Advances in oral therapy for multiple myeloma

Patient-reported outcomes in drug development for hematology

Patient-reported outcomes (PROs) are any outcome evaluated directly by the patient himself and based on the patient's perception of a disease and its treatment(s). PROs are direct outcome measures that can be used as clinical meaningful endpoints to characterize treatment benefit. They provide unique and important information about the effect of treatment from a patient's view. However, PROs will only be considered adequate if the assessment is well-defined and reliable. In 2009, the FDA has issued a guidance, which defines good measurement principles to consider for PRO measures intended to give evidence of treatment benefit in drug development. In hematologic clinical trials, when applied rigorously, they may be used to evaluate overall treatment effectiveness, treatment toxicity, and quality of patient's well-being at short-term and long-term after treatment from a patient's perspective. In situations in which multiple treatment options exist with similar survival outcome or if a new therapeutic strategy needs to be evaluated, the inclusion of PROs as an endpoint can provide additional data and help in clinical decision making. Given the diversity of the hematological field, the approach to measurement needs to be tailored for each specific situation. The importance of PROs in hematologic diseases has been highlighted in a number of international recommendations. In addition, new perspectives in the regulatory field will enhance the inclusion of PRO endpoints in clinical trials in hematology, allowing the voice of the patients with hematologic diseases to be taken into greater consideration in the development of new drugs.

Baicalein decreases side population proportion via inhibition of ABCG2 in multiple myeloma cell line RPMI 8226 in vitro

OBJECTIVE

To investigate the effect of baicalein on side population in human multiple myeloma cell line RPMI 8226 and the underlying molecular mechanisms in vitro and in silico.

METHODS

MTT assay was applied to detect the anti-proliferation effect of baicalein. The detection of side population cells is based on the Hoechst 33342 exclusion assay technique and flow cytometric analysis. Western blotting assay was used to explore the expression of ABCG2 protein. Homology modeling and molecular docking were performed with Discovery Studio 2.1.

RESULTS

Baicalein decreased both cell viability with IC50=168.5 μM and the proportion of SP cells in a dose-dependent manner. Correspondingly, it significantly decreased the expression level of ABCG2 protein. Baicalein also shared similar binding sites and modes with fumitremorgin C to the protein.

CONCLUSIONS

Baicalein possessed novel anticancer properties, such as anti-proliferation and drug efflux inhibition in side population cells, which suggested its potential feature of targeting cancer stem cells of multiple myeloma.

Extramedullary relapse of multiple myeloma in the thyroid cartilage

Multiple myeloma involving the thyroid cartilage is a very uncommon disease entity. Only 10 cases have been reported in the international literature to date and as such it constitutes a rare and challenging diagnosis to make. We report the case of a 63-year-old man with a background of malignant melanoma and multiple myeloma both of which were in remission at the time of presentation. The patient presented with hoarseness and a large neck mass that turned out to be an extramedullary deposit of his previously treated multiple myeloma indicating disease relapse. The differential diagnosis of a mass in the thyroid cartilage is discussed. Despite its rarity, this diagnosis should be considered even in patients with no history of multiple myeloma, as it can arise de-novo in the thyroid cartilage (extramedullary plasmacytoma). The importance of the multidisciplinary team (MDT) approach as well as recent advances in treatment are also discussed.

Acceptance of oral chemotherapy in breast cancer patients - a survey study

Background

Oral (p.o.) chemotherapy treatments gained increasing importance in the palliative treatment of metastatic breast cancer (MBC). Aim of this survey was to evaluate the acceptance of p.o. treatment and patients' individual attitudes towards it.

Methods

A specific 14 item-questionnaire was designed. Patients suffering from breast cancer receiving a newly launched p.o. or i.v. chemotherapy treatment were prospectively evaluated during 4 months of time. 224 questionnaires using descriptive statistics, chi-square test, Spearman correlation were evaluated.

Results

Patients' median age was 54 years, 164 received i.v., 60 p.o therapy. 89% with p.o. and 67% with i.v. regimens would choose p.o. over i.v. therapy, if equal efficacy is guaranteed. Significant differences were especially found in terms of personal benefit (55% i.v., 92% p.o.), reduced feeling of being ill due to p.o. treatment (26% i.v., 65% p.o.), better coping with disease due to p.o. therapy (36% i.v., 68% p.o.). Side effects were significantly less often reported under p.o. treatment (19% p.o. vs. 53% i.v.)

