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Martino EA, Vigna E, Bruzzese A, Labanca C, Mendicino F, Lucia E, Olivito V, Zimbo A, Torricelli F, Neri A, Morabito F, Gentile M. Selinexor in multiple myeloma. Expert Opin Pharmacother 2024; 25:421-434. [PMID: 38503547 DOI: 10.1080/14656566.2024.2333376] [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: 01/29/2024] [Accepted: 03/18/2024] [Indexed: 03/21/2024]
Abstract
INTRODUCTION Selinexor, an XPO1 inhibitor, has emerged as a promising therapeutic option in the challenging landscape of relapsed/refractory multiple myeloma (RRMM). AREAS COVERED This article provides a review of selinexor, with a focus on available clinical studies involving MM patients and its safety profile. Clinical trials, such as STORM and BOSTON, have demonstrated its efficacy, particularly in combination regimens, showcasing notable overall response rates (ORR) and prolonged median progressionfree survival (mPFS). Selinexor's versatility is evident across various combinations, including carfilzomibdexamethasone (XKd), lenalidomidedexamethasone (XRd), and pomalidomidedexamethasone (XPd), with efficacy observed even in tripleclass refractory and highrisk patient populations. However, challenges, including resistance mechanisms and adverse events, necessitate careful management. Realworld evidence also underscores selinexor's effectiveness in RRMM, though dose adjustments and supportive measures remain crucial. Ongoing trials are exploring selinexor in diverse combinations and settings, including pomalidomidenaïve patients and postautologous stem cell transplant (ASCT) maintenance. EXPERT OPINION The evolving landscape of selinexor's role in the sequencing of treatment for RRMM, its potential in highrisk patients, including those with extramedullary disease, as revealed in the most recent international meetings, and ongoing investigations signal a dynamic era in myeloma therapeutics. Selinexor emerges as a pivotal component in multidrug strategies and innovative combinations.
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Affiliation(s)
| | - Ernesto Vigna
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | | | | | | | - Eugenio Lucia
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | | | - Annamaria Zimbo
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- UOC Laboratorio Analisi Cliniche, Biomolecolari e Genetica, Azienda Ospedaliera Annunziata, Cosenza, Italy
| | - Federica Torricelli
- Laboratorio di Ricerca Traslazionale Azienda USL-IRCSS Reggio Emilia, Emilia-Romagna, Italy
| | - Antonino Neri
- Scientific Directorate IRCCS of Reggio Emilia, I-42123 Reggio Emilia, EmiliaRomagna, Italy
| | | | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera Annunziata, Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, Rende, Italy
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2
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Huang Q, Zhao R, Xu L, Hao X, Tao S. Treatment of multiple myeloma with selinexor: a review. Ther Adv Hematol 2024; 15:20406207231219442. [PMID: 38186637 PMCID: PMC10771077 DOI: 10.1177/20406207231219442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
Over the last 20 years, breakthroughs in accessible therapies for the treatment of multiple myeloma (MM) have been made. Nevertheless, patients with MM resistant to immunomodulatory drugs, proteasome inhibitors, and anti-CD38 monoclonal antibodies have a very poor outcome. Therefore, it is necessary to explore new drugs for the treatment of MM. This review summarizes the mechanism of action of selinexor, relevant primary clinical trials, and recent developments in both patients with relapsed/refractory myeloma and patients with newly diagnosed myeloma. Selinexor may be useful for the treatment of refractory MM.
