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Perroud C, Thurian D, Andres M, Künzi A, Wiedemann G, Zeerleder S, Bacher U, Pabst T, Banz Y, Porret N, Rebmann E. Effect of MAPK activation via mutations in NRAS, KRAS and BRAF on clinical outcome in newly diagnosed multiple myeloma. Hematol Oncol 2023; 41:912-921. [PMID: 37452600 DOI: 10.1002/hon.3208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 07/02/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
Until now, next generation sequencing (NGS) data has not been incorporated into any prognostic stratification of multiple myeloma (MM) and no therapeutic considerations are based upon it. In this work, we correlated NGS data with (1) therapy response and survival parameters in newly diagnosed multiple myeloma, treated by VRd * and (2) MM disease stage: newly diagnosed multiple myeloma (ndMM) versus relapsed and/or refractory (relapsed/refractory multiple myeloma). We analyzed 126 patients, with ndMM and relapsed refractory multiple myeloma (rrMM), treated at the University Hospital of Bern (Inselspital). Next generation sequencing was performed on bone marrow, as part of routine diagnostics. The NGS panel comprised eight genes CCND1, DIS3, EGR1, FAM46C (TENT5C), FGFR3, PRDM1, TP53, TRAF3 and seven hotspots in BRAF, IDH1, IDH2, IRF4, KRAS, NRAS. The primary endpoint was complete remission (CR) after VRd in ndMM, in correlation with mutational profile. Mutational load was generally higher in rrMM, with more frequently mutated TP53: 11/87 (13%) in ndMM versus 9/11 (81%) in rrMM (OR 0.0857, p = 0.0007). In ndMM, treated by VRd, mutations in MAPK-pathway members (NRAS, KRAS or BRAF) were associated with reduced probability of CR (21/38, 55%), as compared with wild type NRAS, KRAS or BRAF (34/40, 85%; OR 0.2225, p = 0.006). NRAS c.181C > A (p.Q61K) as a single mutation event showed a trend to reduced probability of achieving CR (OR 0.0912, p = 0.0247). Activation of MAPK pathway via mutated NRAS, KRAS and BRAF genes seems to have a negative impact on outcome in ndMM patients receiving VRd therapy. VRd* - bortezomib (Velcade®), lenalidomide (Revlimid®) and dexamethasone.
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Affiliation(s)
- Camille Perroud
- Department of Hematology and Central Hematology Laboratory, Inselspital, University Hospital of Bern, Bern, Switzerland
- Department of Internal Medicine, Hôpital Cantonal Fribourgeois HFR, Fribourg, Switzerland
| | - Dario Thurian
- Department of Hematology and Central Hematology Laboratory, Inselspital, University Hospital of Bern, Bern, Switzerland
- Department of Internal Medicine, Spital Thun STS AG, Thun, Switzerland
| | - Martin Andres
- Department of Hematology and Central Hematology Laboratory, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Arnaud Künzi
- Clinical Trials Unit, University of Bern, Bern, Switzerland
| | - Gertrud Wiedemann
- Department of Hematology and Central Hematology Laboratory, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Sacha Zeerleder
- Department of Hematology, Kantonsspital Luzern and University of Bern, Luzern, Switzerland
| | - Ulrike Bacher
- Department of Hematology and Central Hematology Laboratory, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Thomas Pabst
- Department of Clinical Oncology, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Yara Banz
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Naomi Porret
- Department of Hematology and Central Hematology Laboratory, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Ekaterina Rebmann
- Department of Hematology and Central Hematology Laboratory, Inselspital, University Hospital of Bern, Bern, Switzerland
- Department of Oncology-Hematology, Hospital of Neuchâtel (RHNe), Neuchâtel, Switzerland
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Ren L, Ren Y, Yang Y, Wang W, Xu T, Wang Y, Xu J, Maihemaiti A, Lan T, Li P, Zhou C, Wang P, Liu P. Clinical profiles in multiple myeloma patients with extreme survivals: a study from a National Medical Center in China. Hematology 2023; 28:2277503. [PMID: 38018564 DOI: 10.1080/16078454.2023.2277503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/25/2023] [Indexed: 11/30/2023] Open
Abstract
OBJECTIVES The clinical outcomes of multiple myeloma (MM) patients are highly variable in the real-world setting. Some MM patients may have clinical endings that do not abide by the book. We aim to describe features of MM patients with extreme survivals in real-world practice. METHODS This retrospective study enrolled 941 patients consecutively visited a national medical center, China, between July 1995 and December 2021. Among patients, we identified two groups of MM patients with extreme survivals, 56 were in the long-term remission (LR) group with progression-free survival (PFS) ≥ 60 months, and 82 were in the rapid progression (RP) group with PFS ≤ 6 months. RESULTS CRAB features, of which hypercalcemia, renal insufficiency, and anemia were more common in the RP group, except for bone disease, with a comparable incidence at diagnosis in both groups (88.8 vs 85.7%, P = 0.52). High-risk cytogenetics was detected in 45.7% of patients in the RP group. Of note, 14.3% of MM patients in the LR group harbored del (17p). According to the Revised International Staging System (R-ISS), 9% of patients belonged to stage I in the RP group, and 19% of patients in the LR group were found in stage III. There were 8 (15.7%) patients in the LR group only achieved partial response (PR) as the best response. Median time to best response (TBR) for LR and RP group patients was 4.6 and 1.4 months, respectively. CONCLUSIONS The disparities in the survivals of MM patients indicated that some unexpected factors have influenced the outcomes in the real-world setting.
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Affiliation(s)
- Liang Ren
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Yuhong Ren
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Yang Yang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Wenjing Wang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Tianhong Xu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Yawen Wang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Jiadai Xu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Aziguli Maihemaiti
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Tianwei Lan
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Panpan Li
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Chi Zhou
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Pu Wang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Peng Liu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
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Yao W, Yang H, You H, Shang J, Zhai Y, Yan Z, Yan S, Shi X, Yao Y, Wang J, Wang P, Xu Y, Jin S, Yan L, Wu D, Fu C. The prognostic significance of circulating plasma cells in newly diagnosed multiple myeloma patients. Front Oncol 2023; 13:1266868. [PMID: 37799469 PMCID: PMC10548821 DOI: 10.3389/fonc.2023.1266868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/25/2023] [Indexed: 10/07/2023] Open
Abstract
Objective Multiple myeloma (MM) is a highly characteristic tumor that is influenced by numerous factors that determine its prognosis. Studies indicate that the presence of circulating plasma cells (cPCs) is a detrimental factor that significantly impacts the prognosis of patients with MM. Methods This study retrospectively analyzed the prognostic value of cPCs quantified by 10-color flow cytometry in 145 newly diagnosed MM (NDMM) cases in the First Affiliated Hospital of Soochow University from November 2018 to February 2021. The study was approved by the Ethics Committee of the hospital (2021 No. 93). Results Of the 145 patients, 99 (68.2%) were detected cPCs. Through receiver operating characteristics (ROC) analysis, an optimal threshold of 0.165% was identified as a predictor for overall survival (OS). The median progression-free survival (PFS) was 33 months in patients with cPCs ≥0.165%, whereas those with cPCs <0.165% had a PFS of <33 months (p=0.001). The median OS was not reached for two groups; the 3-year OS for patients with cPCs ≥0.165% was 71% compared with 87% for those with cPCs <0.165% (p=0.003). In transplant patients, cPCs ≥0.165% also predicted worse prognosis. Similarly, when considering cytogenetic risk factors in conjunction with cPC levels, comparable results were obtained. To evaluate whether the Revised International Staging System (R-ISS) groups could be further stratified based on different prognostic factors related to cPCs, our study revealed similar median PFS and OS rates in R-ISS II stage patients with cPCs ≥0.165% compared to those in the III stage (p=0.659 and 0.249, respectively). Conclusion This study demonstrates that a high ratio of cPCs serves as a reliable indicator for predicting a poorer prognosis in MM cases. Furthermore, incorporating the R-ISS system and cytogenetic risk factors alongside the level of cPCs enhances the accuracy of prognostic predictions for patients with MM.
