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Terao T, Tsushima T, Miura D, Ikeda D, Fukumoto A, Kuzume A, Tabata R, Narita K, Takeuchi M, Matsue K. Carfilzomib-induced thrombotic microangiopathy is underestimated in clinical practice: A report of five patients and literature review. Leuk Lymphoma 2022; 63:1102-1110. [PMID: 35373680 DOI: 10.1080/10428194.2022.2057485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Carfilzomib (Cfz) is widely used to treat multiple myeloma. However, real-world data of the incidence of thrombotic microangiopathy (TMA) caused by Cfz is inconsistent (<1-5%). We evaluated 96 consecutive patients who received Cfz to evaluate the incidence of TMA in clinical practice. TMA developed in five patients (5.2%) who were mainly receiving high-dose Cfz (≥56 mg/m2). Based on a literature review, precaution should be taken for Cfz-induced TMA in male patients receiving high-dose Cfz irrespective of the combination therapy, Cfz administration period, and complement level. In conclusion, Cfz-induced TMA might be underestimated in clinical practice, and early intervention should be considered.
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Affiliation(s)
- Toshiki Terao
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Takafumi Tsushima
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Daisuke Miura
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Daisuke Ikeda
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Ami Fukumoto
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Ayumi Kuzume
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Rikako Tabata
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Kentaro Narita
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Masami Takeuchi
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Kosei Matsue
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, Kamogawa, Japan
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Camilleri M, Cuadrado M, Phillips E, Wilson W, Jenner R, Pang G, Kamora S, Streetly M, Popat R, Bygrave C, Owen R, Cavenagh J, Chapman M, Sive J, Eccersley L, Sheaff M, Benjamin R, Ramasamy K, Cook G, Virchis A, Chavda SJ, Clifton-Hadley L, Scully MA, Yong K. Thrombotic microangiopathy in untreated myeloma patients receiving carfilzomib, cyclophosphamide and dexamethasone on the CARDAMON study. Br J Haematol 2021; 193:750-760. [PMID: 33650100 DOI: 10.1111/bjh.17377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 02/02/2021] [Indexed: 11/29/2022]
Abstract
Proteasome inhibitors have been associated with thrombotic microangiopathy (TMA) - a group of disorders characterised by occlusive microvascular thrombosis causing microangiopathic haemolytic anaemia, thrombocytopenia and end-organ damage. To date, carfilzomib-associated TMA has predominantly been described in relapsed/refractory myeloma patients. We report eight patients with newly diagnosed myeloma who experienced TMA events while receiving carfilzomib on the phase II CARDAMON trial. The first three occurred during maintenance single-agent carfilzomib, two occurred at induction with carfilzomib given with cyclophosphamide and dexamethasone (KCd) and three occurred during KCd consolidation. At TMA presentation 6/8 were hypertensive; 7/8 had acute kidney injury and in three, renal impairment persisted after resolution of TMA in other respects. The mechanism of carfilzomib-associated TMA remains unclear, though patients with known hypertension seem particularly susceptible. Given the first three cases occurred during maintenance after a longer than five-week treatment break, a protocol amendment was instituted with: aggressive hypertension management, carfilzomib step-up dosing (20 mg/m2 on day 1) at start of maintenance before dose escalation to 56 mg/m2 maximum, and adding 10 mg dexamethasone as premedication to maintenance carfilzomib infusions. No further TMA events occurred during maintenance following this amendment and the TMA incidence reduced from 4·2 to 1·6 per 1 000 patient cycles.
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Affiliation(s)
- Marquita Camilleri
- Haematology Department, University College Hospitals, London, UK
- Cancer Institute, University College London, London, UK
| | - Maria Cuadrado
- Haematology Department, University College Hospitals, London, UK
| | - Elizabeth Phillips
- Division of Cancer Sciences, University of Manchester, Manchester Cancer Research Centre, Manchester, UK
| | - William Wilson
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, UK
| | - Richard Jenner
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, UK
| | - Gavin Pang
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, UK
| | - Sumaiya Kamora
- Cancer Research UK and UCL Cancer Trials Centre, University College London, London, UK
| | - Matthew Streetly
- Haematology Department, Guys and St Thomas' NHS Trust, London, UK
| | - Rakesh Popat
- Haematology Department, University College Hospitals, London, UK
- Cancer Institute, University College London, London, UK
| | | | - Roger Owen
- HMDS Laboratory, St James' Institute of Oncology, Leeds, UK
| | - James Cavenagh
- Haematology Department, Barts Health NHS Trust, London, UK