Conclusion

P.o. chemotherapy shows a high acceptance in MBC patients under palliative therapy. Compliance can be achieved in particular through a differentiated indication, patient education and competent support along a p.o. treatment.

Synthesis of purin-2-yl and purin-6-yl-aminoglucitols as C-nucleosidic ATP mimics and biological evaluation as FGFR3 inhibitors

Two new series of C-nucleosidic ATP mimics have been synthesized using an efficient and versatile synthetic pathway. These compounds were designed as FGFR3 inhibitors using purine as a central scaffold. The two substituents, a polyhydroxylated ribose mimic and a lipophilic moiety, were linked either in position 2 or 6 of the purine ring in order to explore any possible binding mode. All the compounds were able to inhibit FGFR3 kinase activity at a concentration of 50 μM. Unexpectedly, the best inhibitor was found to be one of the synthetic intermediates 13 bearing an iodine atom in position 2. Docking studies have confirmed its location in the ATP binding site and revealed halogen bonding among key interactions.

Targeted therapy in haematological malignancies

The recent and rapid development of molecularly targeted therapy is best illustrated by advances in the management of haematological malignancy. In myeloid diseases we have seen dramatic improvements in the overall survival and quality of life for patients with chronic myeloid leukaemia treated with ABL and Src/ABL kinase inhibitors and we are poised to discover whether JAK2 inhibitors may offer similar benefit in myeloproliferative diseases. For acute myeloid leukaemia, the introduction of ATRA and myelotarg have had major impacts on the design of therapy regimens and many novel targeted agents, including farnesyl transferase, FLT3 and histone deacetylase inhibitors, are now in clinical trial. In lymphoid malignancies the highlight has been the introduction of rituximab, with significant improvements in the management of non-Hodgkin lymphoma and chronic lymphocytic leukaemia. The last 10 years has experienced a rapidly expanding interest and acceptance that leukaemic stem cells, including an improved ability to target them, may hold the key to improved response and reduced relapse rates across both myeloid and lymphoid disease. We now eagerly anticipate an era in which a wealth of preclinical discoveries are progressed to the clinic.

Disseminated Plasmacytoma of the Thyroid

Extramedullary plasmacytomas most commonly occur in the nasal cavity, nasopharynx, paranasal sinuses, and larynx. Thyroid involvement is rare, as fewer than 75 cases have been previously reported in the literature. We report a new case of disseminated plasmacytoma of the thyroid, which occurred in a 68-year-old woman. The diagnosis was made with an incisional biopsy. The patient initially experienced a complete response to radiotherapy (46.8Gy in 26 fractions), but she developed multiple metastases at distant sites, including the breast, abdominal wall, and buttock despite various chemotherapy regimens. Ultimately, she was placed on palliative radiotherapy. We also briefly review the diagnostic and treatment options for patients with extramedullary plasmacytoma.

Inhibitory effect of baicalein on IL-6-mediated signaling cascades in human myeloma cells

Interleukin-6 (IL-6) is an important growth factor for myeloma cells. IL-6 promotes the survival and proliferation of multiple myeloma (MM) cells through the phosphorylated proteins, including STAT3, MAPK, and Akt. Chemical components that suppress the signaling proteins' phosphorylation have a potential role for MM therapy. We recently identified that baicalein, a component of Scutellaria radix, suppressed proliferation and induced apoptosis of myeloma cells by blocking IkappaB-alpha degradation followed by down-regulating IL-6 and XIAP gene expression. In the present study of four myeloma cell lines, namely U266, NOP2, AMO1, and ILKM2, we demonstrated that baicalein not only inhibited IL-6-mediated phosphorylation of signaling proteins, such as Jak, STAT3, MAPK, and Akt, but also inhibited the expression of their target genes, such as bcl-xl. Finally, baicalein facilitated myeloma cell proliferation inhibited by dexamethasone. In contrast, baicalin, another major flavonoid derived from Scutellaria radix, had no significant effect on IL-6-mediated protein phosphorylation. Baicalein had no effect on Akt phosphorylation induced by the insulin-like growth factor-1 (IGF-1) in NOP2 cells. Compared with PD98059, an MAPK inhibitor, baicalein exhibited a stronger inhibitory effect on Erk(1/2) phosphorylation. Our results demonstrate that baicalein is a potent inhibitor of protein phosphorylation induced by IL-6, and thus may be a useful agent for the treatment of MM.

