Effective treatment of advanced multiple myeloma refractory to alkylating agents

MRC trial of alpha2b-interferon maintenance therapy in first plateau phase of multiple myeloma. MRC Working Party on Leukaemia in Adults

Plateau phase has been achieved in 64% of all newly diagnosed patients with multiple myeloma treated with the ABCM (adriamycin, BiCNU, cyclophosphamide and melphalan) regimen in the Medical Research Council (MRC) trials; this stable clinical stage of the disease is associated with no more than minimal symptoms. Several studies have found that alpha-interferon (alpha-IFN) maintenance therapy increases the duration of plateau phase, but it is less clear if this translates into prolonged survival. We report the effect of alpha-IFN on the duration of plateau phase and overall survival in a trial with 284 patients who were randomized to receive alpha2b-IFN (Intron-A) or no maintenance therapy during first plateau phase. The minimum follow-up after randomization was 21 months. There was no significant difference in the overall survival between the two treatment groups (X2=0.32, P=0.57). There was a trend towards longer relapse-free survival in the patients allocated alpha-IFN, but this trend to longer plateau phase was not statistically significant (X2 = 1.62, P = 0.2). Disease progression at relapse on alpha-IFN appears to be more severe with greater elevations from plateau levels of serum paraprotein (P = 0.06) and beta2-microglobulin (P= 0.03) levels. Physicians tended to start chemotherapy sooner after diagnosis of relapse when patients had received alpha-IFN (P = 0.16). Although, in common with most other studies, there is a trend for patients treated with alpha-IFN to have a longer plateau phase, this is counteracted by morbidity attributable to the treatment and a somewhat shortened survival post relapse. Meta-analysis of interferon trials is required to assess whether the minor trend for longer survival in patients maintained on alpha-IFN found in some studies is significant and, if so, the extent of this advantage.

Anthracyclines in haematology: pharmacokinetics and clinical studies

The activity of anthracyclines in the treatment of a wide spectrum of haematological malignancies has long been established. Differences in the pharmacokinetic and pharmacodynamic properties of these drugs have resulted in the selection of individual compounds for particular indications while the recent reformulation of anthracyclines in liposomal preparations seems likely to significantly alter their range of activity and toxicity. The problems related to cumulative cardiotoxicity secondary to anthracycline exposure can be ameliorated by the use of dexrazoxane and a number of agents may prove to have a role in altering their cellular resistance to their cytotoxic actions.

Monitoring of multiple myeloma patients by simultaneously measuring marker substances of bone resorption and formation

Fifteen patients (13 males and two females; mean age, 63 years; age range, 46-84 years) with multiple myeloma were studied prospectively (range of follow-up period, 2-6 months) to elucidate the diagnostic validity of biochemical markers of bone formation (bone alkaline phosphatase and the C-terminal propeptide of type I procollagen) and bone resorption (urinary excretion of pyridinium cross-links) for monitoring these patients. Eleven of 15 patients received melphalan i.v. and prednisone p.o. every 4 weeks. All patients were given pamidronate i.v. for inhibition of bone resorption. The mean values of the urinary excretion of pyridinium cross-links were significantly higher in the patients fulfilling the criteria of 'progression' or 'relapse' than in those showing 'response' and those in the 'plateau phase' (P < 0.05). In contrast, neither bone alkaline phosphatase nor C-terminal propeptide serum values differed significantly between these two groups (P > 0.05). The concentrations of both bone formation markers were significantly lower in the patients than in the samples obtained from apparently healthy persons (P < 0.001). There was a significant inverse correlation between the number of pamidronate courses and the serum concentrations of bone alkaline phosphatase (P < 0.05). A lack of correlation was observed between the urinary excretion of pyridinium cross-links and all other laboratory parameters measured (serum concentrations of total protein, calcium, creatinine and (beta 2-microglobulin). In conclusion, the urinary excretion of pyridinium cross-links might be a useful parameter for monitoring multiple myeloma patients. Decreased values of bone formation markers may be due to a suppressive effect of the bisphosphonate agents administered or reflect the severity of osteolytic lesions which have been described as being associated with unbalanced bone remodelling.

Donor Leukocyte Infusions Are Effective in Relapsed Multiple Myeloma After Allogeneic Bone Marrow Transplantation

Donor leukocyte infusions (DLI) can induce sustained remissions in patients with acute and chronic myeloid leukemia who relapse after allogeneic bone marrow transplantation (allo-BMT). Also, in multiple myeloma (MM), incidental reports have indicated the existence of a graft-versus-myeloma effect (GVM) induced by allo-reactive T cells. We performed a retrospective study in a larger group of MM patients to characterize better the effect, prognostic factors, and toxicity of this new treatment modality. Thirteen patients with relapsed MM after allo-BMT were studied. Patients received a total of 29 DLI with T-cell doses ranging from 1 × 106/kg to 33 × 107/kg. Repetitive courses, sometimes with escalated cell doses, were undertaken in case of no response to or relapse after DLI. Eight of 13 patients responded: 4 patients achieved a partial remission and 4 patients achieved a complete remission. Dose escalation was effective in 3 patients. The time to response was median 6 weeks (range, 4 to 10 weeks). Major toxicities were secondary to acute and chronic graft-versus-host disease (GVHD), which occurred in 66% and 56% of all patients and in 87% and 85% of the responders, respectively. Two responding patients developed fatal BM aplasia. The only prognostic factors for response were a T-cell dose greater than 1 × 108/kg and the occurrence of GVHD. Seven of nine patients developing acute GVHD responded, as compared with only 1 response in the 4 patients without GVHD and 6 of 7 patients with chronic GVHD responded, whereas no response was observed in the 5 patients without chronic GVHD. DLI are effective in a high percentage of patients with relapsed MM after allo-BMT, although it is associated with a high treatment-related toxicity. The dose of T cells used may be important in determining the GVM effect, with the highest probability of response after infusion of more than 1 × 108 T cells. Because the optimal individual dose may vary, patient-adapted therapy consisting of repeated infusions with escalating dose of donor leukocytes until maximum response is achieved may therefore be preferable.