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Affiliation(s)
- Weiqin Yao
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Haifei Yang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hongying You
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jingjing Shang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yingying Zhai
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhi Yan
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shuang Yan
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaolan Shi
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Ying Yao
- Suzhou Hongci, Hematology Hospital, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jing Wang
- Suzhou Hongci, Hematology Hospital, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Panfeng Wang
- Suzhou Hongci, Hematology Hospital, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yun Xu
- Suzhou Hongci, Hematology Hospital, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Song Jin
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Lingzhi Yan
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chengcheng Fu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, China
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Fitzpatrick MJ, Murali MR, Nardi V. Molecular Diagnostics of Plasma Cell Neoplasms. Surg Pathol Clin 2023; 16:401-410. [PMID: 37149365 DOI: 10.1016/j.path.2023.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
Genetic characterization of myeloma at diagnosis by interphase fluorescence in situ hybridization and next-generation sequencing (NGS) can assist with risk stratification and treatment planning. Measurable residual disease (MRD) status after treatment, as evaluated by next-generation flow cytometry or NGS on bone marrow aspirate material, is one of the most important predictors of prognosis. Less-invasive tools for MRD assessment such as liquid biopsy approaches have also recently emerged as potential alternatives.
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Schmidt TM. High or low? Assessing disease risk in multiple myeloma. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:349-355. [PMID: 36485159 PMCID: PMC9820796 DOI: 10.1182/hematology.2022000347] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Based upon the development of highly effective therapies such as immunomodulatory drugs, proteasome inhibitors, and monoclonal antibodies that target plasma cell biology, a dramatic improvement in overall survival has been observed for most patients with multiple myeloma (MM) over the past 2 decades. Although it is now commonplace for many patients with myeloma to live in excess of 10 years after diagnosis, unfortunately a large subset of patients continues to experience an aggressive disease course marked by substantial morbidity and early mortality. Many clinical biomarkers and staging systems in use today can help with prognostication, but accurate risk assessment can be difficult due to the presence of many different biomarkers with variable prognostic value. Furthermore, with the implementation of novel therapies and unprecedented rates of deep and durable responses, it is becoming apparent that risk assessment is best envisioned as a dynamic process that requires ongoing reevaluation. As risk and response-adapted approaches are becoming more commonplace, it is essential that clinicians understand the biological and prognostic implications of clinical, genomic, and response-based biomarkers in order to promote management strategies that will help improve both survival and quality of life for patients across the risk spectrum.
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Affiliation(s)
- Timothy Martin Schmidt
- Correspondence Timothy Martin Schmidt, University of Wisconsin, 600 Highland Avenue, K6/544 Clinical Sciences Center, MC5669, Madison, WI 53792; e-mail:
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Rebmann Chigrinova E, Porret NA, Andres M, Wiedemann G, Banz Y, Legros M, Pollak M, Oppliger Leibundgut E, Pabst T, Bacher U. Correlation of plasma cell assessment by phenotypic methods and molecular profiles by NGS in patients with plasma cell dyscrasias. BMC Med Genomics 2022; 15:203. [PMID: 36138464 PMCID: PMC9503268 DOI: 10.1186/s12920-022-01346-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 09/01/2022] [Indexed: 11/25/2022] Open
Abstract
Background Next-generation sequencing (NGS) detects somatic mutations in a high proportion of plasma cell dyscrasias (PCD), but is currently not integrated into diagnostic routine. We correlated NGS data with degree of bone marrow (BM) involvement by cytomorphology (BMC), histopathology (BMH), and multiparameter flow cytometry (MFC) in 90 PCD patients.
Methods Of the 90 patients the diagnoses comprised multiple myeloma (n = 77), MGUS (n = 7), AL-amyloidosis (n = 4) or solitary plasmocytoma (n = 2). The NGS panel included eight genes CCND1, DIS3, EGR1, FAM46C (TENT5C), FGFR3, PRDM1, TP53, TRAF3, and seven hotspots in BRAF, IDH1, IDH2, IRF4, KRAS, NRAS. Results Mutations were detected in 64/90 (71%) of cases. KRAS (29%), NRAS (16%) and DIS3 (16%) were most frequently mutated. At least one mutation/sample corresponded to a higher degree of BM involvement with a mean of 11% pathologic PC by MFC (range, 0.002–62%), and ~ 50% (3–100%) as defined by both BMC and BMH. Conclusions The probability of detecting a mutation by NGS in the BM was highest in samples with > 10% clonal PC by MFC, or > 20% PC by BMC/ BMH. We propose further evaluation of these thresholds as a practical cut-off for processing of samples by NGS at initial PCD diagnosis. Supplementary Information The online version contains supplementary material available at 10.1186/s12920-022-01346-1.
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Affiliation(s)
| | - Naomi A Porret
- Department of Hematology; Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Andres
- Department of Hematology; Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gertrud Wiedemann
- Department of Hematology; Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Yara Banz
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Myriam Legros
- Center for Laboratory Medicine (ZLM), Inselspital, University of Bern, Bern, Switzerland
| | - Matthias Pollak
- Department of Hematology; Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Thomas Pabst
- Department of Medical Oncology, Inselspital, University of Bern, Bern, Switzerland
| | - Ulrike Bacher
- Department of Hematology; Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Baumgart L, Barz M, Delbridge C, Aftahy AK, Janssen IK, Jost PJ, Ryang YM, Meyer B, Gempt J. Spinal Lesions as Clinical Manifestations of Plasma Cell Neoplasia. Curr Oncol 2022; 29:6236-6244. [PMID: 36135059 PMCID: PMC9497614 DOI: 10.3390/curroncol29090490] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/26/2022] [Accepted: 08/27/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Plasma cell neoplasia can be separated into independent subtypes including multiple myeloma (MM) and solitary plasmacytoma of the bone (SBP). The first clinical signs patients present with are skeletal pain, most commonly involving ribs and vertebrae. (2) Methods: Retrospective analysis of 114 patients (38 female, 76 male) receiving spinal surgery from March 2006 until April 2020. Neurological impairments and surgical instability were the criteria for intervention in this cohort. Analysis was based on demographic data, Spinal Instability Neoplastic Score (SINS), location of the lesion, spinal levels of tumor involvement, surgical treatment, histopathological workup, adjuvant therapy, functional outcome, and overall survival (OS). (3) Results: The following surgical procedures were performed: posterior stabilization only in 9 patients, posterior stabilization and decompression without vertebral body replacement in 56 patients, tumor debulking and decompression only in 8 patients, anterior approach in combined approach without vertebral body replacement and without biopsy and/or without kyphoplasty in 33 patients, 3 patients received biopsies only, and 5 patients received kyphoplasty only. The histopathology diagnoses were MM in 94 cases and SBP in 20 cases. Median OS was 72 months (53.4–90.6 months). Preoperative KPSS was 80% (range 40–100%), the postoperative KPSS was 80% (range 50–100%). (4) Conclusions: Surgery for patients with plasma cell neoplasia is beneficial in case of neurological impairment and spinal instability. Moreover, we were able to show that patients with MM and a low number of spinal levels to be supplied have a better prognosis as well as a younger age at the time of the surgical intervention.
