Predictors of Lenalidomide Refractory Relapse Timing With Newly Diagnosed Multiple Myeloma: A FIRST Trial Subanalysis

INTRODUCTION/BACKGROUND

Multiple myeloma (MM) is considered an incurable cancer. Patients with newly diagnosed MM (NDMM) are at risk for relapse within 1 year of frontline therapy. The immunomodulatory agent lenalidomide combined with dexamethasone (Rd) may be used as treatment for NDMM or relapsed MM, including in patients ineligible for autologous stem cell transplant.

PATIENTS

This subanalysis of the phase III FIRST trial characterized patients with transplant-ineligible NDMM who experienced relapse while receiving Rd therapy by relapse timing (early [<12 months] versus late [≥12 months]) and type (CRAB vs. non-CRAB).

METHODS

The Kaplan-Meier product limit method was used to estimate time-to-event endpoints, including progression-free survival (PFS) and overall survival (OS). Factors associated with the odds of late relapse were identified by logistic regression with univariate and multivariate analyses using a binary outcome (relapse at <12 vs. ≥12 months) in patient-, disease-, and treatment-specific baseline variables.

RESULTS

Patients with early refractory relapse had functionally high-risk disease and inferior outcomes. In patients with early relapse versus those with late relapse, median OS (95% CI) was 26.8 months (21.9-32.8) versus 63.9 months (57.0-78.0), median OS from disease progression to death was 19.9 months (16.0-25.5) versus 36.4 months (27.9-47.0), and median PFS from randomization to second progression was 19.1 months (17.3-22.5) versus 42.1 months (37.4-44.9). Lactate dehydrogenase, baseline β2 microglobulin, and myeloma subtype were shown to predict time to relapse.

CONCLUSIONS

Clinicians could use these factors to consider more aggressive treatment regimens for those at highest risk of early relapse.

Pomalidomide, dexamethasone, and daratumumab immediately after lenalidomide-based treatment in patients with multiple myeloma: updated efficacy, safety, and health-related quality of life results from the phase 2 MM-014 trial

Patients with relapsed/refractory multiple myeloma (RRMM) need proven subsequent therapies after early-line lenalidomide treatment failure. The phase 2 MM-014 trial (NCT01946477) investigated pomalidomide, dexamethasone, and daratumumab after 1 to 2 prior treatment lines (62.5%, 1 prior line) in patients with RRMM and prior lenalidomide (75.0%, lenalidomide refractory). With a median follow-up of 28.4 months, overall response rate was 77.7% (52.7% achieved very good partial response or better) and median progression-free survival was 30.8 months. For patients with lenalidomide-refractory disease, these outcomes were 76.2%, 47.6%, and 23.7 months, respectively. No new safety signals were observed; 64.3% experienced grade 3/4 neutropenia. Health-related quality of life was preserved or trended toward improvement through 12 treatment cycles. Pomalidomide, dexamethasone, and daratumumab given immediately after early-line lenalidomide-based treatment continues to demonstrate safety and efficacy, supporting pomalidomide-dexamethasone as a foundation of combination therapy in RRMM and providing evidence that the immunomodulatory agent class delivers benefit after lenalidomide treatment failure.

Pomalidomide plus low-dose dexamethasone in relapsed refractory multiple myeloma after lenalidomide treatment failure

Patients with relapsed/refractory multiple myeloma (RRMM) for whom the benefits of lenalidomide have been exhausted in early treatment lines need effective therapies. In cohort A of the phase 2 MM‐014 trial, we examined the safety and efficacy of pomalidomide plus low‐dose dexamethasone immediately after lenalidomide‐based treatment failure in patients with RRMM and two prior lines of therapy. Pomalidomide 4 mg was given on days 1 to 21 of 28‐day cycles. Dexamethasone 40 mg (20 mg for patients aged >75 years) was given on days 1, 8, 15 and 22 of 28‐day cycles. The primary endpoint was overall response rate (ORR), and secondary endpoints included progression‐free survival (PFS), overall survival (OS) and safety. The intention‐to‐treat population comprised 56 patients; all received prior lenalidomide (87·5% lenalidomide refractory) and 39 (69·6%) received prior bortezomib. ORR was 32·1% (28·2% in the prior‐bortezomib subgroup). Median PFS was 12·2 months (7·9 months in the prior‐bortezomib subgroup). Median OS was 41·7 months (38·6 months in the prior‐bortezomib subgroup). The most common grade 3/4 treatment‐emergent adverse events were anaemia (25·0%), pneumonia (14·3%) and fatigue (14·3%). These findings support earlier sequencing of pomalidomide‐based therapy in lenalidomide‐pretreated patients with RRMM, including those who have become refractory to lenalidomide.

