Pomalidomide, Cyclophosphamide, and Dexamethasone for the Treatment of Relapsed/Refractory Multiple Myeloma: Real-World Analysis of the Pethema-GEM Experience

INTRODUCTION

Treatment of relapsed/refractory multiple myeloma (RRMM) is highly challenging, especially for patients with disease refractory to initial therapy, and in particular for disease developing refractoriness to lenalidomide. Indeed, with currently approved treatments, median progression-free survival (PFS) in the lenalidomide-refractory setting is less than 10 months, reflecting the difficulty in treating this patient population. Pomalidomide is a second-generation immunomodulatory drug that has shown activity in lenalidomide-refractory disease in the setting of different combinations.

PATIENTS AND METHODS

A real-world study was conducted by the Spanish Myeloma group in a cohort of patients with RRMM treated with pomalidomide, cyclophosphamide, and dexamethasone (PomCiDex). One hundred patients were treated with a median of 3 prior lines of therapy.

RESULTS

Overall response rate was 39%, with a clinical benefit rate of 93%. Median PFS was 7.6 months; median overall survival (OS) was 12.6 months. Median PFS and OS survival were consistent across the different subgroups analyzed. Prolonged PFS and OS were found in patients with responsive disease.

CONCLUSION

Our results compared favorably with those obtained with different pomalidomide-based combinations in a similar patient population. PomCiDex remains a manageable, cost-effective, and all-oral triplet combination for RRMM patients.

Recommendations on the clinical use of bendamustine in lymphoproliferative syndromes and multiple myeloma

Bendamustine is an increasingly used hybrid alkylating agent that is active in lymphoid neoplasias via a novel mechanism of action. There are some pending questions about its use in clinical practice because of its developmental features. A consensus panel of several leading Spanish hematologists with broad experience in the clinical use of bendamustine has established recommendations for the management and treatment of hematological patients with bendamustine based on available clinical data and the experience of the participants. These recommendations address the dose and treatment regimen for different clinical indications, the management of toxicity, and support therapy. This article contains the conclusions of this consensus panel, which are intended to serve as guidelines for the use of bendamustine.

Hepatitis C virus-related lymphoproliferative disorders encompass a broader clinical and morphological spectrum than previously recognized: a clinicopathological study

We describe a retrospective series of B-cell lymphoproliferative disorders associated with hepatitis C virus infection. In addition to splenic marginal zone lymphoma, follicular lymphoma and diffuse large B-cell lymphoma, all of which showed some specific features, we found two poorly described groups of cases. The first featured disseminated marginal zone lymphoma without splenic marginal zone lymphoma features, defying the current marginal zone lymphoma classification; the other consisted of monoclonal B lymphocytes in the peripheral blood, bone marrow or other tissues, with no clinical or histological evidence of lymphoma, and exhibiting a pattern that requires proper identification in order to avoid the misdiagnosis of the lymphoma. Diagnosis of hepatitis C virus infection-associated lymphoproliferative disorders requires the integration of clinical, pathological and molecular findings to establish an adequate diagnosis and decide the appropriate therapy to be applied.

High incidence of autoimmune alterations in chronic myeloid leukemia patients treated with interferon-alpha

Interferon-alpha is the frontline therapy of the majority of chronic myeloid leukemia (CML) patients who are not eligible for bone marrow transplantation. Many patients are treated for long periods, and there is concern about the long-term immune effects of its use. Autoimmune disorders in patients treated with IFN-alpha may be related to the direct immunomodulating properties of IFN or may be linked to a possible toxic effect in target organs, triggering autoimmunity. On the other hand, the immune effects of IFN may play a role in its therapeutic actions. The aims of our study were to assess the incidence of autoimmune phenomena in these patients, and to measure the possible association between the generation of autoimmune phenomena and the antileukemic effect of IFN alpha. Therefore, 46 patients with Ph1(+) CML in the first chronic phase were studied for the appearance of immune complications, their connection to IFN dose, time of appearance, and the possible association with the response to treatment. Autoimmune abnormalities have been found in 28% of our patients. Moreover, a significant association was found between autoimmune alterations and female sex (P = 0.02, OR 4.5, 95% CI 1.13-17.9) and a longer treatment time (1.6 vs. 4.1 years) (P = 0.02; OR 1.01, 95% CI 1-1.02). The Kaplan-Meier estimated probability of obtaining a cytogenetic response was significantly higher in patients who developed autoimmune alterations (P = 0.049), and this difference was also evident in Cox's analysis when controlling with other potentially confounding variables (P = 0.078). We conclude that CML patients treated with IFN alpha have a high incidence of autoimmune phenomenon.

[Upward and downward gaze palsy with a unilateral mesencephalic hemorrhage]

INTRODUCTION

Acute vascular lesions limited to the midbrain can yield varied disturbances of eye movements. They are more often infarcts than hemorrhages.

CLINICAL CASE

We present the case of a 49 year old, non-hypertensive man who presented with sudden onset of bilateral up and down gaze palsy. CT defined a unilateral hemorrhage in the right mesencephalic tegmentum.

CONCLUSION

Cases of upward and downward gaze palsy in association with unilateral upper midbrain hemorrhage are very uncommon. We present a new case.