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Affiliation(s)
- Lea Baumgart
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, 81675 Munich, Germany
- Correspondence:
| | - Melanie Barz
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, 81675 Munich, Germany
| | - Claire Delbridge
- Department of Neuropathology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, 81675 Munich, Germany
| | - Amir Kaywan Aftahy
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, 81675 Munich, Germany
| | - Insa Katrin Janssen
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, 81675 Munich, Germany
- Department of Neurosurgery, Hôpitaux Universitaires de Genève, 1205 Genève, Switzerland
| | - Philipp J. Jost
- III. Medical Department of Hematology and Oncology, Klinikum rechts der Isar, School of Medicine, Tech-nical University Munich, 81675 Munich, Germany
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Yu-Mi Ryang
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, 81675 Munich, Germany
- Department of Neurosurgery, Helios Klinikum Berlin Buch, 13125 Berlin, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, 81675 Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, 81675 Munich, Germany
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Rajkumar SV. Multiple myeloma: 2022 update on diagnosis, risk stratification, and management. Am J Hematol 2022; 97:1086-1107. [PMID: 35560063 DOI: 10.1002/ajh.26590] [Citation(s) in RCA: 204] [Impact Index Per Article: 102.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/05/2022] [Accepted: 05/06/2022] [Indexed: 12/22/2022]
Abstract
DISEASE OVERVIEW Multiple myeloma accounts for approximately 10% of hematologic malignancies. DIAGNOSIS The diagnosis requires ≥10% clonal bone marrow plasma cells or a biopsy-proven plasmacytoma plus evidence of one or more multiple myeloma defining events (MDE): CRAB (hypercalcemia, renal failure, anemia, or lytic bone lesions) attributable to the plasma cell disorder, bone marrow clonal plasmacytosis ≥60%, serum involved/uninvolved free light chain (FLC) ratio ≥ 100 (provided involved FLC is ≥100 mg/L), or >1 focal lesion on magnetic resonance imaging. RISK STRATIFICATION The presence of del(17p), t(4;14), t(14;16), t(14;20), gain 1q, or p53 mutation is considered high-risk multiple myeloma. The presence of any two high risk factors is considered double-hit myeloma, and three or more high risk factors is triple-hit myeloma. RISK-ADAPTED INITIAL THERAPY In patients who are candidates for autologous stem cell transplantation, induction therapy consists of bortezomib, lenalidomide, dexamethasone (VRd) given for approximately 3-4 cycles followed by autologous stem cell transplantation (ASCT). In high-risk patients, daratumumab, bortezomib, lenalidomide, dexamethasone (Dara-VRd) is an alternative to VRd. Selected standard-risk patients can collect stem cells, get additional cycles of induction therapy, and delay transplant until first relapse. Patients who are not candidates for transplant are treated with VRd for approximately 8-12 cycles followed by maintenance or alternatively with daratumumab, lenalidomide, dexamethasone (DRd) until progression. MAINTENANCE THERAPY Standard-risk patients need lenalidomide maintenance, while bortezomib plus lenalidomide maintenance is needed for high-risk myeloma. MANAGEMENT OF RELAPSED DISEASE A triplet regimen is usually needed at relapse, with the choice of regimen varying with each successive relapse.
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Bonello F, Cani L, D'Agostino M. Risk Stratification Before and During Treatment in Newly Diagnosed Multiple Myeloma: From Clinical Trials to the Real-World Setting. Front Oncol 2022; 12:830922. [PMID: 35356221 PMCID: PMC8959380 DOI: 10.3389/fonc.2022.830922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/08/2022] [Indexed: 12/22/2022] Open
Abstract
Multiple Myeloma (MM) is a hematologic malignancy characterized by a wide clinical and biological heterogeneity leading to different patient outcomes. Various prognostic tools to stratify newly diagnosed (ND)MM patients into different risk groups have been proposed. At baseline, the standard-of-care prognostic score is the Revised International Staging System (R-ISS), which stratifies patients according to widely available serum markers (i.e., albumin, β 2-microglobulin, lactate dehydrogenase) and high-risk cytogenetic abnormalities detected by fluorescence in situ hybridization. Though this score clearly identifies a low-risk and a high-risk population, the majority of patients are categorized as at “intermediate risk”. Although new prognostic factors identified through molecular assays (e.g., gene expression profiling, next-generation sequencing) are now available and may improve risk stratification, the majority of them need specialized centers and bioinformatic expertise that may preclude their broad application in the real-world setting. In the last years, new tools to monitor response and measurable residual disease (MRD) with very high sensitivity after the start of treatment have been developed. MRD analyses both inside and outside the bone marrow have a strong prognostic impact, and the achievement of MRD negativity may counterbalance the high-risk behavior identified at baseline. All these techniques have been developed in clinical trials. However, their efficient application in real-world clinical practice and their potential role to guide treatment-decision making are still open issues. This mini review will cover currently known prognostic factors identified before and during first-line treatment, with a particular focus on their potential applications in real-world clinical practice.
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Affiliation(s)
- Francesca Bonello
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Lorenzo Cani
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Mattia D'Agostino
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
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Abstract
Multiple myeloma is the second most common hematological malignancy in adults, accounting for 2% of all cancer-related deaths in the UK. Current chemotherapy-based regimes are insufficient, as most patients relapse and develop therapy resistance. This review focuses on current novel antibody- and aptamer-based therapies aiming to overcome current therapy limitations, as well as their respective limitations and areas of improvement. The use of computer modeling methods, as a tool to study and improve ligand-receptor alignments for the use of novel therapy development will also be discussed, as it has become a rapid, reliable and comparatively inexpensive method of investigation.