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Affiliation(s)
- Qianlei Huang
- Department of Hematology, The First Affiliated Hospital of Hainan Medical University, Hainan Province Clinical Medical Center, Haikou, China
| | - Ranran Zhao
- Department of Hematology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Lu Xu
- Department of Hematology, The First Affiliated Hospital of Hainan Medical University, Hainan Province Clinical Medical Center, Haikou, China
| | - Xinbao Hao
- Department of Hematology, The First Affiliated Hospital of Hainan Medical University, Hainan Province Clinical Medical Center, Haikou, China
| | - Shi Tao
- Department of Hematology, The First Affiliated Hospital of Hainan Medical University, Hainan Province Clinical Medical Center, 31 Longhua Road, Haikou 570102, China
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3
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Gu X, Sun C, Xu J, Lin Z, Zhang L, Zheng Y. Optimal timing and drug combination of selinexor in multiple myeloma: a systematic review and meta-analysis. Hematology 2023; 28:2187972. [PMID: 36920065 DOI: 10.1080/16078454.2023.2187972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
OBJECTIVES Multiple myeloma (MM) remains an incurable disease despite advances in treatment options. Recently, selinexor has shown promising efficacy for relapsed/refractory multiple myeloma (RRMM), whereas its optimal timing and drug combination remain unclear. In order to assess the various regimens that incorporate selinexor, a systematic review and meta-analysis was conducted. METHODS Clinical trials and real-world studies involving MM patients treated with selinexor were included. Pooled risk ratio (RR) was calculated to compare the rates, along with a 95% confidence interval (CI) and concurrent p-value assessment. A random-effects model was employed to provide a more conservative evaluation. RESULTS A total of 16 studies enrolling 817 patients were reviewed. The usage of selinexor as the fifth-line or prior therapy achieved a higher objective response rate (ORR) (65.9% versus 23.4%, p < 0.01) and longer pooled progression-free survival (PFS) (median: 12.5 months versus 2.9 months, p < 0.01) than those after the fifth-line usage. In addition, early usage also resulted in a consistent trend of pooled overall survival (median: 22.7 months versus 8.9 months, p = 0.26), compared with post-fifth-line usage. Selinexor and dexamethasone (Xd) plus either protease inhibitors (PIs) or immunomodulatory drugs (IMiDs) achieved better ORRs than the Xd-only regimen for RRMM, with ORRs of 56.1%, 52.5% and 24.6%, respectively (p < 0.01). CONCLUSION In conclusion, using selinexor as the fifth-line or prior therapy had a beneficial impact on RRMM. The regimen of Xd plus PIs or IMiDs was recommended.
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Affiliation(s)
- Xinyuan Gu
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Chunyan Sun
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Juan Xu
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Zhimei Lin
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, People's Republic of China.,Department of Hematology, The Affiliated Hospital of Chengdu University, Chengdu, People's Republic of China
| | - Li Zhang
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yuhuan Zheng
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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4
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Mo CC, Yee AJ, Midha S, Hartley‐Brown MA, Nadeem O, O'Donnell EK, Bianchi G, Sperling AS, Laubach JP, Richardson PG. Selinexor: Targeting a novel pathway in multiple myeloma. EJHAEM 2023; 4:792-810. [PMID: 37601856 PMCID: PMC10435704 DOI: 10.1002/jha2.709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/26/2023] [Accepted: 05/04/2023] [Indexed: 08/22/2023]
Abstract
Selinexor is an orally bioavailable selective inhibitor of nuclear export compound that inhibits exportin-1 (XPO1), a novel therapeutic target that is overexpressed in multiple myeloma (MM) and is responsible for the transport of ∼220 nuclear proteins to the cytoplasm, including tumour suppressor proteins. Inhibition of this process has demonstrated substantial antimyeloma activity in preclinical studies, both alone and in combination with established MM therapeutics. Based on a clinical trial programme encompassing multiple combination regimens, selinexor-based therapy has been approved for the treatment of relapsed/refractory MM (RRMM), with selinexor-dexamethasone approved in the later-relapse setting for penta-refractory patients and selinexor-bortezomib-dexamethasone approved for patients who have received ≥1 prior therapy. Here, we provide a comprehensive review of the clinical data on selinexor-based regimens, including recent updates from the 2022 American Society of Hematology annual meeting, and summarise ongoing studies of this novel targeted agent in newly diagnosed MM and RRMM.
