients, with combinations that included cyclophosphamide and lenalidomide in modest doses and for short courses. Remissions occurred in approximately 90% of patients, with rare episodes of serious drug-related adverse effects. BACKGROUND Recent bortezomib combinations have induced remission in approximately 90% of patients newly diagnosed, with moderate frequency of adverse effects. PATIENTS In an attempt to reduce adverse effects, and to prepare qualified patients for early intensification, we assessed the antimyeloma effect and toxicity of 3 different bortezomib combinations in small numbers of patients. METHODS With reduced doses and short durations of exposure, we combined bortezomib with (a) cyclophosphamide/dexamethasone, (b) lenalidomide/dexamethasone/liposomal doxorubicin, and (c) cyclophosphamide/dexamethasone/lenalidomide. RESULTS Response rates were high, with rare episodes of severe drug-related toxicity. CONCLUSIONS Further study of similar combinations of effective drugs given in limited doses and for short durations would be useful.
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Affiliation(s)
- Raymond Alexanian
- Department of Lymphoma/Myeloma, University of Texas MD Anderson Cancer Center, Houston, TX 77030-4009, USA.
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38
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Moreau P, Giralt SA. Optimizing therapy for transplant-eligible patients with newly diagnosed multiple myeloma. Leuk Res 2012. [DOI: 10.1016/s0145-2126(12)70004-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Jakubowiak A. Management strategies for relapsed/refractory multiple myeloma: current clinical perspectives. Semin Hematol 2012; 49 Suppl 1:S16-32. [PMID: 22727389 DOI: 10.1053/j.seminhematol.2012.05.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
In the last decade, the introduction of novel agents including the immunomodulatory drugs thalidomide and lenalidomide, and the first-in-class proteasome inhibitor bortezomib, has dramatically improved clinical outcome in patients with relapsed/refractory multiple myeloma (MM) compared to conventional chemotherapy alone. Although combination treatment approaches with traditional cytotoxic agents and novel agents have led to response rates as high as 85% in patients with relapsed/refractory disease, not all patients will respond to established novel agents, and even those who do respond will ultimately relapse or become refractory to currently available regimens. There is no generally accepted standard treatment for patients with relapsed/refractory disease; however, both disease-related (eg, quality and duration of response to previous therapies and the aggressiveness of the relapse) and patient-related (eg, preexisting toxicities, comorbid conditions, quality of life, age, and performance status) factors should be considered when selecting the best treatment option. This article will review up-to-date approaches for managing patients with relapsed/refractory MM, including the efficacy and safety of established novel agents, the use of adjunctive/supportive care, and strategies for tailored treatment.
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Podar K. Ask the Experts: Deriving new treatment strategies in multiple myeloma. Int J Hematol Oncol 2012. [DOI: 10.2217/ijh.12.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Klaus Podar, MD PhD, is an Associate Professor of Experimental Oncology and Hematology and a hematologist/oncologist at the National Center for Tumor Diseases, University of Heidelberg, and the German Cancer Research Center (DKFZ) in Heidelberg, Germany. He has published more than 100 peer-reviewed manuscripts and keynote reviews, is a member of several scientific societies including the American Association of Cancer Research (AACR), American Society of Hematology (ASH) and European Hematology Association (EHA), and is the recipient of several prestigious awards.
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Affiliation(s)
- Klaus Podar
- National Center of Tumor Diseases (NCT), University of Heidelberg & German Cancer Research Center (DKFZ), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
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Costa LJ, Abbas J, Ortiz-Cruz KL, Kang Y, Stuart RK. Outcomes of patients with multiple myeloma and renal impairment treated with bortezomib, cyclophosphamide, and dexamethasone without plasma exchange. Eur J Haematol 2012; 89:432-4. [PMID: 22971164 DOI: 10.1111/ejh.12008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Emerging stem cell therapies: treatment, safety, and biology. Stem Cells Int 2012; 2012:521343. [PMID: 22919402 PMCID: PMC3419439 DOI: 10.1155/2012/521343] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 07/03/2012] [Accepted: 07/04/2012] [Indexed: 12/15/2022] Open
Abstract
Stem cells are the fundamental building blocks of life and contribute to the genesis and development of all higher organisms. The discovery of adult stem cells has led to an ongoing revolution of therapeutic and regenerative medicine and the proposal of novel therapies for previously terminal conditions. Hematopoietic stem cell transplantation was the first example of a successful stem cell therapy and is widely utilized for treating various diseases including adult T-cell leukemia-lymphoma and multiple myeloma. The autologous transplantation of mesenchymal stem cells is increasingly employed to catalyze the repair of mesenchymal tissue and others, including the lung and heart, and utilized in treating various conditions such as stroke, multiple sclerosis, and diabetes. There is also increasing interest in the therapeutic potential of other adult stem cells such as neural, mammary, intestinal, inner ear, and testicular stem cells. The discovery of induced pluripotent stem cells has led to an improved understanding of the underlying epigenetic keys of pluripotency and carcinogenesis. More in-depth studies of these epigenetic differences and the physiological changes that they effect will lead to the design of safer and more targeted therapies.