Treatment of multiple myeloma in elderly patients. New developments

The median of survival among patients with multiple myeloma (MM) is about 30 months from the onset of treatment. Tumour burden and a range of other parameters, such as C-reactive protein levels, the plasma cell labelling index and beta2-microglobulin levels, can be used to assign patients to favourable and unfavourable prognostic groups. Conventional chemotherapy consists of melphalan and prednisone, and is as effective as moderately intensive cytotoxic drug regimens. Although second-line chemotherapy is initially effective, all patients eventually die. Maintenance therapy will interferon-alpha prolongs the plateau phase of the disease, but its effects on overall survival are minimal. One of the promising developments in the treatment of MM has been the introduction of high dosage chemotherapy, which can now be safely administered when stem cells are used for haematological recovery. Autologous bone marrow transplantation has been shown to produce a significant improvement in survival compared with conventional therapy. Several studies are under way that are examining the effects of multiple courses of high dosage chemotherapy together with peripheral stem cell support. Purging of autologous stem cell harvests will be performed in the near future to minimise contamination with myeloma cells. It is now feasible to use high dosage chemotherapy, with the support of granulocyte colony-stimulating factor-stimulated whole blood, in selected elderly patients. Besides the promising development of intensive therapy, a number of other treatment strategies have emerged, including treatment with monoclonal antibodies against interleukin-6 and multidrug resistance-modulating agents. Better supportive care can be provided for some patients by using epoetin (recombinant human erythropoietin), and the sequelae of lytic bone lesions can be ameliorated through the use of bisphosphonates.

Maintenance therapy with alpha-interferon following first-line VAD in multiple myeloma

The aim of this study was to evaluate the response characteristics of vincristine, adriamycin and dexamethasone (VAD) as a first-line chemotherapy and to determine the efficacy of maintenance alpha-interferon (alpha-IFN) in multiple myeloma (MM). Between January 1985 and December 1994, a prospective trial was performed in stage II and III MM patients. The study population received only VAD with no maintenance therapy before 1990 (n=31), and those recruited after 1990 (n=33) were planned to be maintained with alpha-IFN (5 mU, 3 times per wk) during the plateau to a maximum of 2 yr. Median follow-up duration (44 vs. 39 months), time to response (3.4 vs. 3.5 months) and rate of objective response (61.3%, 19/31 and 63.6%, 21/33) were similar in VAD-only and VAD+IFN groups, respectively. The survival analyses revealed higher median progression-free (39.6 vs. 12 months) and overall survival (65+ vs. 24 months) durations in VAD+IFN group compared to VAD-only group. VAD regimen was well tolerated and IFN-related side effects were reversible. These findings denote that IFN maintenance prolongs the duration of response obtained by VAD.

Autotransplants in multiple myeloma: pushing the envelope

Substantial progress has been made in understanding the role of autotransplants in multiple myeloma. High dose therapy consistently induces a higher remission rate, longer remission duration, and overall survival. This article summarizes the results of several major studies to illustrate the above conclusions. Feasibility of autotransplants in patients with renal failure, utility of stem cell selection, and prognostic factors are also discussed. Autotransplants should be part of the overall treatment strategy for newly diagnosed myeloma patients under 70 years of age.

Superiority of Tandem Autologous Transplantation Over Standard Therapy for Previously Untreated Multiple Myeloma

Virtually no progress has been made during more than 2 decades of clinical trials for multiple myeloma (MM) involving standard therapy (ST). Recent studies suggest that dose intensification requiring hematopoietic stem cell support results in higher complete response (CR) rates and extended disease control. “Total Therapy” (TT) consisting of non–cross-resistant induction regimens, followed by a double autotransplant (AT) procedure, was administered to 123 untreated patients with symptomatic MM. Upon hematologic recovery, interferon (IFN) maintenance (3 million units [MU]/m2 subcutaneously thrice weekly) was given until disease recurrence/progression. Results were compared with the outcome of untreated patients receiving ST according to Southwest Oncology Group (SWOG) trials. One hundred sixteen pair mates were selected from both TT and among 1,123 patients to match for the major prognostic features. TT induced CR in 40% of all 123 patients (intent-to-treat). By 12 months, 7% had died, including 4% from treatment-related complications. With a median follow-up of 31 months, median durations of event-free survival (EFS) and overall survival (OS) are 49 and 62+ months, respectively. Abnormalities of chromosomes 11q and 13 were associated with inferior outcome, whereas CR within 6 months after induction was a favorable prognostic feature for both EFS and OS. In comparison to ST, TT induced higher PR rates (85% v 52%, P < .0001) (CR rates not available on SWOG trials) and extended EFS (49 v 22 months, P = .0001) and OS (62+ v 48 months, P = .01). Compared to ST, dose intensification with double AT markedly augments tumor cytoreduction, effecting not only higher CR rates but also significantly extending EFS and OS in previously untreated patients with MM.

Phase II trial of rhIL-6 (interleukin-6) prior to and concurrently with VAD (vincristine, doxorubicin and dexamethasone) chemotherapy for patients with multiple myeloma

We examined the tolerability and safety of interleukin-6 (rhIL-6) when administered prior to and concurrent with vincristine, doxorubicin and dexamethasone (VAD) in patients with progressive multiple myeloma previously treated with VAD alone. Typical rhIL-6-related effects such as fever, chills, acute phase reactions and reversible abnormalities in liver function tests were observed. The study examined whether rhIL-6 predictably modulated indices of myeloma activity. No consistent, predictable change in myeloma-related parameters was documented upon rhIL-6 administration for either 8 days or 11 days prior to and concurrent with VAD. Two patients showed improved sensitivity to VAD chemotherapy when this was administered with rhIL-6. The overall response rate to rhIL-6 and VAD therapy in this study of relapsed and refractory patients was 50%, comparable to our previous experience with VAD alone in this cohort of patients.

