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Kumar S, Baizer L, Callander NS, Giralt SA, Hillengass J, Freidlin B, Hoering A, Richardson PG, Schwartz EI, Reiman A, Lentzsch S, McCarthy PL, Jagannath S, Yee AJ, Little RF, Raje NS. Gaps and opportunities in the treatment of relapsed-refractory multiple myeloma: Consensus recommendations of the NCI Multiple Myeloma Steering Committee. Blood Cancer J 2022; 12:98. [PMID: 35768410 PMCID: PMC9243011 DOI: 10.1038/s41408-022-00695-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 05/29/2022] [Accepted: 06/08/2022] [Indexed: 01/05/2023] Open
Abstract
A wide variety of new therapeutic options for Multiple Myeloma (MM) have recently become available, extending progression-free and overall survival for patients in meaningful ways. However, these treatments are not curative, and patients eventually relapse, necessitating decisions on the appropriate choice of treatment(s) for the next phase of the disease. Additionally, an important subset of MM patients will prove to be refractory to the majority of the available treatments, requiring selection of effective therapies from the remaining options. Immunomodulatory agents (IMiDs), proteasome inhibitors, monoclonal antibodies, and alkylating agents are the major classes of MM therapies, with several options in each class. Patients who are refractory to one agent in a class may be responsive to a related compound or to a drug from a different class. However, rules for selection of alternative treatments in these situations are somewhat empirical and later phase clinical trials to inform those choices are ongoing. To address these issues the NCI Multiple Myeloma Steering Committee formed a relapsed/refractory working group to review optimal treatment choices, timing, and sequencing and provide recommendations. Additional issues considered include the role of salvage autologous stem cell transplantation, risk stratification, targeted approaches for genetic subsets of MM, appropriate clinical trial endpoints, and promising investigational agents. This report summarizes the deliberations of the working group and suggests potential avenues of research to improve the precision, timing, and durability of treatments for Myeloma.
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Affiliation(s)
- Shaji Kumar
- Hematologic Malignancies, Mayo Clinic College of Medicine and Science, Rochester, USA
| | - Lawrence Baizer
- Division of Lung Diseases, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Natalie S Callander
- Myeloma Clinical Program, University of Wisconsin Carbone Cancer Center, Madison, USA
| | - Sergio A Giralt
- Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, Madison, USA
| | - Jens Hillengass
- Oncology and Internal Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, USA
| | - Boris Freidlin
- Biometric Research Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Antje Hoering
- Cancer Research and Biostatistics and University of Washington School of Public Health, Seattle, USA
| | - Paul G Richardson
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Boston, USA
| | - Elena I Schwartz
- Coordinating Center for Clinical Trials, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Anthony Reiman
- University of New Brunswick, Department of Medicine, Dalhousie University Department of Oncology, Saint John Regional Hospital, Fredericton, Canada
| | - Suzanne Lentzsch
- Multiple Myeloma and Amyloidosis Service, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Philip L McCarthy
- Department of Medicine, Oncology and Internal Medicine, Transplant & Cellular Therapy Center, Roswell Park Comprehensive Cancer Center, Buffalo, USA
| | - Sundar Jagannath
- Division of Hematology and Medical Oncology, Mount Sinai School of Medicine, Center of Excellence for Multiple Myeloma, New York, USA
| | - Andrew J Yee
- Department of Medicine, Harvard Medical School, Multiple Myeloma Program, Medical Oncology, Massachusetts General Hospital, Boston, USA
| | - Richard F Little
- Clinical Investigations Branch, Cancer Therapy Evaluation Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Noopur S Raje
- Department of Medicine, Harvard Medical School, Multiple Myeloma Program, Medical Oncology, Massachusetts General Hospital, Boston, USA
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Rodeghiero F, Pecci A, Balduini CL. Thrombopoietin receptor agonists in hereditary thrombocytopenias. J Thromb Haemost 2018; 16:1700-1710. [PMID: 29956472 DOI: 10.1111/jth.14217] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Indexed: 12/15/2022]
Abstract
Hereditary thrombocytopenias (HTPs) constitute a heterogeneous group of diseases characterized by a reduction in platelet count and a potential bleeding risk. As a result of advances in diagnostic methods, HTPs are increasingly being identified, and appear to be less rare than previously thought. Most HTPs do not have effective treatments, except for platelet transfusion when bleeding occurs and in preparation for procedures associated with a risk of bleeding. Preliminary clinical evidence suggests that thrombopoietin receptor agonists (TPO-RAs) with an established use in the treatment of certain acquired thrombocytopenias are well tolerated and provide clinical benefits in patients with some forms of HTP. These drugs may therefore be considered for the treatment of HTPs in clinical practice. However, caution and close monitoring are recommended, owing to the absence of long-term safety data and the potential risks posed by prolonged bone marrow stimulation in certain HTPs. In this review, we summarize the available clinical data on TPO-RAs in the treatment of HTPs, and discuss their use in patients with these disorders. We believe that TPO-RAs will play a major role in the treatment of HTPs, particularly myosin heavy chain 9-related disease, Wiskott-Aldrich syndrome, X-linked thrombocytopenia, and thrombocytopenia caused by THPO mutations.