Results and prognostic factors in stage I(E)-II(E) primary gastric lymphoma after gastrectomy

BACKGROUND

Infrequency of gastric lymphomas and lack of homogeneity of studies dealing with them preclude accurate management schemes. Helicobacter pylori (HP) and Isaacson's classification are new factors to consider. Our aim was to analyze these and other prognostic factors in a homogeneous series.

STUDY DESIGN

Fifty-four patients (mean age 62.4 years) treated by gastrectomy for primary gastric non-Hodgkin's lymphoma in stages IE or IIE were retrospectively reviewed. Twenty-seven patients received postoperative chemotherapy. HP and histologic features were studied using new slides from the paraffin-embedded gastrectomy specimens.

RESULTS

Postoperative morbidity and mortality rates were 19% and 5.6%, respectively. Five-year survival was 83%. Classification showed low-grade tumors in 59% and high-grade tumors in 41%. HP was positive in 64% of the patients. A poorer survival was associated with high-grade tumors (p = 0.02) and serosa involvement (p = 0.02). We did not find any significant difference between patients treated either by partial or total gastrectomy (p = 0.2), or receiving chemotherapy or not (p = 0.9). Nor did we appreciate any differences concerning margin involvement (p = 0.9).

CONCLUSIONS

Most primary gastric lymphoma patients have gastric HP. Serosa involvement and high-grade tumors adversely influence survival but gastrectomy type, resection margin invasion, and postoperative chemotherapy did not appear to have any influence.

Cholecystectomy and fistula closure versus enterolithotomy alone in gallstone ileus

BACKGROUND

The management of gallstone ileus is controversial. This study compared the results of simple enterolithotomy with those of enterolithotomy, cholecystectomy and fistula closure.

METHODS

A retrospective analysis was made of 25 patients with a mean age of 75 (range 55-84) years. Enterolithotomy was performed in 16 patients (group 1) and cholecystectomy and fistula closure were added in nine patients (group 2).

RESULTS

The diagnosis was made before operation in 12 patients, and was associated with previous biliary disorder (P = 0.03) and pneumobilia (P < 0.001). Postoperative morbidity occurred in eight patients in group 1 and in six in group 2. Three patients died in each group; all but one of the deaths were unrelated to the surgical procedure. There was no relationship between age and mortality, and patients in American Society of Anesthesiologists (ASA) classes III and IV did not have higher rates of morbidity or mortality than those in ASA classes I and II.

CONCLUSION

Evidence from this study does not support one-stage enterolithotomy, cholecystectomy and fistula closure as the procedure of choice; simple enterolithotomy is appropriate in most patients. However, the one-stage procedure may be acceptable in patients at low risk.

Chimerism after allogeneic hematopoietic cell transplantation in childhood acute lymphoblastic leukemia

Leukemic relapse after allogeneic bone marrow transplantation or allogeneic peripheral blood progenitor cell transplantation arises normally from residual malignant host hematopoiesis. The lack of specific tumor markers in acute lymphoblastic leukemia presents a problem for detection of residual disease post-infusion. In the present prospective study, we used PCR amplification of variable numbers of tandem repeat genetic regions for close follow-up of chimeric status in order to try to distinguish those patients at high risk of relapse. We found that chimeric status evolution was different between the long-term surviving patients and relapsed patients. The former showed either donor chimerism (DC) or transient mixed chimerism (tMC), while the latter always showed a recipient-growing MC (r.gMC). In addition, we found that complete substitution of hematopoiesis was achieved better with radiation-containing regimens, and that chronic graft-versus-host disease never appeared in MC patients. We conclude that very close follow-up of serial samples can facilitate the early detection of those leukemic children with a poor outcome after hematopoietic cell transplantation.

Busulfan and melphalan as conditioning regimen for autologous peripheral blood stem cell transplantation in multiple myeloma

Twenty-four patients with multiple myeloma (MM), three (12.5%) in complete remission (CR) and 21 (87.5%) in partial remission (PR) were treated with high-dose chemotherapy (HDCT) (busulfan 12 mg/kg+melphalan 140 mg/m2) as preparative regimen for autologous peripheral blood stem cell (PBSC) transplantation. These cells were previously collected by leukapheresis after mobilization by high-dose cyclophosphamide (HD Cy)+rhGM-CSF (18 patients) or rhG-CSF alone (six patients). Considering 23 evaluable patients following HDCT, the CR rate was 58% (14 patients) and the PR rate was 38% (nine patients). One transplant-related death occurred following this regimen (4%). With a median follow-up of 20 months (range 4-34) after transplantation, 21 patients are alive (87%). Disease progression after transplantation was observed in four patients. Overall and relapse-free actuarial survival at 24 months was 91% and 74%, respectively. 12 patients (50%) remain in CR 15 months (4-34) post transplant. The major toxicity was mucositis. Busulfan+melphalan is a safe and feasible conditioning regimen for APBSCT in MM with acceptable toxicity and a high objective response rate, which may result in prolonged survival.

Hypertriglyceridemia may be severe in CML patients treated with interferon-alpha

We analyzed serum triglyceride (TG) levels in 22 chronic myeloid leukemia (CML) patients treated with interferon-alpha (IFN-alpha). Hypertriglyceridemia was present in one-half of patients at diagnosis, and IFN-alpha treatment was associated with a further increase in 90% of the total group of patients. This increase was maximal during the first months of therapy. Four patients (18%) reached levels higher than 1,000 mg/dl. This is the first report describing this secondary effect in CML patients treated with IFN-alpha.