Diagnosis, prognosis, and standard treatment of multiple myeloma

The diagnosis of multiple myeloma (MM) is often difficult; most patients present with asymptomatic gammopathy. The only findings that confirm a diagnosis of MM are an elevation in the M-component or extension of the lytic bone lesions that are the hallmark of the disease. Tests that delineate plasma cell biology, such as plasma cell proliferation rate, are helpful; magnetic resonance imaging can disclose bone marrow lesions leading to subsequent osteolytic disease. After the diagnosis of MM has been established and prognostic factors identified, the appropriate therapy can be determined. Melphalan and prednisone are no longer considered to be the "gold standard" of therapy. In fact, this approach is suitable for less than half of patients with myeloma. This article presents guidelines for standard treatment options and examines the efficacy of new high-dose chemotherapy approaches.

A risk-benefit assessment of anthracycline antibiotics in antineoplastic therapy

The anthracycline antibiotics comprise a group of cytotoxic compounds with wide-ranging activity against human malignancies. They are used extensively for curative, adjuvant and palliative therapy, both as single agents and in combination regimens. They produce a number of adverse effects, some of which are shared by other cytotoxic drugs. The most important adverse effect is cardiotoxicity, which is unique to this class of compounds. Strategies have been devised to circumvent these adverse effects, including the development of less toxic analogues, alterations in scheduling, the addition of cardioprotectant agents and methods of monitoring for cardiac abnormalities.

[Prognosis of multiple myeloma treated with conventional chemotherapy has not improved in 20 years]

The treatment of multiple myeloma has changed over the last 20 years. We investigated the effects of theses changes on patient survival in the current practice of a rheumatology ward. Two hundred and seventy-nine patients were hospitalised between 1972 and 1993: 30 from 1972 to 1976, 70 from 1977 to 1981, 86 from 1982 to 1986, 75 from 1987 to 1991 and 18 from 1992 to 1993. Staging according to Durie and Salmon was I in 8%, II in 29% and III in 65%. In principle, the initial therapy was monochemotherapy in 65% of the cases and polychemotherapy in 35%. At the time of the present study, 197 patients have died. The actuarial curves of survival were similar in all historical classes defined by the date of first admission. Curves of median of follow-up and of floating means were level between 1972 and 1990. No correlation was found between the date of first admission and survival in the 174 patients who died between 1972 and 1987. The following parameters were associated with longer survival: achievement of an objective response on chemotherapy, lower patient's age, high haemoglobin, low creatinine, low stage according to Durie and Salmon, low number of plasma cells in bone marrow, low calcemia and low levels of IgA, monoclonal component. The comparison of prognosis factors in historical classes showed a difference only for haemoglobin which was lower in the earlier class. The type of the first chemotherapy regimen varied widely between historical classes. The number of responders was significantly greater after polychemotherapy than after monochemotherapy but no correlation was observed between the type of chemotherapy and survival. The frequencies of early death, and the causes of death in general, were not different in the historical classes. The lack of improvement of survival over the last 20 years shows that the efficacy of current chemotherapies is limited, a conclusion which warrants the exploration of other therapeutic avenues.

Determination of plasma concentrations of epirubicin and its metabolites by high-performance liquid chromatography during a 96-h infusion in cancer chemotherapy

In order to determine epirubicin and its metabolites at low concentrations (< 38 ng/ml) in small plasma samples, a fast reliable method based on a precipitation pre-treatment and sensitive reversed-phase isocratic HPLC has been developed and validated for epirubicin in the range 5-100 ng/ml. The R.S.D. was 5-9% over this concentration range. For human serum containing 25 ng/ml of epirubicin, the inter- and intra-day variation was < 10%. Recoveries of the metabolites epirubicinol, 7-deoxydoxorubicinone and 7-deoxydoxorubicinolone at 20 ng/ml ranged from 94-104%. The assay has been used to study human plasma samples taken during a 96-h infusion of epirubicin in a patient with multiple myeloma. The combined levels of the unseparated metabolites, epirubicin glucuronide and epirubicinol glucuronide, were semiquantitatively determined after treatment with beta-glucuronidase. The metabolites epirubicinol and 7-deoxydoxorubicinolone, but not 7-deoxydoxorubicinone, were also detected and measured.

[Use of interferon alpha in multiple myeloma]

Alpha Interferon has been used for fifteen years in the management of patients with multiple myeloma. However this indication remains controversial. Seven multicenter randomized trials have compared alpha Interferon with observation in patients responding to conventional chemotherapy. Three of these studies have given negative results. In the other four, alpha Interferon therapy has prolonged remission duration but in none of them has the overall survival been significantly prolonged. After intensive treatments the results of only one study are available and are in favour of alpha Interferon. Seven randomized studies have tested the impact of a combination chemotherapy plus alpha Interferon as compared to chemotherapy alone. Only one has shown a significant benefit for patients receiving chemotherapy plus natural alpha Interferon. This benefit has been limited of IgA and BJ myelomas and to stage II myelomas. Finally, the combination high dose dexamethasone-alpha Interferon has given promising preliminary results which justify prospective ongoing studies. These clinical results are analyzed in relation to the in vitro data.