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Wallington-Beddoe CT, Mynott RL. Prognostic and predictive biomarker developments in multiple myeloma. J Hematol Oncol 2021; 14:151. [PMID: 34556161 PMCID: PMC8461914 DOI: 10.1186/s13045-021-01162-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 09/07/2021] [Indexed: 12/24/2022] Open
Abstract
New approaches to stratify multiple myeloma patients based on prognosis and therapeutic decision-making, or prediction, are needed since patients are currently managed in a similar manner regardless of individual risk factors or disease characteristics. However, despite new and improved biomarkers for determining the prognosis of patients, there is currently insufficient information to utilise biomarkers to intensify, reduce or altogether change treatment, nor to target patient-specific biology in a so-called predictive manner. The ever-increasing number and complexity of drug classes to treat multiple myeloma have improved response rates and so clinically useful biomarkers will need to be relevant in the era of such novel therapies. Therefore, the field of multiple myeloma biomarker development is rapidly progressing, spurred on by new technologies and therapeutic approaches, and underpinned by a deeper understanding of tumour biology with individualised patient management the goal. In this review, we describe the main biomarker categories in multiple myeloma and relate these to diagnostic, prognostic and predictive applications. ![]()
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Affiliation(s)
- Craig T Wallington-Beddoe
- College of Medicine and Public Health, Level 4, Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, SA, 5042, Australia. .,Flinders Medical Centre, Bedford Park, SA, 5042, Australia. .,Centre for Cancer Biology, SA Pathology and The University of South Australia, Adelaide, SA, 5000, Australia. .,Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, 5000, Australia.
| | - Rachel L Mynott
- College of Medicine and Public Health, Level 4, Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, SA, 5042, Australia
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12
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da Cunha AD, Silveira MN, Takahashi MES, de Souza EM, Mosci C, Ramos CD, Brambilla SR, Pericole FV, Prado CM, Mendes MCS, Carvalheira JBC. Adipose tissue radiodensity: A new prognostic biomarker in people with multiple myeloma. Nutrition 2021; 86:111141. [PMID: 33596528 DOI: 10.1016/j.nut.2021.111141] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 12/19/2020] [Accepted: 12/29/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Standard prognostic markers based on individual characteristics of individuals with multiple myeloma (MM) remain scarce. Body-composition features have often been associated with survival outcomes in different cancers. However, the association of adipose tissue radiodensity with MM prognosis has not yet, to our knowledge, been explored. METHODS Computed tomography at the third lumbar vertebra was used for body-composition analysis, including adipose tissue radiodensity, in 91 people with MM. Additionally, fludeoxyglucose F 18 (18F-FDG) positron emission tomography was used to assess adipose tissue 18F-FDG uptake. Proinflammatory cytokine and adipokine levels were measured. RESULTS Event-free survival and overall survival were both shorter in participants with high subcutaneous adipose tissue (SAT) radiodensity. Those in the highest SAT radiodensity tertile had an independently higher risk for both overall survival (hazard ratio, 4.55; 95% confidence interval, 1.26-16.44; Ptrend = 0.036) and event-free survival (hazard ratio, 3.08; 95% confidence interval, 1.02-9.27; Ptrend = 0.035). Importantly, higher SAT radiodensity was significantly correlated with increased 18F-FDG adipose tissue uptake and proinflammatory cytokine (tumor necrosis factor and interleukin-6) levels, and with decreased leptin levels. CONCLUSIONS SAT radiodensity may serve as a biomarker to predict host-related metabolic and proinflammatory milieu, which ultimately correlates with MM prognosis.
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Affiliation(s)
- Ademar Dantas da Cunha
- Division of Oncology, Department of Internal Medicine, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil; Hematology and Oncology Clinics, Cancer Hospital of Cascavel, União Oeste de Estudos e Combate ao Câncer (UOPECCAN), Cascavel, Brazil; Department of Internal Medicine, State University of Western Paraná (UNIOESTE), Cascavel, Brazil
| | - Marina Nogueira Silveira
- Division of Oncology, Department of Internal Medicine, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | | | - Edna Marina de Souza
- Center of Biomedical Engineering, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Camila Mosci
- Division of Nuclear Medicine, Department of Radiology, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Celso Dario Ramos
- Division of Nuclear Medicine, Department of Radiology, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Sandra Regina Brambilla
- Division of Oncology, Department of Internal Medicine, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Fernando Vieira Pericole
- Hematology and Blood Transfusion Center, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Carla M Prado
- Human Nutrition Research Unit, Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Maria Carolina Santos Mendes
- Division of Oncology, Department of Internal Medicine, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | - José Barreto Campello Carvalheira
- Division of Oncology, Department of Internal Medicine, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil.
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13
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Galieni P, Travaglini F, Vagnoni D, Ruggieri M, Caraffa P, Bigazzi C, Falcioni S, Picardi P, Mazzotta S, Troiani E, Dalsass A, Mestichelli F, Angelini M, Camaioni E, Maravalle D, Angelini S, Pezzoni V. The detection of circulating plasma cells may improve the Revised International Staging System (R-ISS) risk stratification of patients with newly diagnosed multiple myeloma. Br J Haematol 2021; 193:542-550. [PMID: 33792026 DOI: 10.1111/bjh.17118] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/02/2020] [Indexed: 11/25/2022]
Abstract
The Revised International Staging System (R-ISS) stratifies patients affected by Multiple Myeloma (MM) into three distinct risk groups: R-ISS I [ISS Stage I, Standard-Risk cytogenetics and normal Lactase DeHydrogenase (LDH)], R-ISS III (ISS stage III and either high-risk cytogenetics or high LDH) and R-ISS II (any other characteristics). With the aim to verify whether the three R-ISS groups could be divided into subgroups with different prognostic factors based on the detection of Circulating Plasma Cells (CPCs) at diagnosis, in this retrospective analysis, we evaluated 161 patients with MM treated at our centre between 2005 and 2017. In all, 57 patients (33·9%) were staged as R-ISS III, 98 (58·3%) as R-ISS II and six (3·6%) as R-ISS I. CPCs were detected in 125 patients (74·4%), while in 43 patients (25·6%) no CPCs were seen. Our analysis revealed that Overall Survival (OS) and progression-free survival (PFS) rates in R-ISS II patients were higher in the subgroup without CPCs compared to the subgroup with ≥1 CPCs (OS: 44·7% vs. 16·3%, P = 0·0089; PFS: 27·8% vs. 8·1%, P = 0·0118). Our present findings suggest that the detection of CPCs at diagnosis may be used as a further prognostic biomarker to improve the risk stratification of patients with MM staged as R-ISS II.