Thalidomide decreases gelatinase production by malignant B lymphoid cell lines through disruption of multiple integrin-mediated signaling pathways

BACKGROUND

Thalidomide and its analogs are effective agents in the treatment of multiple myeloma. Since gelatinases (matrix metalloproteinases-2 and -9) play a crucial role in tumor progression, we explored the effect of thalidomide on gelatinase production by malignant B lymphoid cell lines.

DESIGN AND METHODS

We investigated the effect of therapeutic doses of thalidomide on integrin-mediated production of gelatinases by malignant B lymphoid cell lines by gelatin zymography, western-blot, reverse transcriptase polymerase chain reaction and invasive capacity through Matrigel-coated Boyden chambers. We also explored the effect of thalidomide on the activation status of the main signaling pathways involved in this process.

RESULTS

Thalidomide strongly inhibited gelatinase production by B-cell lines and primary myeloma cells in response to fibronectin, the most efficient gelatinase inducer identified in lymphoid cells. Thalidomide disrupted integrin-mediated signaling pathways involved in gelatinase induction and release, such as Src and MAP-kinase ERK activation, resulting in decreased cell motility and invasiveness. Unexpectedly, treatment with thalidomide elicited an increase in fibronectin-induced Akt phosphorylation through phosphoinositide 3-kinase-independent pathways since thalidomide decreased fibronectin-induced phosphoinositide 3-kinase phosphorylation and reversed the inhibition of Akt phosphorylation achieved by the phosphoinositide 3-kinase inhibitors wortmannin and LY294002.

CONCLUSIONS

Disruption of integrin-mediated signaling may be an important mechanism through which thalidomide and its analogs impair tumor cell interactions with the microenvironment. The unexpected effects of thalidomide on Akt activation indicate the need for further studies to elucidate whether the interference with Akt downstream effects would synergize with the anti-tumor activity of thalidomide.

Targeted therapies in multiple myeloma

Increasing knowledge of the biology of multiple myeloma led the way for the development of novel drugs that have changed the management of the disease. New treatments target not only to the malignant plasma cell but also target the interactions of myeloma cells with their microenvironment. Several preclinical studies have identified potential targets and drugs are developed that act on pathways crucial for myeloma cell survival, proliferation, migration and drug resistance. The identification of active agents in the laboratory is followed by rationally designed clinical studies that validate these drugs, either as single agents or in combinations with other active drugs. These novel agents may be either small molecules or monoclonal antibodies targeting receptors, kinase activity of receptors or key molecules within critical pathways, intracellular maintenance mechanisms and immune modulation.

Current status of antivascular therapy and targeted treatment in the clinic

Antivascular and targeted therapy are now an integrated part of the treatment of myelogenous leukemias, GIST tumours, B-cell lymphomas and breast cancer. In various malignancies improved responses and prolongation of survival for several months is regularly reported. The progress in this field is relevant for hyperthermia. Heat has among other effects documented antivascular effects, and can be considered as one of the established methods in the field based on several randomised phase III studies. Hyperthermia should be considered for combination with other antiangiogenic agents.

Evaluation of the developmental toxicity of lenalidomide in rabbits

BACKGROUND

Lenalidomide, a thalidomide analog, is indicated for treatment of patients with deletion-5q myelodysplastic syndromes or multiple myeloma. NZW rabbits were used because of sensitivity to thalidomide's teratogenicity.

METHODS

Range-finding and pulse-dosing studies preceded a full developmental toxicity study in New Zealand white (NZW) rabbits (25/group) given lenalidomide (0, 3, 10, or 20 mg/kg/day) or thalidomide (180 mg/kg/day) by stomach tube on gestation days (GD) 7-19. Clinical signs, body weights, and feed consumption were recorded daily from GD 7. On GD 29, standard maternal necropsy, uterine content, and fetal evaluations were carried out.