2',2'-Difluorodeoxycytidine (gemcitabine) induces apoptosis in myeloma cell lines resistant to steroids and 2-chlorodeoxyadenosine (2-CdA)

The paucity of effective cytotoxic agents for the treatment of steroid resistant multiple myeloma explains the ongoing search for alternative substances for chemotherapy of this disease. In the present study, the purine antagonist 2-chlorodeoxyadenosine (2-CdA, cladribine) and the pyrimidine antagonist 2',2'-difluorodeoxycytidine (gemcitabine) were tested on four myeloma cell lines (i.e., U 266, OPM 2, RPMI 8226, IM 9), one plasma cell leukemia cell line (HS Sultan) and a myeloid control cell line (HL 60), all of which are resistant to 10-6 M dexamethasone. Gemcitabine has been found to be promising in the chemotherapy of other tumors with low proliferative activity, but its effectiveness against myeloma cells has not been analyzed so far. In our tests, gemcitabine induced a significant degree of apoptosis in all cell lines investigated. After incubation for 48 h with 10 microM gemcitabine, the median numbers of apoptotic cells were in the range of 45% in the OPM 2 and 79% in the U 266 cell line. All of the investigated cell lines were responsive to concentrations of 10 microM gemcitabine even after an exposure of only 30 min, three of them (U 266, HS Sultan, IM 9) also responded to a concentration of 10 nM. Higher concentrations and longer exposure times were necessary to suppress the growth of normal hematopoietic bone marrow progenitor cells. In contrast to gemcitabine, standard concentrations of 2-CdA (i.e., 30 and 300 nM) failed to induce a significant degree of apoptosis in the cell lines investigated but inhibited the growth of myeloid progenitor cells. The results suggest that gemcitabine induces apoptosis in myeloma and plasma cell leukemia lines resistant to steroids and 2-CdA. The fact that tumor cell apoptosis was achieved at concentrations clinically achievable and tolerable, which at the same time do not inhibit the growth of normal CFU-GM progenitor cells, favors the initiation of phase I trials with this drug for the treatment of multiple myeloma.

Treatment of extravasation of both doxorubicin and vincristine administration in a Y-site infusion

OBJECTIVE

To describe a patient treated with vincristine, doxorubicin, and dexamethasone who experienced extravasation of both doxorubicin and vincristine during a Y-site infusion.

CASE SUMMARY

A 74-year-old white woman was diagnosed with multiple myeloma IgA kappa in stage IIA. One year after a complete remission she relapsed. Her treatment included daily doxorubicin 16 mg in 500 mL of dextrose 5% and vincristine 0.4 mg in 500 mL of dextrose 5% administered in a Y-site continuous infusion into a peripheral vein of her left forearm. Extravasation occurred during administration of these drugs. Immediately, chondroitinsulfatase, a mucopolysaccharidase similar to hyaluronidase, was administered subcutaneously around the extravasation area and repeated 24 hours later. Furthermore, dimethyl sulfoxide 90% v/v was applied topically on the area four times daily for 2 weeks. All inflammatory signs resolved and no necrosis developed.

DISCUSSION

Ths is the first report of an extravasation of two cytotoxic drugs. Doxorubicin and vincristine have different antidotes and opposite physical treatments for their extravasation. The antidotes dimethyl sulfoxide and chondroitinsulfatase have different mechanisms of action, but both cause uptake of the cytotoxic agent from the tissue and are likely to be administered together. No warming or cooling was performed.

CONCLUSIONS

Topical dimethyl sulfoxide four times daily for 14 days plus subcutaneous chondroitinsulfatase in one or two applications effectively treated an extravasation of both doxorubicin and vincristine in our patient.

The role of chemotherapy in the treatment of multiple myeloma

Plasma cell neoplasms often present in an asymptomatic, stable phase. Treatment should not be started until manifestations, such as bone pain, increased susceptibility to infections, renal failure, anaemia and weight loss, announce that the disease has progressed to the MM phase. Conventional therapy with melphalan and prednisone results in objective improvement in about 50% of patients and improves median survival to about 32 months from the start of treatment. Induction therapy should be continued until the M-protein reaches a stable plateau that lasts for at least 4 months. Maintenance therapy with melphalan prolongs the duration of the initial response, but does not improve overall survival, in comparison with patients receiving no maintenance therapy, because survival following relapse is shortened in those receiving maintenance melphalan. In two randomized clinical trials, maintenance treatment with interferon alpha prolonged remissions durations and overall survival of MM patients who responded to induction chemotherapy. Second-line treatment for MM patients who are primary refractory to melphalan, and for those who respond initially and then relapse with refractory disease, is outlined. Although long-term control is possible for a minority of patients, it is unlikely that MM can be cured with currently available chemotherapeutic agents. We need to learn more about the basic biology of the disease.

Complications and supportive therapy of multiple myeloma

The clinical spectrum of MM is variable. Infiltration of bone and bone marrow by malignant plasma cells results in severe osteopenia, lytic lesions, pathological fractures and anaemia. Occasionally, significant numbers of plasma cells circulate in the bloodstream. Hypercalcaemia and Bence Jones proteinuria are the main reasons for renal impairment, but amyloidosis and monoclonal immunoglobulin deposition should also be considered. Neurological impairment is most often due to spinal cord pressure by an extradural plasma cell tumour. In some patients, symptoms and signs of peripheral neuropathy may be present. Amyloidosis complicates the course of a minority of patients with MM and further impairs the performance of affected patients. Circulating monoclonal protein may increase serum viscosity, impair the function of platelets and coagulation factors, and behave as a cryoglobulin. The levels of uninvolved immunoglobulins are usually decreased, rendering patients susceptible to various bacterial infections. One or more of these complications provides a clue for the diagnosis, forms the basis for defining prognosis and must be managed expeditiously and concurrently, with the institution of specific treatment for the myeloma.

A phase I trial of intermittent high-dose alpha-interferon and dexamethasone in metastatic renal cell carcinoma

BACKGROUND

Evidence exists that the toxic of alpha-interferon can be ameliorated by co-administration of dexamethasone without compromise of therapeutic efficacy. We therefore conducted a phase I trial to determine the maximum tolerated dose of intermittent interferon when combined with oral dexamethasone.

PATIENTS AND METHODS

Thirty patients with metastatic renal cell carcinoma were enrolled. The starting dose of interferon was 20 million IU/m2/day given as a subcutaneous injection days 1 to 4 of each 14 day cycle. Dose levels were escalated at increments of 5 million IU/m2. Dexamethasone 4 mg was administered orally every 6 hours during administration of high-dose interferon. Low-dose maintenance interferon, 3 million IU/m2/day, was administered without dose escalation on days 5 to 14 of each cycle.