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Affiliation(s)
- Piero Galieni
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Fosco Travaglini
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Davide Vagnoni
- UOC Clinical Pathology, ASUR Marche, Civitanova Marche Hospital, Costamartina, Italy
| | - Miriana Ruggieri
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Patrizia Caraffa
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Catia Bigazzi
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Sadia Falcioni
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Paola Picardi
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Serena Mazzotta
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Emanuela Troiani
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Alessia Dalsass
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Francesca Mestichelli
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Mario Angelini
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Elisa Camaioni
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Denise Maravalle
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Stefano Angelini
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Valerio Pezzoni
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
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14
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Paquin A, Visram A, Kumar SK, Gertz MA, Cantwell H, Buadi FK, Lacy MQ, Dispenzieri A, Dingli D, Hwa L, Fonder A, Hobbs M, Hayman SR, Lust JA, Russell SJ, Leung N, Kapoor P, Go RS, Lin Y, Gonsalves WI, Kourelis T, Warsame R, Kyle RA, Rajkumar SV. Characteristics of exceptional responders to autologous stem cell transplantation in multiple myeloma. Blood Cancer J 2020; 10:87. [PMID: 32859899 PMCID: PMC7455690 DOI: 10.1038/s41408-020-00353-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 08/06/2020] [Accepted: 08/17/2020] [Indexed: 11/09/2022] Open
Abstract
Autologous stem cell transplantation (ASCT) is an important treatment modality in multiple myeloma (MM). However, relapse following ASCT is considered almost inevitable. This study aimed to characterize exceptional responders to ASCT, defined as progression-free survival (PFS) >8 years in the absence of maintenance therapy. We retrospectively analyzed patients treated at Mayo Clinic between August 1, 1998 and January 3, 2006, and included those with symptomatic MM, treated with an ASCT within 12 months of diagnosis. We found that 46 (9%) of the 509 patients who underwent ASCT during the study period were exceptional responders. The median duration of follow-up from diagnosis was 16.2 (interquartile range 14.3–17.7) years. The best response to therapy was a complete response (CR) or better in 34 (74%) of patients, and less than a CR in 12 (26%) of patients. The median PFS was 13.8 (95% confidence interval 10.5–18.5) years, and at the time of the last hematology assessment, 24 of 46 (52%) patients remained in remission. In conclusion, we showed that a small subset of patients with MM attains durable disease control without maintenance therapy post ASCT. Pre-emptive identification of these patients may help prevent undue toxicities and costs of subsequent therapy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Yi Lin
- Mayo Clinic, Rochester, MN, USA
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15
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Jo A, Jung JY, Lee SY, Lee SE, Park H, Lee SE, Min CK. Prognosis Prediction in Initially Diagnosed Multiple Myeloma Patients Using Intravoxel Incoherent Motion-Diffusion Weighted Imaging and Multiecho Dixon Imaging. J Magn Reson Imaging 2020; 53:491-501. [PMID: 32812318 DOI: 10.1002/jmri.27321] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Multiparametric MRI provides complementary information for the diagnosis and management of multiple myeloma (MM). PURPOSE To evaluate the association of prognostic factors of MM and parameters derived from intravoxel-incoherent motion diffusion-weighted imaging (IVIM-DWI) and multiecho (ME) Dixon. STUDY TYPE Retrospective. POPULATION In all, 78 MM patients. FIELD STRENGTH/SEQUENCES T1 -weighted turbo spin-echo sequences (TSE), IVIM-DWI, ME 3D gradient echo sequence with multistep adaptive fitting at 3T. ASSESSMENT The region of interest (ROI) on the vertebral body was independently measured on four parametric maps (Dslow , Dfast and perfusion fraction [f], and proton-density fat-fraction [Ff] maps) by two readers. All patients were categorized into three groups based on the International Staging System (ISS). STATISTICAL TESTS Three groups were compared using analysis of variance (ANOVA) and post-hoc tests with Bonferroni correction. Logistic regression analysis was performed to predict the advancement of disease (early vs. advanced). Principal component analysis (PCA) was used to find the deterministic parameters. RESULTS Dslow and Ff were significantly different among ISS-1 (n = 38), ISS-2 (n = 22), and ISS-3 (n = 18) groups in both readers: 0.36, 0.41, and 0.58 × 10-3 mm2 /s for Dslow (P < 0.05), and 46%, 30%, and 15% for Ff (P < 0.05) in reader 1; 0.34, 0.41, and 0.58 × 10-3 mm2 /s for Dslow (P < 0.05), 43%, 27%, and 13.2% for Ff (P < 0.05) in reader 2, respectively. Dfast between ISS-3 and the other groups was significantly different in one reader only: 2.03, 2.29, and 2.85 × 10-3 mm2 /s (P < 0.05). There was no significant difference in f among the groups in both readers. Logistic regression by stepwise selection indicated Ff as the single most significant factor for differentiating early and advanced stages of MM with an accuracy of 76% and area under the curve (AUC) of 0.83 (P < 0.05). PCA revealed Ff, and Dslow as the deterministic parameters, with a cumulative proportion of 0.84. DATA CONCLUSION D slow and Ff are associated with the prognostic factor of MM. Level of Evidence 3 Technical Efficacy Stage 5. J. MAGN. RESON. IMAGING 2021;53:491-501.
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Affiliation(s)
- Aram Jo
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joon-Yong Jung
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - So-Yeon Lee
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung Eun Lee
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyerim Park
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Eun Lee
- Department of Hematology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chang-Ki Min
- Department of Hematology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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16
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Rajkumar SV. Multiple myeloma: 2020 update on diagnosis, risk-stratification and management. Am J Hematol 2020; 95:548-567. [PMID: 32212178 DOI: 10.1002/ajh.25791] [Citation(s) in RCA: 443] [Impact Index Per Article: 110.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/18/2020] [Indexed: 12/11/2022]
Abstract
DISEASE OVERVIEW Multiple myeloma accounts for approximately 10% of hematologic malignancies. DIAGNOSIS The diagnosis requires ≥10% clonal bone marrow plasma cells or a biopsy proven plasmacytoma plus evidence of one or more multiple myeloma defining events (MDE) namely CRAB (hypercalcemia, renal failure, anemia, or lytic bone lesions) features felt related to the plasma cell disorder, bone marrow clonal plasmacytosis ≥60%, serum involved/uninvolved free light chain (FLC) ratio ≥100 (provided involved FLC is ≥100 mg/L), or >1 focal lesion on magnetic resonance imaging (MRI). RISK STRATIFICATION The presence of del(17p), t(4;14), t(14;16), t(14;20), gain 1q, or p53 mutation is considered high-risk multiple myeloma. Presence of any two high risk factors is considered double-hit myeloma; three or more high risk factors is triple-hit myeloma. RISK-ADAPTED INITIAL THERAPY In transplant eligible patients, induction therapy consists of bortezomib, lenalidomide, dexamethasone (VRd) given for approximately 3-4 cycles followed by autologous stem cell transplantation (ASCT). In high-risk patients, daratumumab, bortezomib, lenalidomide, dexamethasone (Dara-VRd) is an alternative to VRd. Selected standard risk patients can get additional cycles of induction, and delay transplant until first relapse. Patients not candidates for transplant are typically treated with VRd for approximately 8-12 cycles followed by lenalidomide; alternatively these patients can be treated with daratumumab, lenalidomide, dexamethasone (DRd). MAINTENANCE THERAPY After ASCT, standard risk patients need lenalidomide maintenance, while bortezomib-based maintenance is needed for patients with high-risk myeloma. MANAGEMENT OF REFRACTORY DISEASE Most patients require a triplet regimen at relapse, with the choice of regimen varying with each successive relapse.