RESULTS

In all studies, thalidomide was selectively toxic to development. In the pulse-dosing study, lenalidomide did not affect development at 100 mg/kg/day. Increases in C(max) and AUC(0-24 hr) values for lenalidomide were slightly less than dose-proportional; lenalidomide occurred in the fetuses. At 10 and 20 mg/kg/day, lenalidomide was maternally toxic (reduced body weight gain and feed consumption; at 20 mg/kg/day, weight loss and one abortion). Developmental toxicity at 10 and 20 mg/kg/day included reduced fetal body weights and increased postimplantation losses and fetal variations (morbidity/purple-discolored skin, undeveloped intermediate lung lobe, irregular nasal-frontal suture, and delayed metacarpal ossification). Thalidomide selectively reduced fetal body weight, increased postimplantation loss and caused characteristic limb and other dysmorphology.

CONCLUSIONS

The maternal and developmental NOAELs for lenalidomide are 3 mg/kg/day. Unlike thalidomide, lenalidomide affected embryo-fetal development only at maternally toxic dosages, confirming that structure-activity relationships may not predict maternal or developmental effects. No fetal malformations were attributable to lenalidomide.

[Multiple myeloma]

Multiple myeloma is the second most common hematological malignancy. It is defined by the presence of monoclonal plasma cells capable to produce a monoclonal paraprotein causing clinical abnormalities such as anemia, renal insufficiency, hypercalcemia, or bone lesions. New chromosomal or molecular abnormalities have been identified allowing a better management. Multiple myeloma is treatable and, although it remains incurable, the patient prognosis and quality of life has notably improved, so it is not rare to see series with a median survival longer than 5 years. Even more, it is possible by now to expect improvements respect to the standard autologous stem cell transplantation. This must be attributed to the emergence of a number of new therapies entering clinical practice over the last 6 years: thalidomide (Thalidomid Pharmion, Boulder, CO, USA), lenalidomide (Revlimid, Celgene Corporation, Summit, NJ, USA) and bortezomib (Velcade, Janssen Pharmaceutica N.V., Belgium). Finally, we also will review the current clinical experience in supportive therapy, which has also contributed to the patient outcome improvement with approaches such as: new indications for dialysis, use of erythropoietin receptor stimulating agents and bisphosphonates, and new surgical therapies such as vertebroplastia and kyphoplastia.

The treatment of the elderly multiple myeloma patients

Multiple myeloma (MM) is an incurable malignancy of the plasma cells. Most patients are diagnosed when they are older than 65 years. Therapeutic options include chemotherapy, using either established (e.g. melphalan) or newly available (e.g. thalidomide) drugs and high-dose treatment with stem-cell support (autologous as well as allogeneic). Recent research has focused on defining the target population for the different therapeutic approaches, taking into account pre-treatment characteristics of patients, particularly age, and aims to balance treatment benefit with potential adverse events. In this review we present the data available on the most recent trials dealing with the treatment of elderly MM patients.

Hypersensitivity pneumonitis-like syndrome associated with the use of lenalidomide

Lenalidomide is an immunomodulatory agent approved for use in patients with myelodysplastic syndrome, and in combination with dexamethasone for refractory or relapsed multiple myeloma. Pulmonary toxicity is believed to be uncommon. In this report, we describe a patient receiving lenalidomide in whom dyspnea, fever, hypoxia, and diffuse pulmonary infiltrates developed. BAL demonstrated a significant lymphocytic alveolitis typical for hypersensitivity pneumonitis. Extensive workup for other causes, including infections, was negative. Finally, the patient had improvement in symptoms and oxygenation after withdrawing lenalidomide and recurrence of symptoms when the drug was restarted. Thus, the patient's clinical course and workup strongly support a diagnosis of lenalidomide-induced hypersensitivity pneumonitis-like syndrome. Physicians should be cognizant of this potential complication in patients receiving thalidomide or thalidomide-like drugs who present with fever and pulmonary infiltrates and fail to improve despite treatment with broad-spectrum antibiotics.

Medical management update: Multiple myeloma

Multiple myeloma (MM) is a hematologic malignancy characterized by abnormal proliferation of immunoglobulin-secreting plasma cells. Manifestations of MM may include anemia, osteolytic lesions, and renal dysfunction. Treatment for this disease chiefly consists of corticosteroids, bisphosphonates, chemotherapy, and hematopoietic stem-cell transplantation. This medical management update will review recent clinical and therapeutic advances in the field of MM and highlight issues that are important to the oral health care provider.