RESULTS

The maximum tolerated dose of intermittent high-dose interferon was 40 million IU/m2/day. The dose limiting toxicity was fatigue. EEG abnormalities developed in five patients and neuropsychiatric parameters deteriorated significantly in seventeen.

CONCLUSIONS

We conclude that co-administration of dexamethasone improves the tolerance of intermittent high-dose interferon. The results of this trial may be useful in designing high-dose interferon regimens for renal cell carcinoma and other interferon-sensitive diseases.

Development of a criterion for response to therapy at 6 months in multiple myeloma

To investigate the prognostic value of therapy at 6 months on survival in multiple myeloma, to develop a new criterion assessing response to initial therapy at 6 months, and to compare it to a current criterion. The types of initial and 6-month therapy were considered in a prognostic factor analysis in 70 patients treated in routine practice. Using the response to initial therapy defined by the clinician's decision as grouping variable in this group, a discriminant analysis identified the characteristics of responder patients. The validity of the resulting criterion was tested in another test group. Its prognostic ability was compared to the CLMTF criterion (50% M-component reduction from baseline). The therapy at 6 months, reflecting the clinician's appraisal of response to initial therapy, predicted survival significantly. A criterion combining two variables (M-component change and haemoglobin level at 6 months) classified 70% and 72.4% of patients correctly regarding response status in the training and test groups respectively. This criterion was shown to perform better than the CLMTF criterion in predicting survival.

CONCLUSION

A new criterion for response to therapy at 6 months, also presented in a nomogram, combines M-component change and haemoglobin level at 6 months.

Vincristine and oral etoposide in refractory multiple myeloma

A total of 15 patients with refractory multiple myeloma (MM; 4 primary unresponsive and 11 relapsed and resistant to re-induction/salvage therapy) received i.v. vincristine on day 1 and oral etoposide daily for 4 days, the treatment being repeated at 3-weekly intervals. The patients were re-assessed after three cycles of chemotherapy, and non-responders received no further therapy. There was no complete or partial response. A minimal response was seen in two patients, and two others showed stable disease. None of the responses was sustained, and all patients eventually had progressive disease. It is concluded that combination chemotherapy with vincristine and oral etoposide given by this schedule is unlikely to be of any value in refractory myeloma.

A phase III randomized study of oral verapamil as a chemosensitizer to reverse drug resistance in patients with refractory myeloma. A Southwest Oncology Group study

BACKGROUND

Multiple myeloma is considered to be a drug responsive disease; however, there is no cure for this disease and virtually all patients will develop drug resistance. One form of drug resistance that has been documented is the multidrug resistance phenotype or MDR.

METHODS

A randomized trial of the combination of vincristine, doxorubicin, and dexamethasone (VAD) and VAD plus oral verapamil (VAD/v) in drug refractory multiple myeloma patients was performed by the Southwestern Oncology Group. Verapamil was used as a chemosensitizing agent to attempt to overcome or prevent MDR and improve the therapeutic outcome.

RESULTS

Response rates between the two treatment arms were similar with an overall response rate of 41% for the VAD alone arm and 36% for the VAD/v arm. Overall survival of patients was also similar with a median survival of 10 months for the VAD arm and 13 months for the VAD/v arm. The toxicity profile was also similar for both treatments, with myelosuppression being the dose-limiting toxicity. No significant correlation was observed between expression of P-glycoprotein, serum verapamil levels, and response to therapy.

CONCLUSIONS

No beneficial effect was observed from the addition of oral verapamil to the VAD chemotherapy regimen for the treatment of drug-resistant myeloma patients. More effective and less toxic chemosensitizers are needed to study the role of chemosensitizers in reversing MDR in the clinic.

Prognostic factors in low tumour mass asymptomatic multiple myeloma: a report on 91 patients. The Groupe d'Etudes et de Recherche sur le Myélome (GERM)

Between January 1985 and July 1989 we diagnosed asymptomatic stage I multiple myeloma according to Durie and Salmon [Durie and Salmon: Cancer 36:842, 1975] in 91 patients. All patients were followed without chemotherapy. Disease progression occurred in 41 patients and the median time to progression for all patients was 48 months. In the Cox multivariate regression analysis, hemoglobin levels < 12 g/dl (P < .01), bone marrow plasmacytosis > 25% (P < .01), and M-component size > or = 30 g/l for Ig G or > or = 25 g/l for Ig A (P < .01) were the only significant prognostic factors for progression. The 38 patients without any harmful factor remained free of progression for a median of more than 50 months. The 18 patients with two or three of these characteristics (high-risk group) had the shortest median time to progression of 6 months. Despite different times to progression, the response rate and survival after chemotherapy were similar for all groups of patients. Patients in the high-risk group for progression have to be frequently monitored for disease progression and might benefit from early treatment.

VAD chemotherapy as remission induction for multiple myeloma

A total of 142 patients with multiple myeloma received VAD as remission induction therapy. Seventy-five were previously untreated and 67 had relapsed (31) or refractory disease (36). Vincristine (total dose 1.6 mg) was infused with doxorubicin 36 mg m-2 by continuous ambulatory pump over 4 days. In addition, oral dexamethasone 40 mg day-1 was given for 4 days. Intermittent dexamethasone was only given to 19 patients. Courses were repeated every 21 days. The overall response rate was 84% [27% complete response (CR)] in previously untreated patients and 61% (3% CR) in patients with relapsed and refractory disease. The median survival was 36 months for untreated patients and 10 months for those who had received prior therapy. VAD was well tolerated; however, despite prophylaxis, 54% patients received antibiotics at some time during therapy and 37% had dyspepsia. Twenty-three patients subsequently received a transplant (eight allografts, eight marrow autografts and seven peripheral blood stem cell transplants). Eight have died-four in the allogeneic group and four in the autologous group. The overall median survival of transplanted patients has not yet been reached. VAD is an effective, out-patient therapy for inducing remission in multiple myeloma. Post-remission therapy needs to be optimised, but it is likely that the needs of previously untreated patients may be different from those with relapsed and refractory disease.