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17
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Abuelgasim KA, Alherz N, Alhejazi A, Damlaj M. Venetoclax in combination with carfilzomib and dexamethasone in relapsed/refractory multiple myeloma harboring t(11,14)(q13;q32): two case reports and a review of the literature. J Med Case Rep 2020; 14:54. [PMID: 32321588 PMCID: PMC7178736 DOI: 10.1186/s13256-020-02376-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/19/2020] [Indexed: 01/10/2023] Open
Abstract
Background Multiple myeloma has witnessed significant advances due to the approval of many novel agents. However, in spite of all these new developments, multiple myeloma remains an incurable disease with inevitable relapse in the majority of patients. Venetoclax is a selective antiapoptotic protein B-cell lymphoma 2 inhibitor that induces cell death in multiple myeloma cells, particularly in those harboring t(11,14)(q13;q32). We report two cases of patients with multiple myeloma with t(11,14)(q13;q32) who were treated with venetoclax/carfilzomib/dexamethasone with rapid initial response; however, the response was short-lived. Cases presentation Patient 1 was a 50-year-old Saudi man with International Staging System stage III kappa light chain multiple myeloma with normal karyotype diagnosed in May 2013. He received bortezomib/thalidomide/dexamethasone treatment and underwent autologous hematopoietic stem cell transplant. Three years later, he presented with disease progression and received multiple lines of chemotherapy, including carfilzomib/lenalidomide/dexamethasone. Venetoclax/carfilzomib/dexamethasone was started after acquiring t(11,14)(q13;q32) 5 years into his disease course. He achieved complete remission, with disease progression after cycle 6. Patient 2 was a 48-year-old Saudi man with International Staging System stage III immunoglobulin G kappa multiple myeloma with t(11,14)(q13;q32) diagnosed in May 2017. He received bortezomib/thalidomide/dexamethasone treatment and underwent autologous hematopoietic stem cell transplant. Eighteen months later, he had disease progression, and he received multiple lines of chemotherapy, including carfilzomib/dexamethasone. He was shifted to venetoclax/carfilzomib/dexamethasone in April 2019 and had an initial clinical response; two months later, he progressed to plasma cell leukemia with rapid deterioration to multiorgan failure. Conclusions Acquired t(11;14)(q13;q32) is unreported in the multiple myeloma literature. In the era of targeted therapy, it is essential to repeat the cytogenetic and multiple myeloma fluorescence in situ hybridization panel with each disease progression. Multiple myeloma remains a challenging hematological malignancy despite advances in personalized/precision medicine.
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Affiliation(s)
- Khadega A Abuelgasim
- King Abdullah International Medical Research Center, Riyadh, 11481, Saudi Arabia. .,Oncology Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, 11426, Saudi Arabia. .,King Saud bin Abdulaziz University for Health Sciences, Riyadh, 14611, Saudi Arabia.
| | - Noha Alherz
- Oncology Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, 11426, Saudi Arabia
| | - Ayman Alhejazi
- King Abdullah International Medical Research Center, Riyadh, 11481, Saudi Arabia.,Oncology Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, 11426, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, 14611, Saudi Arabia
| | - Moussab Damlaj
- King Abdullah International Medical Research Center, Riyadh, 11481, Saudi Arabia.,Oncology Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, 11426, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, 14611, Saudi Arabia
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18
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Mass cytometry dissects T cell heterogeneity in the immune tumor microenvironment of common dysproteinemias at diagnosis and after first line therapies. Blood Cancer J 2019; 9:72. [PMID: 31462637 PMCID: PMC6713712 DOI: 10.1038/s41408-019-0234-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 07/26/2019] [Indexed: 12/14/2022] Open
Abstract
Dysproteinemias progress through a series of clonal evolution events in the tumor cell along with the development of a progressively more “permissive” immune tumor microenvironment (iTME). Novel multiparametric cytometry approaches, such as cytometry by time-of-flight (CyTOF) combined with novel gating algorithms can rapidly characterize previously unknown phenotypes in the iTME of tumors and better capture its heterogeneity. Here, we used a 33-marker CyTOF panel to characterize the iTME of dysproteinemia patients (MGUS, multiple myeloma—MM, smoldering MM, and AL amyloidosis) at diagnosis and after standard of care first line therapies (triplet induction chemotherapy and autologous stem cell transplant—ASCT). We identify novel subsets, some of which are unique to the iTME and absent from matched peripheral blood samples, with potential roles in tumor immunosurveillance as well as tumor immune escape. We find that AL amyloidosis has a distinct iTME compared to other dysproteinemias with higher myeloid and “innate-like” T cell subset infiltration. We show that T cell immune senescence might be implicated in disease pathogenesis in patients with trisomies. Finally, we demonstrate that the early post-ASCT period is associated with an increase of senescent and exhausted subsets, which might have implications for the rational selection of post-ASCT therapies.
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19
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Hájek R, Delforge M, Raab MS, Schoen P, DeCosta L, Spicka I, Radocha J, Pour L, Gonzalez-McQuire S, Bouwmeester W. Development and validation of a novel risk stratification algorithm for relapsed multiple myeloma. Br J Haematol 2019; 187:447-458. [PMID: 31388996 PMCID: PMC6899684 DOI: 10.1111/bjh.16105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/11/2019] [Indexed: 01/07/2023]
Abstract
Multiple myeloma (MM) is a malignancy with varying survival outcomes and drivers of disease progression. Existing MM staging tools were developed using data from newly diagnosed patients. As patient characteristics and disease‐related factors change between diagnosis and the initiation of second‐line (2L) treatment, an unmet need exists for a tool that can evaluate risk of death at first relapse. We have developed a risk stratification algorithm (RSA) using data from patients with MM who were at 2L. Hazard ratios for independent predictors of overall survival (OS) were derived from a Cox models, and individual patient scores were calculated for total risk. K‐adaptive partitioning for survival was used to stratify patients into groups based on their scores. Relative risk doubled with ascending risk group; median OSs for patients in group 1 (lowest risk)–4 (highest risk) were 61·6, 29·6, 14·2 and 5·9 months, respectively. Differences in OS between risk groups were significant. Similar stratification was observed when the RSA was applied to an external validation data set. In conclusion, we have developed a validated RSA that can quantify total risk, frailty risk and disease aggressiveness risk, and stratify patients with MM at 2L into groups with profoundly different survival expectations.
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Affiliation(s)
- Roman Hájek
- Department of Haemato-oncology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Michel Delforge
- Department of Haematology, University Hospital Leuven, Leuven, Belgium
| | - Marc S Raab
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | | | | | - Ivan Spicka
- 1st Medical Department - Clinical Department of Haematology, 1st Faculty of Medicine and General Teaching Hospital, Charles University, Prague, Hradec Králové, Czech Republic
| | - Jakub Radocha
- 4th Department of Medicine - Haematology, Charles University Hospital and Faculty of Medicine Hradec Králové, Hradec Králové, Czech Republic
| | - Ludek Pour
- Department of Internal Medicine, Haematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
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20
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Gassiot S, González Y, Morgades M, Motlló C, Clapés V, Maluquer C, Ibarra G, Abril L, Ribera JM, Oriol A. Response to First Cycle Is the Major Predictor of Long-Term Response to Lenalidomide and Dexamethasone Therapy in Relapsed and Refractory Multiple Myeloma: Can We Spare Patients the Toxicity and Costs of Additional Agents? CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:585-592.e1. [PMID: 31255588 DOI: 10.1016/j.clml.2019.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/30/2019] [Accepted: 05/26/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Lenalidomide plus dexamethasone (Ld) is still considered an option of care for some selected patients with relapsed or refractory multiple myeloma (RRMM), despite the proven superiority of lenalidomide-based triplet therapy. Up to 20% of patients obtain long-term benefit from Ld alone. The aim of this multicenter retrospective study was to identify and characterize those with good response to Ld salvage therapy, defined as progression-free survival lasting more than 24 months. PATIENTS AND METHODS Patients treated with Ld in a consortium of 3 tertiary-care hospitals (Institut Català d'Oncologia) between 2009 and 2016 were prospectively registered; 227 patients had evaluable data. RESULTS In multivariate analysis, obtaining partial response after the first therapy cycle was the main independent factor associated with progression-free survival lasting more than 24 months. Together with standard risk cytogenetics, partial response after first cycle was also independently associated with a higher rate of complete response. Previous plasma-cell dyscrasia remained as the only baseline characteristic independently associated with long-lasting responses. High-risk cytogenetics and no history of monoclonal gammopathy of undetermined significance were the only statistically significant negative prognostic factors for overall survival. Patients who had received only one prior therapy showed a trend toward higher overall survival. CONCLUSION If Ld is to be considered a treatment choice, at least a partial response should be obtained after the first therapy cycle to maintain double-agent therapy safely.