Trial registration: http://www.ClinicalTrials.gov identifier NCT01946477.

[Pilonidal sinus in a patient with Buckley's syndrome. A case report]

Buckley's syndrome is a nosologic entity characterized by the presence from birth of extremely elevated levels of circulating immunoglobulin E and an important deficiency of polymorphonuclear chemotaxis. The consequences of such alterations are represented by the premature rising of recurrent cutaneous, pulmonary and articular infections, slowing down of growth and quite significant disturbances of the immune system. We report a case which presents all the characteristics of Buckley's syndrome: familial history for atopy; otorhinolaryngologic, gynecologic and pulmonary recurrent infections from birth (caused by Staphylococcus, Candida albicans but also Proteus, Enterococcus, Pyocyanea and Moraxella) some of which necessitate surgery therapy; immune disturbances. The patient had hospitalized in our Surgery Department for sinus pilonidalis abscess. At a first treatment of removal of the primary orifice and accurate curettage of the cavity (Marti's intervention) there followed another operation of larger exeresis for an abscess relapse of the sinus at a distance of 2 months. In the interval between the two treatments, an eczematous patch of 8 cm diameter appeared on the left buttock, a probable manifestation of the state of hypersensitivity of the patient. We believe, therefore, that in patients with Buckley's syndrome who must be subjected to surgical intervention it is necessary to resort to a radical treatment from the beginning, given the particular tendency to an infection relapse presented in these cases.

Laparoscopic appendectomy. A study of 154 consecutive cases

The recent development of mini-invasive surgery includes appendectomy. We report our results of 4 years experience in this type of approach. We have operated on 154 patients (61 men, 93 women), mean age 26.7 years, presenting with clinical signs of appendicitis. The operation was completely carried out by laparoscopy in 144 cases, including treatment of abscess in 13 and peritonitis in 8 cases. Operation was converted into laparotomy in 10 cases, 4 of which because of some difficulty in appendix dissection. No deaths were recorded. Eight (5.2%) post-operative complications occurred: 4 infections of the trocar hole, one of which the cause of readmission; 3 cases of pain and fever (in one a re-laparoscopy was performed because of suspicion of leakage of the appendicular stump); 1 residual hematoma requiring second laparoscopy. Mean duration of hospitalisation was 4.9 days (range 2-25 days): at present, mean hospitalisation is 2 and 6 days respectively in cases with and without peritonitis. In conclusion, laparoscopic appendectomy appears to be feasible in the majority of cases, with better results when the appendix is ectopic and/or in the presence of peritoneal reaction.

[Cholecystectomy via laparoscopy in situs inversus totalis. A case report and review of the literature]

The authors report a case of symptomatic cholelithiasis in a patient with situs inversus totalis, in which the surgical treatment was performed by laparoscopy. They discuss the etiopathogenesis of this anomaly and malformations often associated, moreover related clinical and surgical problems. Finally, they describe operative technique stressing the real possibility to perform the operation by laparoscopy on condition that the surgeons have sufficiently experience of biliary and laparoscopic surgery.

[A case of a left-sided gallbladder treated surgically via laparoscopy]

The authors relate about a case of symptomatic cholelithiasis, in which the organ was located in the inferior face of III hepatic segment and the surgical treatment was performed by laparoscopy. They discuss about etiopathogenesis of this anomaly, symptomatology referred by the patients and diagnostic procedures. Finally, they stress the necessity, in this case, to perform the cholecystectomy by anterograde approach in order to well visualize the anatomic structures and be safe to avoid injury of hepatic pedicle.

[Gastric schwannoma. A case diagnosed by puncture biopsy]

One case of schwannoma of the stomach diagnosed with ultrasound-guided biopsy puncture is reported. This diagnosis is usually not established with radiographic and endoscopic examinations. A preoperative diagnosis allows partly predicting the type of exeresis to be performed. On the other hand, guided biopsy puncture seldom allows establishing a prognosis, for which the criteria are based on the analysis of the whole tumor and the possible discovery of synchronous or metachronous metastases.