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Affiliation(s)
- Clifton C. Mo
- Department of Medical OncologyDana‐Farber Cancer InstituteJerome Lipper Center for Multiple Myeloma ResearchHarvard Medical SchoolBostonMassachusettsUSA
| | - Andrew J. Yee
- Massachusetts General Cancer CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Shonali Midha
- Department of Medical OncologyDana‐Farber Cancer InstituteJerome Lipper Center for Multiple Myeloma ResearchHarvard Medical SchoolBostonMassachusettsUSA
- Division of HematologyBrigham and Women's HospitalBostonMassachusettsUSA
| | - Monique A. Hartley‐Brown
- Department of Medical OncologyDana‐Farber Cancer InstituteJerome Lipper Center for Multiple Myeloma ResearchHarvard Medical SchoolBostonMassachusettsUSA
- Division of HematologyBrigham and Women's HospitalBostonMassachusettsUSA
| | - Omar Nadeem
- Department of Medical OncologyDana‐Farber Cancer InstituteJerome Lipper Center for Multiple Myeloma ResearchHarvard Medical SchoolBostonMassachusettsUSA
| | - Elizabeth K. O'Donnell
- Department of Medical OncologyDana‐Farber Cancer InstituteJerome Lipper Center for Multiple Myeloma ResearchHarvard Medical SchoolBostonMassachusettsUSA
- Division of HematologyBrigham and Women's HospitalBostonMassachusettsUSA
| | - Giada Bianchi
- Department of Medical OncologyDana‐Farber Cancer InstituteJerome Lipper Center for Multiple Myeloma ResearchHarvard Medical SchoolBostonMassachusettsUSA
- Division of HematologyBrigham and Women's HospitalBostonMassachusettsUSA
| | - Adam S. Sperling
- Department of Medical OncologyDana‐Farber Cancer InstituteJerome Lipper Center for Multiple Myeloma ResearchHarvard Medical SchoolBostonMassachusettsUSA
- Division of HematologyBrigham and Women's HospitalBostonMassachusettsUSA
| | - Jacob P. Laubach
- Department of Medical OncologyDana‐Farber Cancer InstituteJerome Lipper Center for Multiple Myeloma ResearchHarvard Medical SchoolBostonMassachusettsUSA
| | - Paul G. Richardson
- Department of Medical OncologyDana‐Farber Cancer InstituteJerome Lipper Center for Multiple Myeloma ResearchHarvard Medical SchoolBostonMassachusettsUSA
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Dima D, Ullah F, Mazzoni S, Williams L, Faiman B, Kurkowski A, Chaulagain C, Raza S, Samaras C, Valent J, Khouri J, Anwer F. Management of Relapsed-Refractory Multiple Myeloma in the Era of Advanced Therapies: Evidence-Based Recommendations for Routine Clinical Practice. Cancers (Basel) 2023; 15:2160. [PMID: 37046821 PMCID: PMC10093129 DOI: 10.3390/cancers15072160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/14/2023] Open
Abstract
Multiple myeloma (MM) is the second most common hematologic malignancy in adults worldwide. Over the past few years, major therapeutic advances have improved progression-free and overall survival, as well as quality of life. Despite this recent progress, MM remains incurable in the vast majority of cases. Patients eventually relapse and become refractory to multiple drug classes, making long-term management challenging. In this review, we will focus on the treatment paradigm of relapsed/refractory MM (RRMM) in the era of advanced therapies emphasizing the available novel modalities that have recently been incorporated into routine practice, such as chimeric antigen receptor T-cell therapy, bispecific antibodies, and other promising approaches. We will also discuss major factors that influence the selection of appropriate drug combinations or cellular therapies, such as relapse characteristics, and other disease and patient related parameters. Our goal is to provide insight into the currently available and experimental therapies for RRMM in an effort to guide the therapeutic decision-making process.
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Affiliation(s)
- Danai Dima
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Fauzia Ullah
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Sandra Mazzoni
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Louis Williams
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Beth Faiman
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Austin Kurkowski
- Department of Pharmacy, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Chakra Chaulagain
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Maroone Cancer Center, Weston, FL 33331, USA
| | - Shahzad Raza
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Christy Samaras
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Jason Valent
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Jack Khouri
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Faiz Anwer
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
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6
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Zhang X, Zhang H, Lan H, Wu J, Xiao Y. CAR-T cell therapy in multiple myeloma: Current limitations and potential strategies. Front Immunol 2023; 14:1101495. [PMID: 36891310 PMCID: PMC9986336 DOI: 10.3389/fimmu.2023.1101495] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/09/2023] [Indexed: 02/22/2023] Open
Abstract
Over the last decade, the survival outcome of patients with multiple myeloma (MM) has been substantially improved with the emergence of novel therapeutic agents, such as proteasome inhibitors, immunomodulatory drugs, anti-CD38 monoclonal antibodies, selective inhibitors of nuclear export (SINEs), and T cell redirecting bispecific antibodies. However, MM remains an incurable neoplastic plasma cell disorder, and almost all MM patients inevitably relapse due to drug resistance. Encouragingly, B cell maturation antigen (BCMA)-targeted chimeric antigen receptor T (CAR-T) cell therapy has achieved impressive success in the treatment of relapsed/refractory (R/R) MM and brought new hopes for R/R MM patients in recent years. Due to antigen escape, the poor persistence of CAR-T cells, and the complicated tumor microenvironment, a significant population of MM patients still experience relapse after anti-BCMA CAR-T cell therapy. Additionally, the high manufacturing costs and time-consuming manufacturing processes caused by the personalized manufacturing procedures also limit the broad clinical application of CAR-T cell therapy. Therefore, in this review, we discuss current limitations of CAR-T cell therapy in MM, such as the resistance to CAR-T cell therapy and the limited accessibility of CAR-T cell therapy, and summarize some optimization strategies to overcome these challenges, including optimizing CAR structure, such as utilizing dual-targeted/multi-targeted CAR-T cells and armored CAR-T cells, optimizing manufacturing processes, combing CAR-T cell therapy with existing or emerging therapeutic approaches, and performing subsequent anti-myeloma therapy after CAR-T cell therapy as salvage therapy or maintenance/consolidation therapy.