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Affiliation(s)
- Susanna Gassiot
- Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Leukaemia Research Institute, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Yolanda González
- Institut Català d'Oncologia, Hospital Josep Trueta, Girona, Spain
| | - Mireia Morgades
- Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Leukaemia Research Institute, Badalona, Spain
| | - Cristina Motlló
- Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Leukaemia Research Institute, Badalona, Spain
| | - Victòria Clapés
- Institut Català d'Oncologia, Hospital Duran i Reynals, L'Hospitalet de Llobregat, Llobregat, Spain
| | - Clara Maluquer
- Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Leukaemia Research Institute, Badalona, Spain
| | - Gladys Ibarra
- Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Leukaemia Research Institute, Badalona, Spain
| | - Laura Abril
- Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Leukaemia Research Institute, Badalona, Spain
| | - Josep-Maria Ribera
- Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Leukaemia Research Institute, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Albert Oriol
- Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Josep Carreras Leukaemia Research Institute, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
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Lê GN, Bones J, Coyne M, Bazou D, Dowling P, O'Gorman P, Larkin AM. Current and future biomarkers for risk-stratification and treatment personalisation in multiple myeloma. Mol Omics 2019; 15:7-20. [PMID: 30652172 DOI: 10.1039/c8mo00193f] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Multiple myeloma, an incurable malignancy of the plasma cells in the bone marrow, has a complex pathogenesis due to clonal heterogeneity. Over the years, many clinical trials and researches have led to the development of effective myeloma treatments, resulting in survival prolongation. Molecular prognostic markers for risk-stratification to predict survival, and predictive markers for treatment response are being extensively explored. This review discusses the current risk-adaptive strategies based on genetic and molecular risk signatures that are in practice to predict survival and describes the future prognostic and predictive biomarkers across the fields of genomics, proteomics, and glycomics in myeloma. Gene expression profiling and next generation sequencing are coming to the forefront of risk-stratification and therapeutic-response prediction. Similarly, proteomic and glycomic-based platforms are gaining momentum in biomarker discovery to predict drug resistance and disease progression.
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Affiliation(s)
- Giao N Lê
- NIBRT - The National Institute for Bioprocessing Research and Training, Foster Avenue, Mount Merion, Blackrock Co., Dublin A94 X099, Ireland.
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Alahmadi M, Masih-Khan E, Atenafu EG, Chen C, Kukreti V, Tiedemann R, Trudel S, Reece DE. Addition of Cyclophosphamide "On Demand" to Lenalidomide and Corticosteroids in Patients With Relapsed/Refractory Multiple Myeloma-A Retrospective Review of a Single-center Experience. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 19:e195-e203. [PMID: 30723035 DOI: 10.1016/j.clml.2018.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/30/2018] [Accepted: 12/12/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The combination of lenalidomide and dexamethasone (Len-Dex) is an established regimen for patients with relapsed or refractory myeloma. To prolong the benefit of this effective regimen, the Myeloma Program at Princess Margaret Cancer Centre has routinely added a third agent, oral cyclophosphamide (Cy) given weekly, to Len-Dex at disease progression. PATIENTS AND METHODS In the present report, we describe the cases of 53 patients who had received Len-Dex-Cy for a minimum of 4 weeks from January 2007 to December 2014 after progression with Len-Dex alone. The dose of added Cy ranged from 250 to 500 mg weekly. The median number of previous regimens, including Len-Dex, was 2 (range, 2-4); 80% of patients had undergone previous autologous stem cell transplantation. RESULTS The overall rate of response equal to or greater than a partial response was 34%, and clinical benefit (stable disease or better) was observed in 87% of the patients. The median duration of Len-Dex-Cy therapy was 6.9 months (range, 0.9-55.1 months). The median progression-free survival was 6.1 months (range, 4.2-8.1 months) from the addition of Cy and 24.1 months (range, 15.9-32.0 months) from start of Len-Dex. CONCLUSION The addition of Cy for patients with myeloma developing progression with Len-Dex was an inexpensive option with manageable toxicity that resulted in a clinically meaningful extension of disease control.
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Affiliation(s)
- Majed Alahmadi
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Esther Masih-Khan
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Christine Chen
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Vishal Kukreti
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Rodger Tiedemann
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Suzanne Trudel
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Donna E Reece
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.
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Pugh TJ, Fink JM, Lu X, Mathew S, Murata-Collins J, Willem P, Fang M. Assessing genome-wide copy number aberrations and copy-neutral loss-of-heterozygosity as best practice: An evidence-based review from the Cancer Genomics Consortium working group for plasma cell disorders. Cancer Genet 2018; 228-229:184-196. [DOI: 10.1016/j.cancergen.2018.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 07/16/2018] [Accepted: 07/30/2018] [Indexed: 12/28/2022]
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Multiple myeloma: 2018 update on diagnosis, risk‐stratification, and management. Am J Hematol 2018; 93:981-1114. [PMID: 30400719 PMCID: PMC6223128 DOI: 10.1002/ajh.25117] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 04/17/2018] [Indexed: 12/22/2022]
Abstract
Disease overview Multiple myeloma accounts for approximately 10% of hematologic malignancies. Diagnosis The diagnosis requires ≥10% clonal bone marrow plasma cells or a biopsy proven plasmacytoma plus evidence of one or more multiple myeloma defining events (MDE): CRAB (hyperc alcemia, r enal failure, a nemia, or lytic b one lesions) features felt related to the plasma cell disorder, bone marrow clonal plasmacytosis ≥60%, serum involved/uninvolved free light chain (FLC) ratio ≥100 (provided involved FLC is ≥100 mg/L), or >1 focal lesion on magnetic resonance imaging. Risk stratification Patients with del(17p), t(14;16), and t(14;20) have high-risk multiple myeloma. Patients with t(4;14) translocation and gain(1q) have intermediate-risk. All others are considered standard-risk. Risk-adapted initial therapy Initial treatment consists of bortezomib, lenalidomide, dexamethasone (VRd). In high-risk patients, carfilzomib, lenalidomide, dexamethasone (KRd) is an alternative to VRd. In eligible patients, initial therapy is given for approximately 3–4 cycles followed by autologous stem cell transplantation (ASCT). Standard risk patients can opt for delayed ASCT at first relapse. Patients not candidates for transplant are treated with VRd for approximately 8–12 cycles followed by lenalidomide or lenalidomide plus dexamethasone. Maintenance therapy After ASCT, lenalidomide maintenance is recommended for standard risk patients, while maintenance with a bortezomib-based regimen is needed for patients with intermediate or high-risk disease. Management of refractory disease Most patients require a triplet regimen at relapse, with the choice of regimen varying with each successive relapse. Aggressive relapse with extramedullary plasmacytomas or plasma cell leukemia may require anthracycline containing combination chemotherapy regimens.