Salvage therapy for multiple myeloma: the University of Arkansas experience

OBJECTIVE

To summarize a spectrum of salvage regimens for multiple myeloma (MM) developed during the past decade.

DESIGN

We reviewed the experience at the University of Arkansas in the management of patients with MM who failed to achieve remission ("primary unresponsive") or had a relapse despite myelosuppressive doses of chemotherapy ("resistant relapse").

MATERIAL AND METHODS

Results with use of the various chemotherapeutic protocols are presented, and multivariate regression analysis was applied to determine the independent contributions of certain factors toward event-free and overall survival.

RESULTS

The VAD regimen (vincristine sulfate, Adriamycin [doxorubicin hydrochloride], and dexamethasone) yielded responses in 29% of previously unresponsive and 46% of relapsed cases of MM, in comparison with 25% and 21%, respectively, with use of dexamethasone only. Responses occurred more frequently when tumor cell RNA content was high, tumor burden was low, and duration of drug resistance was less than 1 year. The duration of survival in patients who received high doses of melphalan was decreased in those with increased serum levels of lactate dehydrogenase. EDAP (etoposide, dexamethasone, ara-C, and cisplatin) produced 75% or more tumor cytoreduction in 8 of 20 patients. Overall in patients with an increasing number of adverse factors, response rates and survival decreased progressively with less intensive therapy but were unaffected when more intensive therapy was used. In the multivariate analysis, the most important features for extended survival were a low beta 2-microglobulin level before transplantation and application of two bone marrow transplants within 6 months.

CONCLUSION

Variables relative to the patient's overall medical condition, prior treatment, characteristics of MM at diagnosis, and response history should be carefully assessed to determine a plan for salvage therapy that will maximize the opportunity for sustained remission and survival.

Infusional cyclophosphamide, doxorubicin and etoposide in HIV-related non-Hodgkin's lymphoma: a follow-up report of a highly active regimen

Based on our prior data suggesting a therapeutic advantage for infusional administration of cyclophosphamide (C), doxorubicin (D), and etoposide (E) in patients with relapsed and resistant non-Hodgkin's lymphoma (NHL), we administered C (750 mg/m2), D (50 mg/m2), and E (240 mg/m2) via continuous intravenous infusion over 96 hours as first line therapy for 21 patients with intermediate- or high-grade non-Hodgkin's lymphoma associated with human immunodeficiency virus (HIV) infection. Treatment was repeated every 28 or more days. The median CD4 count of the study group was 87/ul, and the median serum lactate dehydrogenase was 383 IU/L. Extranodal disease, lymphomatous marrow involvement, and lymphomatous meningitis were present at diagnosis in 90%, 33%, and 10% of patients, respectively. Complete response (CR) occurred in 13 patients (62%, 95% confidence intervals 41%, 81%) and partial response occurred in five patients (24%). The estimated median survival of the study group was 18.0 months. Hematologic toxicity required dose reduction for 47% of cycles and for 79% of patients who received at least two cycles. The mean dose intensity for C, D, and E were 73%, 70%, and 73% of the intended dose intensity, respectively. Opportunistic infection included oral/esophageal candidiasis (N = 7), herpes labialis (N = 3), pulmonary Mycobacterium avium-intracellulare (N = 1), candidemia (N = 1), pneumonitis (N = 1), and disseminated aspergillosis than resulted in a single treatment-related death (5%). Treatment resulted in a significant decrease in the CD4+ lymphocytes, as well as total lymphocytes, T lymphocytes, and CD8+ lymphocytes.(ABSTRACT TRUNCATED AT 250 WORDS)

Intensive sequential therapy for VAD-resistant multiple myeloma

Few effective regimens are available for patients with advanced multiple myeloma resistant to alkylating agents and VAD. We treated 65 patients with advanced and refractory multiple myeloma with the combination of cyclophosphamide (3.0 gm/m2) and etoposide (900 mg/m2) followed by GM-CSF at a daily dose of 0.125 mg/m2. Thirty-five percent of patients responded with a 6% mortality rate. After a median of 2 months, 16 patients received myeloablative treatment supported by autologous bone marrow or blood stem cells. Four of ten previously resistant patients responded so that the overall response rate was 42%. The median survival for all patients was 10 months and the median remission was 8 months. The median survival for patients with both low serum lactate dehydrogenase and B2 microglobulin, or for those who received myeloablative treatment, was projected at 18 months. Our combination of cyclophosphamide and etoposide provided an effective rescue treatment for many patients with advanced multiple myeloma resistant to conventional therapies. This program allowed early blood stem cell collection in support of subsequent myeloablative therapy for selected patients.

Multiple myeloma

Multiple myeloma occurs in over 2000 new patients in England and Wales each year. It presents most frequently as bone pain and patients tend to become dehydrated and may develop renal failure. No available treatment is curative, but about two thirds of patients achieve a stable response with low dose combination chemotherapy. Combination chemotherapy including doxorubicin and carmustine with the alkylating agents cyclophosphamide and melphalan achieve a higher stable response rate than conventional treatment with melphalan and prednisone without additional haematological toxicity. These responses are associated with loss of bone pain and patients remain symptom free for months without further treatment. Relapse occurs on average in a little under two years and, though second responses are frequently obtained, the disease eventually becomes refractory. This paper looks at who should be treated and the benefits that may be expected from the treatments available.

Continuous infusion ABDIC therapy for relapsed or refractory Hodgkin's disease

BACKGROUND

Patients whose Hodgkin's disease is refractory to standard combination chemotherapy usually have a poor prognosis. These patients are generally considered for bone marrow transplantation if the disease is still sensitive to chemotherapy.