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A phase 1/2 study of carfilzomib in combination with lenalidomide and low-dose dexamethasone as a frontline treatment for multiple myeloma. Blood 2012; 120:1801-9. [PMID: 22665938 DOI: 10.1182/blood-2012-04-422683] [Citation(s) in RCA: 338] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
This phase 1/2 study in patients with newly diagnosed multiple myeloma (N = 53) assessed CRd--carfilzomib (20, 27, or 36 mg/m2, days 1, 2, 8, 9, 15, 16 and 1, 2, 15, 16 after cycle 8), lenalidomide (25 mg/d, days 1-21), and weekly dexamethasone (40/20 mg cycles 1-4/5+)--in 28-day cycles. After cycle 4, transplantation-eligible candidates underwent stem cell collection (SCC) then continued CRd with the option of transplantation. The maximum planned dose level (carfilzomib 36 mg/m2) was expanded in phase 2 (n = 36). Thirty-five patients underwent SCC, 7 proceeded to transplantation, and the remainder resumed CRd. Grade 3/4 toxicities included hypophosphatemia (25%), hyperglycemia (23%), anemia (21%), thrombocytopenia (17%), and neutropenia (17%); peripheral neuropathy was limited to grade 1/2 (23%). Most patients did not require dose modifications. After a median of 12 cycles (range, 1-25), 62% (N = 53) achieved at least near-complete response (CR) and 42% stringent CR. Responses were rapid and improved during treatment. In 36 patients completing 8 or more cycles, 78% reached at least near CR and 61% stringent CR. With median follow-up of 13 months (range, 4-25 months), 24-month progression-free survival estimate was 92%. CRd was well tolerated with exceptional response rates. This study is registered at http://www.clinicaltrials.gov as NCT01029054.
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Abstract
Proteasome inhibition has emerged as an important therapeutic strategy in multiple myeloma (MM). Since the publication of the first phase 1 trials of bortezomib 10 years ago, this first-in-class proteasome inhibitor (PI) has contributed substantially to the observed improvement in survival in MM patients over the past decade. Although first approved as a single agent in the relapsed setting, bortezomib is now predominantly used in combination regimens. Furthermore, the standard twice-weekly schedule may be replaced by weekly infusion, especially when bortezomib is used as part of combination regimens in frontline therapy. Indeed, bortezomib is an established component of induction therapy for patients eligible or ineligible for autologous stem cell transplantation. Bortezomib has also been incorporated into conditioning regimens before autologous stem cell transplantation, as well as into post-ASCT consolidation therapy, and in the maintenance setting. In addition, a new route of bortezomib administration, subcutaneous infusion, has recently been approved. Recently, several new agents have been introduced into the clinic, including carfilzomib, marizomib, and MLN9708, and trials investigating these "second-generation" PIs in patients with relapsed/refractory MMs have demonstrated positive results. This review provides an overview of the role of PIs in the treatment of MM, focusing on developments over the past decade.
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Sanchez E, Li M, Wang C, Nichols CM, Li J, Chen H, Berenson JR. Anti-Myeloma Effects of the Novel Anthracycline Derivative INNO-206. Clin Cancer Res 2012; 18:3856-67. [PMID: 22619306 DOI: 10.1158/1078-0432.ccr-11-3130] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eric Sanchez
- Institute for Myeloma & Bone Cancer Research, West Hollywood, CA 90069, USA
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Lee JH, Lee JH, Kim DY, Kim SD, Choi Y, Kang YA, Seol M, Lee KH. Two cycles of the PS-341/bortezomib, adriamycin, and dexamethasone combination followed by autologous hematopoietic cell transplantation in newly diagnosed multiple myeloma patients. Eur J Haematol 2012; 88:478-84. [DOI: 10.1111/j.1600-0609.2012.01771.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Randomized, multicenter, phase 2 study (EVOLUTION) of combinations of bortezomib, dexamethasone, cyclophosphamide, and lenalidomide in previously untreated multiple myeloma. Blood 2012; 119:4375-82. [PMID: 22422823 DOI: 10.1182/blood-2011-11-395749] [Citation(s) in RCA: 335] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Combinations of bortezomib (V) and dexamethasone (D) with either lenalidomide (R) or cyclophosphamide (C) have shown significant efficacy. This randomized phase 2 trial evaluated VDC, VDR, and VDCR in previously untreated multiple myeloma (MM). Patients received V 1.3 mg/m2 (days 1, 4, 8, 11) and D 40 mg (days 1, 8, 15), with either C 500 mg/m2 (days 1, 8) and R 15 mg (days 1-14; VDCR), R 25 mg (days 1-14; VDR), C 500 mg/m2 (days 1, 8; VDC) or C 500 mg/m2 (days 1, 8, 15; VDC-mod) in 3-week cycles (maximum 8 cycles), followed by maintenance with V 1.3 mg/m2 (days 1, 8, 15, 22) for four 6-week cycles (all arms)≥very good partial response was seen in 58%, 51%, 41%, and 53% (complete response rate of 25%, 24%, 22%, and 47%) of patients (VDCR, VDR, VCD, and VCD-mod, respectively); the corresponding 1-year progression-free survival was 86%, 83%, 93%, and 100%, respectively. Common adverse events included hematologic toxicities, peripheral neuropathy, fatigue, and gastrointestinal disturbances. All regimens were highly active and well tolerated in previously untreated MM, and, based on this trial, VDR and VCD-mod are preferred for clinical practice and further comparative testing. No substantial advantage was noted with VDCR over the 3-drug combinations. This trial is registered at www.clinicaltrials.gov (NCT00507442).