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Affiliation(s)
- Xiaomin Zhang
- Department of Hematology, Jinshazhou Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hui Zhang
- School of Medicine, Jishou University, Jishou, China
| | - Huixuan Lan
- School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Jinming Wu
- Department of Hematology, Jinshazhou Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yang Xiao
- Department of Hematology, Shenzhen Qianhai Shekou Pilot Free Trade Zone Hospital, Shenzhen, China
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7
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Baljevic M, Gasparetto C, Schiller GJ, Tuchman SA, Callander NS, Lentzsch S, Monge J, Kotb R, Bahlis NJ, White D, Chen CI, Sutherland HJ, Madan S, LeBlanc R, Sebag M, Venner CP, Bensinger WI, Biran N, DeCastro A, Van Domelen DR, Zhang C, Shah JJ, Shacham S, Kauffman MG, Bentur OS, Lipe B. Selinexor-based regimens in patients with multiple myeloma after prior anti-B-cell maturation antigen treatment. EJHAEM 2022; 3:1270-1276. [PMID: 36467792 PMCID: PMC9713049 DOI: 10.1002/jha2.572] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 06/17/2023]
Abstract
There is a lack of consensus on therapy sequencing in previously treated multiple myeloma, particularly after anti-B-cell maturation antigen (BCMA) therapy. Earlier reports on selinexor (X) regimens demonstrated considerable efficacy in early treatment, and after anti-BCMA-targeted chimeric antigen receptor-T cell therapy. Here, we present data from 11 heavily pretreated patients who predominantly received BCMA-antibody-drug conjugate therapy. We observe that X-containing regimens are potent and achieve durable responses with numerically higher overall response and clinical benefit rates, as well as median progression free survival compared to patients' prior anti-BCMA therapies, despite being used later in the treatment course. In an area of evolving unmet need, these data reaffirm the efficacy of X-based regimens following broader anti-BCMA therapy.
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Affiliation(s)
- Muhamed Baljevic
- Vanderbilt‐Ingram Cancer CenterVanderbilt University Medical CenterNashvilleTennesseeUSA
| | | | - Gary J. Schiller
- Hematological Malignancy/Stem Cell Transplant ProgramUniversity of California ‐ Los Angeles David Geffen School of MedicineLos AngelesCaliforniaUSA
| | - Sascha A. Tuchman
- Department of MedicineDivision of HematologyThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Natalie S. Callander
- Division of Hematology/Oncology, Department of MedicineUniversity of Wisconsin‐Madison School of Medicine and Public HealthMadisonWisconsinUSA
| | | | | | - Rami Kotb
- Medical Oncology and Hematology CancerCare ManitobaWinnipegManitobaCanada
| | - Nizar J. Bahlis
- Arnie Charbonneau Cancer Research InstituteUniversity of CalgaryCalgaryAlbertaCanada
| | - Darrell White
- Department of Medicine/Division of HematologyDalhousie UniversityHalifaxNova ScotiaCanada
| | | | | | - Sumit Madan
- Banner MD Anderson Cancer CenterGilbertArizonaUSA
| | - Richard LeBlanc
- Maisonneuve‐Rosemont HospitalUniversity of MontrealMontrealQuébecCanada
| | - Michael Sebag
- Division of HematologyMcGill University Health CentreMontrealQuébecCanada
| | | | - William I. Bensinger
- Center for Blood Disorders and Stem Cell Transplantation Swedish Cancer InstituteSeattleWashingtonUSA
| | - Noa Biran
- John Theurer Cancer Center, Hackensack Meridian HealthHackensack University Medical CenterHackensackNew JerseyUSA
| | | | | | - Chris Zhang
- Karyopharm Therapeutics Inc.NewtonMassachusettsUSA
| | | | | | | | | | - Brea Lipe
- Wilmot Cancer InstituteUniversity of Rochester Medical CenterRochesterNew YorkUSA
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8
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Zhang X, Zhu L, Zhang H, Chen S, Xiao Y. CAR-T Cell Therapy in Hematological Malignancies: Current Opportunities and Challenges. Front Immunol 2022; 13:927153. [PMID: 35757715 PMCID: PMC9226391 DOI: 10.3389/fimmu.2022.927153] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 05/16/2022] [Indexed: 12/13/2022] Open
Abstract
Chimeric antigen receptor T (CAR-T) cell therapy represents a major breakthrough in cancer treatment, and it has achieved unprecedented success in hematological malignancies, especially in relapsed/refractory (R/R) B cell malignancies. At present, CD19 and BCMA are the most common targets in CAR-T cell therapy, and numerous novel therapeutic targets are being explored. However, the adverse events related to CAR-T cell therapy might be serious or even life-threatening, such as cytokine release syndrome (CRS), CAR-T-cell-related encephalopathy syndrome (CRES), infections, cytopenia, and CRS-related coagulopathy. In addition, due to antigen escape, the limited CAR-T cell persistence, and immunosuppressive tumor microenvironment, a considerable proportion of patients relapse after CAR-T cell therapy. Thus, in this review, we focus on the progress and challenges of CAR-T cell therapy in hematological malignancies, such as attractive therapeutic targets, CAR-T related toxicities, and resistance to CAR-T cell therapy, and provide some practical recommendations.