METHODS

Between May 1988 and January 1992, 19 patients with refractory or relapsed Hodgkin's disease were treated with a regimen of doxorubicin, bleomycin, dacarbazine, lomustine, and prednisone (ABDIC). The ABDIC regimen as modified for continuous infusion by Hagemeister consisted of doxorubicin 25 mg/m2 by continuous infusion daily for 2 days, dacarbazine 200 mg/m2 by continuous infusion daily for 5 days, bleomycin 5 U/m2 intravenously on days 1 and 5, CCNU 40 mg/m2 on day 1, and prednisone 40 mg/m2 daily on days 1-5. Treatment was repeated every 28 days.

RESULTS

At the time of treatment, mean age was 30.5 years (range 19-70), and time to ABDIC from initial diagnosis was 5.6 years (range 1-14). The mean number of prior chemotherapy regimens was 2.7 (range 1-5), and three of the patients had had autologous bone marrow transplantation before ABDIC: All patients had earlier received either mechlorethamine, vincristine, procarbazine, and prednisone or a regimen of doxorubicin, bleomycin, vinblastine, and dacarbazine, and 16 had received both. The mean number of ABDIC cycles was 3.9 (range 2-12). Total response rate was 63%, with 10 patients having partial response and 2 having complete response of 12 and 27 months' duration. Seven patients subsequently underwent bone marrow transplantation; two of these are free of disease at 35 and 41 months. The treatment was well tolerated; major toxicities were nausea and bone marrow suppression.

CONCLUSION

ABDIC is an active and well tolerated therapy in patients with relapsed or refractory Hodgkin's disease, including those previously treated with ABVD. More importantly, perhaps, ABDIC as cytoreductive therapy followed by bone marrow transplantation offers the possibility of long term disease free survival in this heavily pretreated patient population.

Bi-weekly vincristine, epirubicin and methylprednisolone in alkylator-refractory multiple myeloma

Nine patients with poor-prognosis, alkylator-refractory stage III multiple myeloma (MM) were treated with a 23-h continuous infusion (CI) of a compatible mixture of vincristine (VCR) and epirubicin (EPI) daily for 4 days along with a daily 1-h infusion of high-dose methyl prednisolone (MP) to total of 5 days (VEMP); cycles were repeated every 2 weeks when possible, usually on an outpatient basis. WHO grade 3 or 4 neutropenia and infection were the predominant toxicities encountered, necessitating some treatment delays and dose reductions. Two patients died during treatment. Peripheral neuropathy necessitated discontinuation of the VCR in six patients without obvious loss of efficacy of the regimen. Skeletal muscle dysfunction and cardiomyopathy did not occur; trivial ECG abnormalities occurred during a minority of infusions but were of indeterminate relationship to the chemotherapy. Confusion occurred in two patients; alopecia was frequent but reversible, and mild/moderate dyspepsia and stomatitis were common but easily managed. Eight patients achieved a partial response (PR); another patient experienced early death during his second cycle before response assessment. The median survival from the first VEMP administration was 9 months (range, 1-64 + months), the median response duration was 7 months (range, 1-64 + months). Two patients experienced responses too short to be clinically relevant (< or = 2 months). An analysis of weekly paraprotein estimations suggests that the intended bi-weekly cycle length may be optimal. Six of these nine patients derived major benefit from this bi-weekly regimen, which deserves further exploration.

Phase II study of carboplatin (CBDCA) in refractory multiple myeloma. A Southwest Oncology Group study

Nineteen patients with multiple myeloma resistant to standard alkylating agent therapy or to the VAD regimen received carboplatin at a planned daily dose of 100 mg/M2 on four successive days. Two patients erroneously received a four-fold higher drug dose resulting in bone marrow aplasia and death without antitumor effect in one patient with post-mortem examination. No anti-tumor effect was observed among 15 patients evaluable for response (two lacked follow-up examination of tumor markers). Major toxicities were hematologic and included grade > or = III, leukopenia in 9, thrombocytopenia in 6 and anemia in 3 of the 17 evaluable patients. Their median survival was 9 months. These results indicate that carboplatin is inactive in refractory multiple myeloma.

Hematopoietic stem cell autografts in support of myeloablative therapy for multiple myeloma

This paper reports the experience of a single investigator team on the use of autografting in support of myeloablative therapy for multiple myeloma. This demonstrates continued progress toward decreased morbidity, and virtual elimination of mortality, as a result of rapid hematopoietic recovery, due to the use of peripheral blood stem cell grafts in newly diagnosed patients receiving several non-cross-resistant induction regimens followed by two autologous transplants, complete remission rates in excess of 50% can be achieved. Prognostic factors have also been identified for event-free and overall survival.

Cellular pharmacokinetics of doxorubicin in patients with chronic lymphocytic leukemia: comparison of bolus administration and continuous infusion

The purpose of this study was to determine whether administration of doxorubicin (DOX) as a continuous infusion or a bolus injection resulted in similar leukemic cell drug concentration in patients with refractory chronic lymphocytic leukemia (CLL). This study was carried out on five patients with refractory CLL, with DOX administered either as a bolus injection (35 mg/m2; CHOP protocol) or as a constant-rate infusion for a period of 96 h (9 mg/m2 per day; VAD protocol). The two types of drug administration were used alternatively with the same patient. Plasma and cellular DOX concentration were determined using high-performance liquid chromatography. Peak plasma DOX levels were higher after the bolus injection than after continuous administration (1509 +/- 80 ng/ml vs 11.6 +/- 1.8 ng/ml, respectively), whereas the plasma area under the curve (AUC) levels were similar. Maximum DOX cellular concentrations were 8629 +/- 2902 ng/10(9) cells (bolus injection) and 2745 +/- 673 ng/10(9) cells (96 h infusion). The cellular AUC after the bolus injection was 2.85 times greater than that observed after continuous administration. This difference was due to a higher cellular peak level followed by a relatively prolonged retention of the drug, with a loss of only 25% in the first 24 h following. These findings demonstrated that in CLL the cellular DOX exposure can be notably modified by the method of drug administration, with higher drug intracellular concentrations being achieved after bolus administration than with the infusion schedule.