Capecitabine in Combination with Novel Targeted Agents in the Management of Metastatic Breast Cancer: Underlying Rationale and Results of Clinical Trials

At present there is no established standard of care for metastatic breast cancer and prognosis remains poor, although the use of newer chemotherapeutic regimens has led to modest improvements in survival. Capecitabine, an oral prodrug of 5-fluorouracil, is a promising addition to these approaches, having already shown single-agent activity against metastatic breast cancer. Following a pivotal trial demonstrating that capecitabine confers increased survival when used in combination with docetaxel, it is being investigated intensively in combined regimens using other standard chemotherapeutic agents, as well as with novel molecularly targeted therapies. Among the novel agents, the most intensively studied in combination with capecitabine is trastuzumab. Despite preclinical data suggesting that these two agents might not show additive effects, clinical trials have been very encouraging for both heavily pretreated patients and for patients receiving first-line therapy in the metastatic setting. This work is being further extended in an ongoing trial in the neoadjuvant setting. An initial trial in combination with bevacizumab, enrolling heavily pretreated patients, was less successful, but following the example of the E2100 trial, this combination is being re-examined in less heavily treated patients. In addition, this review discusses ongoing trials with an array of newer molecularly targeted agents. Significant improvement in time to progression has already been demonstrated in the combination of lapatinib and capecitabine compared with capecitabine monotherapy; for the most part, however, these trials are still in early stages.

Part II: Spinal-cord neoplasms—primary tumours of the bony spine and adjacent soft tissues

Primary tumours of the bony spine and adjacent soft tissues most frequently present with pain although neurological deficits and spinal deformity can be present too. Knowledge of the spectrum of lesions that can affect the bony spine and the surrounding soft tissues is crucial in directing appropriate investigation and treatment. Patients need individualised approaches and treatment plans in view of the variations in tumour aggressiveness, spinal level, location within the vertebral body or posterior elements, involvement of soft tissues and structures surrounding the vertebral column, neurological deficits, and spinal instability.

Thalidomide Analogs from Diamines: Synthesis and Evaluation as Inhibitors of TNF-.ALPHA. Production

Fourteen thalidomide analogs bearing two phthalimido units were prepared in high yields (83-94%) by condensation of different diamines with phthalic or 3-nitrophthalic anhydride. An in vitro investigation of the compounds as inhibitors of the TNF-alpha production was performed. The inhibition was higher for compounds bearing amino and nitro groups and was modulated by increasing the size of the spacers between the phthalimide groups.

New frontiers in the treatment of multiple myeloma

Recent leaps in elucidating the biology of myeloma, particularly the intracellular pathways and the complex interaction with the bone marrow microenvironment, have resulted in an unprecedented surge of novel, targeted therapies and therapeutic regimens. There are currently over 30 new agents being tested in the treatment of multiple myeloma (MM). Many of these are novel, targeted agents that have demonstrated significant efficacy and prolonged survival. In this review, we summarize the current understanding of the mechanisms of action of novel therapies being tested in the preclinical and clinical settings in MM. These include agents that act directly on the intracellular signaling pathways, cell maintenance processes, and cell surface receptors. Finally, we present the clinical responses to some of these agents when used alone or in combination in clinical trials of patients with MM. Indeed, MM has become a model disease for the development of novel, therapeutic agents.

Effects of paraprotein heavy and light chain types and free light chain load on survival in myeloma: an analysis of patients receiving conventional-dose chemotherapy in Medical Research Council UK multiple myeloma trials

While investigating 2592 patients enrolled in multicenter myeloma trials, we found light chain–only (LCO) patients had worse median survival times (1.9 years) than patients with IgA and IgG paraproteins (2.3 and 2.5 years, respectively) (P < .001). However, IgA and IgG patients with levels of LC excretion similar to those of LCO patients also had poor survival times because of renal failure, resulting in worse survival during induction therapy and at relapse with no difference in progression-free survival between LCO and IgG patients. LC excretion was higher for λ than for κ types, but there was no difference in survival between the 2 LC types when stratified for level of LC excretion, indicating that care of renal function is vital to improving the survival of any patient with LC excretion. LCO patients were younger (P = .001), had worse performance status (P = .001), and had more lytic lesions (P < .001), perhaps reflecting late and missed diagnoses in younger and older LCO patients, respectively. No differences were observed between IgA and IgG patients in presentation characteristics, response, or survival from disease progression. The worse survival of IgA patients was attributed to shorter progression-free survival (median, 1.2 vs 1.6 years; P < .001), which is important for maintenance therapy.