| | - Mike Chapman
- Haematology Department, Cambridge Institute for Medical Research, Cambridge, UK
| | - Jonathan Sive
- Haematology Department, University College Hospitals, London, UK
| | | | - Michael Sheaff
- Cellular Pathology Department, Barts Health NHS Trust, London, UK
| | | | - Karthik Ramasamy
- Haematology Department, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Gordon Cook
- Leeds Institute of Clinical Trial Research, University of Leeds, Leeds, UK
| | - Andres Virchis
- Haematology Department, Royal Free Hospitals NHS Trust, London, UK
| | - Selina J Chavda
- Haematology Department, University College Hospitals, London, UK
- Haematology Department, Guys and St Thomas' NHS Trust, London, UK
| | - Laura Clifton-Hadley
- Division of Cancer Sciences, University of Manchester, Manchester Cancer Research Centre, Manchester, UK
| | - Marie Anne Scully
- Haematology Department, University College Hospitals, London, UK
- Cardiometabolic Programme, NIHR UCLH/UCL Biomedical Research Centre, London, UK
| | - Kwee Yong
- Haematology Department, University College Hospitals, London, UK
- Haematology Department, Guys and St Thomas' NHS Trust, London, UK
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Venner CP, LeBlanc R, Sandhu I, White D, Belch AR, Reece DE, Chen C, Dolan S, Lalancette M, Louzada M, Kew A, McCurdy A, Monteith B, Reiman T, McDonald G, Sherry M, Gul E, Chen BE, Hay AE. Weekly carfilzomib plus cyclophosphamide and dexamethasone in the treatment of relapsed/refractory multiple myeloma: Final results from the MCRN-003/MYX.1 single arm phase II trial. Am J Hematol 2021; 96:552-560. [PMID: 33650179 DOI: 10.1002/ajh.26147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/29/2021] [Accepted: 02/14/2021] [Indexed: 11/09/2022]
Abstract
The MCRN-003/CCTGMYX.1 is a single arm phase II trial of weekly carfilzomib, cyclophosphamide and dexamethasone (wKCd), exploring a convenient immunomodulator (IMiD)-free regimen in relapsed myeloma. Weekly carfilzomib (20/70 mg/m2 ), dexamethasone 40 mg and cyclophosphamide 300 mg/m2 was delivered over 28-day cycles. The primary endpoint was overall response after four cycles. Secondary endpoints included toxicity, response depth, PFS and OS. Exploratory endpoints included the impact of cytogenetics, prior therapy exposure and serum free light chain (sFLC) escape; 76 patients were accrued. The ORR was 85% (68% ≥very good partial response [VGPR] and 29% ≥complete response [CR]). The median OS and PFS were 27 and 17 months respectively. High-risk cytogenetics conferred a worse ORR (75% vs. 97%, p = .013) and median OS (18 months vs. NR, p = .002) with a trend toward a worse median PFS (14 vs. 22 months, p = .06). Prior proteasome inhibitor (PI) or lenalidomide did not influence OS or PFS. The sFLC was noted in 15% of patients with a median PFS of 17 months when included as a progression event. The most common ≥ grade 3 non-hematologic adverse events were infectious (40%), vascular (17%) and cardiac (15%). The wKCD is a safe and effective regimen in relapse, especially for patients ineligible for lenalidomide-based therapies.
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Affiliation(s)
| | - Richard LeBlanc
- CIUSSS de lʼEst de lʼIle de Montréal Université de Montréal Montreal Quebec Canada
| | - Irwindeep Sandhu
- The Cross Cancer Institute University of Alberta Edmonton Alberta Canada
| | - Darrell White
- Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax Nova Scotia Canada
| | - Andrew R. Belch
- The Cross Cancer Institute University of Alberta Edmonton Alberta Canada
| | | | | | - Sean Dolan
- University of New Brunswick Saint John Regional Hospital Saint John New Brunswick Canada
| | | | - Martha Louzada
- London Regional Cancer Centre University of Western Ontario London Ontario Canada
| | - Andrea Kew
- The Ottawa Hospital University of Ottawa Ottawa Ontario Canada
| | - Arleigh McCurdy
- The Ottawa Hospital University of Ottawa Ottawa Ontario Canada
| | - Bethany Monteith
- Queenʼs University Canadian Cancer Trials Group Kingston Ontario Canada
| | - Tony Reiman
- University of New Brunswick Saint John Regional Hospital Saint John New Brunswick Canada
| | - Gail McDonald
- Queenʼs University Canadian Cancer Trials Group Kingston Ontario Canada
| | - Max Sherry
- Queenʼs University Canadian Cancer Trials Group Kingston Ontario Canada
| | - Engin Gul
- Canadian Myeloma Research Group (formerly the Myeloma Canada Research Network) Vaughan Ontario Canada
| | - Bingshu E. Chen
- Queenʼs University Canadian Cancer Trials Group Kingston Ontario Canada
| | - Annette E. Hay
- Queenʼs University Canadian Cancer Trials Group Kingston Ontario Canada
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Monteith BE, Venner CP, Reece DE, Kew AK, Lalancette M, Garland JS, Shepherd LE, Pater JL, Hay AE. Drug-induced Thrombotic Microangiopathy with Concurrent Proteasome Inhibitor Use in the Treatment of Multiple Myeloma: A Case Series and Review of the Literature. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e791-e800. [DOI: 10.1016/j.clml.2020.04.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 01/29/2023]
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