Multiple myeloma treated with mitoxantrone in combination with vincristine and prednisolone (NOP regimen) versus melphalan and prednisolone: a phase III study. Nordic Myeloma Study Group (NMSG)

One-hundred-and-fifty-one patients with previously untreated multiple myeloma were allocated to treatment with either NOP regimen (mitoxantrone 16 mg/m2 and vincristine 2 mg day 1 and prednisolone 250 mg day 1-4 and 17-20) or M+P regimen (melphalan 0.25 mg/kg and prednisolone 100-200 mg/day day 1-4). Both regimens were repeated every 4 weeks and were scheduled for 1 year. Seventy-seven patients were treated with NOP and 74 patients with M+P. No major clinical differences were recorded between the groups before treatment. Sixty percent of the patients responded (CR+PR) to NOP versus 64% to M+P (NS). The time to progression was 16 months (95% C.L. 14-51) in the NOP group versus 21 months (95% C.L. 15-27) in the M+P group (NS). The median survival was 14 months (7-21) in the NOP group and 31 months (21-43) in the M+P group (p = 0.02). NOP was significantly more toxic than M+P. Seven patients treated with NOP died due to infection and neutropenia and 1 patient died of cardiac toxicity, in contrast to 1 death due to infection and neutropenia in the M+P group. Gastrointestinal toxicity was acceptable in both groups. In conclusion, NOP was inferior to M+P as primary treatment of multiple myeloma.

Etoposide, doxorubicin, cyclophosphamide and high-dose betamethasone (EACB) as outpatient salvage therapy for refractory multiple myeloma

Fifty-six patients with refractory multiple myeloma were treated with intermittent courses of etoposide, doxorubicin, cyclophosphamide and high-dose betamethasone (EACB) every 4th week. The overall response rate was 30%. Durable remissions exceeding 1 year were obtained in 12 of the 17 responding patients. A significant prolongation of the survival time was found for responding patients (median 13 months) compared to those patients who did not respond (median 9 months) to EACB therapy (p = 0.01). A low frequency of neutropenic fever episodes was noted compared to other salvage treatment regimens. The EACB regimen was usually well tolerated and could be administered safely on an out-patient basis. This regimen might be an alternative especially for elderly patients unresponsive to initial therapy.

VAD regimen in the treatment of resistant multiple myeloma: slow or fast infusion?

The VAD regimen is effective in the treatment of resistant and relapsing multiple myeloma. In the original VAD regimen, vincristine (V) and doxorubicin (A) are given as continuous infusions together with peroral dexamethasone (D). For practical reasons, we have shortened the infusion times: 8 hours for vincristine and 1 hour for doxorubicin. In this retrospective analysis, we have compared the efficacy and toxicity of the original and modified VAD protocols in the treatment of myeloma patients at our institution. Of the 31 consecutive patients with myeloma, primarily or secondarily resistant to alkylating agents, 16 were treated by the original and 15 by the modified VAD protocol. We found no significant difference in the response rates (good responses 31% and 20% respectively), survival times (17 and 9 months respectively) or toxicity between the two protocols. VAD may well be modified so as to consist of short infusions of V and A. The overall efficacy of the traditional and modified regimens is, however, rather unsatisfactory in patients with advanced myeloma.

Recombinant interferon-alpha 2b and high dose methyl prednisolone in relapsed and resistant multiple myeloma

Twenty-one patients with refractory myeloma (10 primary resistant and 11 relapsed resistant) were treated with a combination of high dose methyl prednisolone and recombinant interferon alpha 2b (IFN-alpha 2b). This treatment included three megaunits/m2 of IFN-alpha 2b three times a week for 12 weeks, plus 5-day pulsed high dose methyl prednisolone every 3 weeks for two courses. A partial response (more than 50 per cent reduction in paraprotein) was observed in six patients; two of these had a greater than 75 per cent reduction in paraprotein, and evaluation of bone marrow showed <5 per cent plasma cells. A minimal response (more than 25 per cent reduction in paraprotein) was seen in four patients, giving an overall objective response rate of 10/21 (48 per cent). Subjective response, in terms of subsidence of pain and improvement of performance status, was seen in all patients who had adequate therapy. The protocol was generally well tolerated with minimal side-effects. There were 4/21 (19 per cent) treatment-related deaths which, though considerable, was anticipated in such a study population. The excellent subjective response seen supplements the objective response observed, and suggests a potential role for the combination of methyl prednisolone and IFN-alpha 2b in refractory myeloma.

Modified vincristine, doxorubicin, and dexamethasone regimen in the treatment of resistant or relapsed chronic lymphocytic leukemia. An Eastern Cooperative Oncology Group study

BACKGROUND

Thirty-six patients with relapsing or refractory chronic lymphocytic leukemia were entered into a Phase II study of the Eastern Cooperative Oncology Group.

METHODS

A modified VAD regimen was given: a 96-hour infusion of 1.6 mg vincristine and 36 mg/m2 doxorubicin with dexamethasone 40 mg by mouth daily for 4 days every 3 weeks. The treatment was continued until two cycles beyond maximal response, which was evaluated after two and six cycles.

RESULTS

Of the 33 evaluable patients, 7 (21%) achieved a partial response (PR), with no complete remissions. One-third of the patients (11 of 33) had progressive disease and 15 of 33 (45%) had stable disease, as defined by the National Cancer Institute Working Group criteria. The median duration of PR was 6.5 months, with a median survival time of 14.8 months. A PR was achieved by 3 of 19 patients (16%) who had received prior vincristine +/- doxorubicin and 4 of 14 patients (28%) who had not received vincristine or doxorubicin. Of the nine patients whose disease was refractory to prior therapy, five (55%) achieved a PR. The neurotoxicity of VAD was reduced by decreasing the frequency of the dexamethasone, but 22 of 36 (61%) patients still became infected. Only on infection (2.8%) was life threatening, and there were no infectious deaths.

CONCLUSIONS

Because fludarabine has shown superior responses, VAD should be reserved for patients who do not respond to alkylating agents and fludarabine and in whom alternative treatments are not appropriate.