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Affiliation(s)
- Xiaomin Zhang
- Department of Hematology, Jinshazhou Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.,Institute of Clinical Medicine College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Lingling Zhu
- Cancer Center, Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Hui Zhang
- School of Medicine, Jishou University, Jishou, China
| | - Shanshan Chen
- Cancer Center, Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Yang Xiao
- Institute of Clinical Medicine College, Guangzhou University of Chinese Medicine, Guangzhou, China.,Department of Hematology, Shenzhen Qianhai Shekou Pilot Free Trade Zone Hospital, Shenzhen, China
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9
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Abstract
Multiple myeloma (MM) is an incurable malignancy of plasma cells with a clinical course characterized by multiple relapses and treatment refractoriness. While recent treatment advancements have extended overall survival (OS), refractory MM has a poor prognosis, with a median OS of between 4 and 6 months. Nuclear export inhibition, specifically inhibition of CRM1/XPO1, is an emerging novel treatment modality that has shown promise in treatment-refractory MM. Initially discovered in yeast in 1983, early clinical applications were met with significant toxicities that limited their utility. The creation of small molecule inhibitors of nuclear export (SINE) has improved on toxicity limitations and has led to investigation in a number of malignancies at the preclinical and clinical stages. Preclinical studies of SINEs in MM have shown that these molecules are cytotoxic to myeloma cells, play a role in therapy resensitization, and suggest a role in limiting bone disease progression. In July 2019, selinexor became the first nuclear export inhibitor approved for use in relapsed/refractory MM based on the STORM trial. As of May 2020, there were eight ongoing trials combining selinexor with standard treatment regimens in relapsed/refractory MM. Eltanexor, a second-generation SINE, is also under investigation and has shown preliminary signs of efficacy in an early clinical trial while potentially having an improved toxicity profile compared with selinexor. Results in ongoing trials will help further define the role of SINEs in MM.
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Affiliation(s)
| | - Guido Lancman
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, Box 1185, New York, NY, 10029, USA
| | - Ajai Chari
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, Box 1185, New York, NY, 10029, USA.
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10
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Joseph NS, Tai YT, Anderson KC, Lonial S. Novel Approaches to Treating Relapsed and Refractory Multiple Myeloma with a Focus on Recent Approvals of Belantamab Mafodotin and Selinexor. Clin Pharmacol 2021; 13:169-180. [PMID: 34434061 PMCID: PMC8380622 DOI: 10.2147/cpaa.s288840] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/28/2021] [Indexed: 01/10/2023] Open
Abstract
Though survival outcomes in multiple myeloma patients have improved drastically over the past few decades, there still remains an ongoing need for effective and tolerable treatment options in the relapsed and refractory space. Encouragingly, there have been three recent FDA approvals for triple-class refractory multiple myeloma, and there is promising ongoing development of additional agents with varying novel mechanisms of action. Here, we will review the most recent data on both belantamab mafodotin, an antibody drug conjugate (ADC) targeting BCMA, and selinexor, a first-in-class selective inhibitor of XPO1, as well as touch on some of the recently published data for other immunotherapies in development, namely bispecific T cell engagers, ADCs, and CAR-T cell therapies.