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Faiman BM, Mangan P, Spong J, Tariman JD. Renal complications in multiple myeloma and related disorders: survivorship care plan of the International Myeloma Foundation Nurse Leadership Board. Clin J Oncol Nurs 2012; 15 Suppl:66-76. [PMID: 21816711 DOI: 10.1188/11.cjon.s1.66-76] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Kidney dysfunction is a common clinical feature of symptomatic multiple myeloma. Some degree of renal insufficiency or renal failure is present at diagnosis or will occur during the course of the disease and, if not reversed, will adversely affect overall survival and quality of life. Chronic insults to the kidneys from other illnesses, treatment, or multiple myeloma itself can further damage renal function and increase the risk for additional complications, such as anemia. Patients with multiple myeloma who have light chain (Bence Jones protein) proteinuria may experience renal failure or progress to end-stage renal disease (ESRD) and require dialysis because of light chain cast nephropathy. Kidney failure in patients with presumed multiple myeloma also may result from amyloidosis, light chain deposition disease, or acute tubular necrosis caused by nephrotoxic agents; therefore, identification of patients at risk for kidney damage is essential. The International Myeloma Foundation's Nurse Leadership Board has developed practice recommendations for screening renal function, identifying positive and negative contributing risk and environmental factors, selecting appropriate therapies and supportive care measures to decrease progression to ESRD, and enacting dialysis to reduce and manage renal complications in patients with multiple myeloma.
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Affiliation(s)
- Beth M Faiman
- Hematology and Medical Oncology Department, Cleveland Clinic in Ohio, USA.
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Berenson JR, Yellin O, Kazamel T, Hilger JD, Chen CS, Cartmell A, Woliver T, Flam M, Bravin E, Nassir Y, Vescio R, Swift RA. A phase 2 study of pegylated liposomal doxorubicin, bortezomib, dexamethasone and lenalidomide for patients with relapsed/refractory multiple myeloma. Leukemia 2012; 26:1675-80. [DOI: 10.1038/leu.2012.51] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Du BY, Song W, Bai L, Shen Y, Miao SY, Wang LF. Synergistic effects of combination treatment with bortezomib and doxorubicin in human neuroblastoma cell lines. Chemotherapy 2012; 58:44-51. [PMID: 22327308 DOI: 10.1159/000335603] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Accepted: 12/04/2011] [Indexed: 01/05/2023]
Abstract
BACKGROUND Neuroblastoma (NB) is the most common extracranial solid tumor in infants. Currently, the mainstay of NB chemotherapy is combination treatment with some traditional drugs, but these combination regimens are always inefficient. METHODS The aim of this study was to evaluate the inhibitory effect of a combination of doxorubicin and bortezomib, a novel anticancer drug and the first prote-asome inhibitor approved for the treatment of human malignant tumors, on the proliferation of two human NB cell lines, SK-N-SH and SH-SY5Y. The general mechanism underlying this combined effect was also investigated. Synergistic inhibitory effects on human NB cell proliferation were evaluated using the median-effect principle. The pro-apoptotic effects of these drugs were evaluated using double staining with annexin-V-FITC and propidium iodide. RESULTS Synergistic inhibitory effects on proliferation were observed when a combination of bortezomib and doxorubicin was applied to cultured NB cells. A similar synergistic effect on apoptosis was also observed when the two drugs were used concurrently, which suggested that the possible mechanism underlying the observed synergistic inhibitory effect might be related to apoptosis. CONCLUSION The combination of bortezomib and doxorubicin appears to be a promising strategy to treat NB.
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Affiliation(s)
- Bo-Yu Du
- National Laboratory of Medical Molecular Biology, School of Basic Medicine, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, PR China
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