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Kumar SK, Rajkumar SV. The multiple myelomas — current concepts in cytogenetic classification and therapy. Nat Rev Clin Oncol 2018; 15:409-421. [DOI: 10.1038/s41571-018-0018-y] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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A DNA target-enrichment approach to detect mutations, copy number changes and immunoglobulin translocations in multiple myeloma. Blood Cancer J 2016; 6:e467. [PMID: 27588520 PMCID: PMC5056967 DOI: 10.1038/bcj.2016.72] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 05/25/2016] [Accepted: 06/16/2016] [Indexed: 01/31/2023] Open
Abstract
Genomic lesions are not investigated during routine diagnostic workup for multiple myeloma (MM). Cytogenetic studies are performed to assess prognosis but with limited impact on therapeutic decisions. Recently, several recurrently mutated genes have been described, but their clinical value remains to be defined. Therefore, clinical-grade strategies to investigate the genomic landscape of myeloma samples are needed to integrate new and old prognostic markers. We developed a target-enrichment strategy followed by next-generation sequencing (NGS) to streamline simultaneous analysis of gene mutations, copy number changes and immunoglobulin heavy chain (IGH) translocations in MM in a high-throughput manner, and validated it in a panel of cell lines. We identified 548 likely oncogenic mutations in 182 genes. By integrating published data sets of NGS in MM, we retrieved a list of genes with significant relevance to myeloma and found that the mutational spectrum of primary samples and MM cell lines is partially overlapping. Gains and losses of chromosomes, chromosomal segments and gene loci were identified with accuracy comparable to conventional arrays, allowing identification of lesions with known prognostic significance. Furthermore, we identified IGH translocations with high positive and negative predictive value. Our approach could allow the identification of novel biomarkers with clinical relevance in myeloma.
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Thumallapally N, Yu H, Asti D, Vennepureddy A, Terjanian T. Salvage therapies in relapsed and/or refractory myeloma: what is current and what is the future? Onco Targets Ther 2016; 9:4843-58. [PMID: 27540299 PMCID: PMC4981158 DOI: 10.2147/ott.s110189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The treatment landscape for multiple myeloma (MM) is evolving with our understanding of its pathophysiology. However, given the inevitable cohort heterogeneity in salvage therapy, response to treatment and overall prognoses tend to vary widely, making meaningful conclusions about treatment efficacy difficult to derive. Despite the hurdles in current research, progress is underway toward more targeted therapeutic approaches. Several new drugs with novel mechanism of action and less toxic profile have been developed in the past decade, with the potential for use as single agents or in synergy with other treatment modalities in MM therapy. As our discovery of these emerging therapies progresses, so too does our need to reshape our knowledge on knowing how to apply them. This review highlights some of the recent landmark changes in MM management with specific emphasis on salvage drugs available for relapsed and refractory MM and also discusses some of the upcoming cutting-edge therapies that are currently in various stages of clinical development.
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Affiliation(s)
| | - Hana Yu
- Department of Internal Medicine
| | | | | | - Terenig Terjanian
- Division of Hematology and Oncology, Staten Island University Hospital, New York, NY, USA
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Rajkumar SV. Multiple myeloma: 2016 update on diagnosis, risk-stratification, and management. Am J Hematol 2016; 91:719-34. [PMID: 27291302 PMCID: PMC5291298 DOI: 10.1002/ajh.24402] [Citation(s) in RCA: 311] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 04/25/2016] [Indexed: 02/07/2023]
Abstract
Multiple myeloma accounts for approximately 10% of hematologic malignancies.The diagnosis requires ≥10% clonal bone marrow plasma cells or a biopsy proven plasmacytoma plus evidence of one or more multiple myeloma defining events (MDE): CRAB (hypercalcemia, renal failure, anemia, or lytic bone lesions) features felt related to the plasma cell disorder, bone marrow clonal plasmacytosis ≥60%, serum involved/uninvolved free light chain (FLC) ratio ≥100 (provided involved FLC is ≥100 mg/L), or >1 focal lesion on magnetic resonance imaging. Patients with del(17p), t(14;16), and t(14;20) have high-risk multiple myeloma. Patients with t(4;14) translocation and gain(1q) have intermediate-risk. All others are considered standard-risk. Initial treatment consists of bortezomib, lenalidomide, dexamethasone (VRD). In high-risk patients, carfilzomib, lenalidomide, dexamethasone (KRD) is an alternative to VRD. In eligible patients, initial therapy is given for approximately 3-4 months followed by autologous stem cell transplantation (ASCT). Standard risk patients can opt for delayed ASCT at first relapse. Patients not candidates for transplant are treated with Rd until progression, or alternatively, a triplet regimen such as VRD for approximately 12-18 months. After ASCT, lenalidomide maintenance is considered for standard risk patients especially in those who are not in very good partial response or better, while maintenance with a bortezomib-based regimen is needed for patients with intermediate or high-risk disease. Patients with indolent relapse can be treated with 2-drug or 3-drug combinations. Patients with more aggressive relapse require a triplet regimen or a combination of multiple active agents. Am. J. Hematol. 91:720-734, 2016. © 2016 Wiley Periodicals, Inc.
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Rajkumar SV. Myeloma today: Disease definitions and treatment advances. Am J Hematol 2016; 91:90-100. [PMID: 26565896 PMCID: PMC4715763 DOI: 10.1002/ajh.24236] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 11/06/2015] [Indexed: 12/12/2022]
Abstract
There have been major advances in the diagnosis, staging, risk-stratification, and management of multiple myeloma (MM). In addition to established CRAB (hypercalcemia, renal failure, anemia, and lytic bone lesions) features, new diagnostic criteria include three new biomarkers to diagnose the disease: bone marrow clonal plasmacytosis ≥60%, serum involved/uninvolved free light chain ratio ≥100, and >1 focal lesion on magnetic resonance imaging. MM can be classified into several subtypes based on baseline cytogenetics, and prognosis varies according to underlying cytogenetic abnormalities. A Revised International Staging System has been developed which combines markers of tumor burden (albumin, beta-2 microglobulin) with markers of aggressive disease biology (high-risk cytogenetics and elevated serum lactate dehydrogenase). Although the approach to therapy remains largely the same, the treatment options at every stage of the disease have changed. Carfilzomib, pomalidomide, panobinostat, daratumumab, elotuzumab, and ixazomib have been approved for the treatment of the disease. These drugs combined with older agents such as cyclophosphamide, dexamethasone, thalidomide, bortezomib, and lenalidomide dramatically increase the repertoire of regimens available for the treatment of MM. This review provides a concise overview of recent advances in MM, including updates to diagnostic criteria, staging, risk-stratification, and management.
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