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Affiliation(s)
- Nisha S Joseph
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Yu-Tzu Tai
- Dana-Farber Cancer Institute, Harvard University, Boston, MA, USA
| | | | - Sagar Lonial
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
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11
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Mo CC, Jagannath S, Chari A, Nooka AK, Lonial S, Siegel D, Biran N, Gasparetto C, Bahlis NJ, Richardson P. Selinexor for the treatment of patients with previously treated multiple myeloma. Expert Rev Hematol 2021; 14:697-706. [PMID: 33985401 DOI: 10.1080/17474086.2021.1923473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Multiple myeloma (MM) is an increasingly treatable but still incurable hematologic malignancy. Prognosis has improved significantly over recent years, although further advances remain urgently needed, especially for patients with heavily pre-treated and resistant disease for whom there are limited options. Selinexor is a first-in-class, oral, selective inhibitor of nuclear export (SINE) compound that triggers apoptosis in malignant cells by inducing nuclear retention of oncogene messenger RNAs (mRNAs) and reactivation of tumor suppressor proteins (TSPs). In clinical studies of patients with relapsed and/or refractory MM, selinexor has demonstrated both manageable toxicity and encouraging efficacy. AREAS COVERED This review will provide an overview of the mechanism of action of selinexor as well as the efficacy and safety data from clinical studies using selinexor for the treatment of multiple myeloma. EXPERT OPINION Long-term outcomes for patients with MM will continue to improve due to numerous recent and imminent therapeutic advances, although critical areas of unmet need remain. Oral selinexor is likely to contribute to the meeting of these needs and the further advancement of MM therapy in a meaningful way.
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Affiliation(s)
- Clifton C Mo
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Sundar Jagannath
- Department of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ajai Chari
- Department of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ajay K Nooka
- Department of Hematology and Medical Oncology and the Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Sagar Lonial
- Department of Hematology and Medical Oncology and the Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - David Siegel
- John Theurer Cancer Center, Hackensack University, Hackensack, NJ, USA
| | - Noa Biran
- John Theurer Cancer Center, Hackensack University, Hackensack, NJ, USA
| | | | - Nizar J Bahlis
- Charbonneau Cancer Research Institute, Calgary, AB, Canada
| | - Paul Richardson
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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12
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van de Donk NWCJ, Usmani SZ, Yong K. CAR T-cell therapy for multiple myeloma: state of the art and prospects. LANCET HAEMATOLOGY 2021; 8:e446-e461. [PMID: 34048683 DOI: 10.1016/s2352-3026(21)00057-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 12/30/2022]
Abstract
Chimeric antigen receptors (CAR) are fusion proteins containing an antigen-recognition domain coupled to a T-cell activation domain (eg, CD3ζ [CD247]) and to a costimulatory domain (eg, CD28 or 4-1BB [TNFRSF9, also known as CD137]). The B-cell maturation antigen (BCMA; TNFRSF17) is an attractive target for CAR T-cell therapy because it is only expressed by normal and malignant plasma cells and by a subset of mature B cells. Several trials of anti-BCMA CAR T cells have shown high-quality responses, including minimal residual disease-negativity in patients with multiple myeloma who were heavily pretreated. Phase 3 trials are currently evaluating CAR T-cell therapy versus standard-of-care regimens in patients in earlier stages of the disease. Trials are also ongoing in newly diagnosed patients with high-risk cytogenetic profiles or with residual disease after transplantation. CAR T cells targeting other multiple myeloma antigens, such as CD19, CD38, CD138 (SYND1), and SLAMF7, are also being explored. Toxicities associated with CAR T cells include cytokine-release syndrome, different types of cytopenia, infections, and neurotoxicity. Although some subsets of patients have sustained responses for more than 1 year, most patients eventually relapse, which might be related to the loss of CAR T cells, loss of antigen expression on the tumour cell surface, or to an immunosuppressive microenvironment that impairs the activity of T cells. Efforts to improve the effectiveness of CAR T-cell therapy include optimising CAR design and adapting the manufacturing process to generate cell products enriched for specific subsets of T cells (eg, early memory cells). Other strategies explored in trials include dual-antigen targeting to prevent antigen escape and rational combination therapy to enhance persistence. Several approaches are also being developed to improve the safety of CAR T-cell therapy, such as the incorporation of a suicide gene safety system.
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Affiliation(s)
- Niels W C J van de Donk
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.
| | - Saad Z Usmani
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Kwee Yong
- Department of Haematology, University College London, London, UK
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