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Affiliation(s)
- F Rodeghiero
- Hematology Project Foundation, Affiliated to the Department of Haematology, S. Bortolo Hospital, Vicenza, Italy
| | - A Pecci
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
| | - C L Balduini
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
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Balduini CL, Melazzini F. Research at the heart of hematology: thrombocytopenias and platelet function disorders. Haematologica 2018; 102:203-205. [PMID: 28143952 DOI: 10.3324/haematol.2016.158055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Carlo L Balduini
- Department of Medicine, Università of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Federica Melazzini
- Department of Medicine, Università of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Abstract
Multiple myeloma (MM) is an incurable hematopoietic cancer that is characterized by malignant plasma cell infiltration of the bone marrow and/or extramedullary sites. Multi-modality approaches including "novel agents," traditional chemotherapy, and/or stem cell transplantation are used in MM therapy. Drug resistance, however, ultimately develops and the disease remains incurable for the vast majority of patients. In this chapter, we review both tumor cell-autonomous and non-autonomous (microenvironment-dependent) mechanisms of drug resistance. MM provides an attractive paradigm highlighting a number of current concepts and challenges in oncology. Firstly, identification of MM cancer stem cells and their unique drug resistance attributes may provide rational avenues towards MM eradication and cure. Secondly, the oligoclonal evolution of MM and alternation of "clonal tides" upon therapy challenge our current understanding of treatment responses. Thirdly, the success of MM "novel agents" provides exemplary evidence for the impact of therapies that target the immune and non-immune microenvironment. Fourthly, the rapid pace of drug approvals for MM creates an impetus for development of precision medicine strategies and biomarkers that promote efficacy and mitigate toxicity and cost. While routine cure of the disease remains the ultimate and yet unattainable prize, MM advances in the last 10-15 years have provided an astounding paradigm for the treatment of blood cancers in the modern era and have radically transformed patient outcomes.
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Affiliation(s)
- Athanasios Papadas
- Division of Hematology and Oncology, Department of Medicine, University of Wisconsin-Madison, Madison, WI, 53705, USA.
- UW Carbone Cancer Center, Madison, WI, 53705, USA.
| | - Fotis Asimakopoulos
- Division of Hematology and Oncology, Department of Medicine, University of Wisconsin-Madison, Madison, WI, 53705, USA
- UW Carbone Cancer Center, Madison, WI, 53705, USA
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Abstract
Multiple myeloma is a malignancy of terminally differentiated plasma cells, and patients typically present with bone marrow infiltration of clonal plasma cells and monoclonal protein in the serum and/or urine. The diagnosis of multiple myeloma is made when clear end-organ damage attributable to the plasma cell proliferative disorder or when findings that suggest a high likelihood of their development are present. Distinguishing symptomatic multiple myeloma that requires treatment from the precursor stages of monoclonal gammopathy of undetermined significance and smouldering multiple myeloma is important, as observation is the standard for those conditions. Much progress has been made over the past decade in the understanding of disease biology and individualized treatment approaches. Several new classes of drugs, such as proteasome inhibitors and immunomodulatory drugs, have joined the traditional armamentarium (corticosteroids, alkylating agents and anthracyclines) and, along with high-dose therapy and autologous haemopoietic stem cell transplantation, have led to deeper and durable clinical responses. Indeed, an increasing proportion of patients are achieving lasting remissions, raising the possibility of cure for this disease. Success will probably depend on using combinations of effective agents and treating patients in the early stages of disease, such as patients with smouldering multiple myeloma.
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Beyond immune thrombocytopenia: the evolving role of thrombopoietin receptor agonists. Ann Hematol 2017; 96:1421-1434. [PMID: 28275823 DOI: 10.1007/s00277-017-2953-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 02/13/2017] [Indexed: 01/19/2023]
Abstract
Since its discovery, the thrombopoietin (TPO) pathway has been an important pharmaceutical target for the treatment of thrombocytopenia. The first generation of TPO mimetics included peptide agents sharing homology with endogenous TPO, but these introduced a risk of antibody formation to endogenous TPO and were not successful. However, second-generation TPO mimetics or TPO receptor agonists (RAs) are currently being used to treat thrombocytopenia associated with a number of conditions, such as immune thrombocytopenia (ITP), severe aplastic anaemia (SAA), and hepatitis C virus-associated chronic liver disease. Accumulating efficacy and safety data suggest that the role of TPO-RAs in the treatment of thrombocytopenia may evolve in the near future with broader use of these agents in ITP and SAA, as well as approval in other indications, potentially including myelodysplastic syndromes, chemotherapy-associated thrombocytopenia, and post-transplant thrombocytopenia. This review provides an overview of clinical data on the efficacy and safety of TPO-RAs, emphasising recent findings that may expand their clinical utility.
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Abstract
Genetic diagnosis in families with inherited platelet disorders (IPD) is not performed widely because of the genetic heterogeneity of this group of disorders and because in most cases, it is not possible to select single candidate genes for analysis using clinical and laboratory phenotypes. Next-generation sequencing (NGS) technology has revolutionized the scale and cost-effectiveness of genetic testing, and has emerged as a valuable tool for IPD. This review examines the potential utility of NGS as a diagnostic tool to streamline detection of causal variants in known IPD genes and as a vehicle for new gene discovery.
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Affiliation(s)
- S K Westbury
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - A D Mumford
- School of Clinical Sciences, University of Bristol, Bristol, UK.,Bristol Haemophilia Comprehensive Care Centre, Bristol, UK.,West of England Genomic Medicine Centre, Bristol, UK
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Verma R, Green JM, Schatz PJ, Wojchowski DM. A dimeric peptide with erythropoiesis-stimulating activity uniquely affects erythropoietin receptor ligation and cell surface expression. Exp Hematol 2016; 44:765-769.e1. [PMID: 27174804 DOI: 10.1016/j.exphem.2016.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 04/14/2016] [Accepted: 04/20/2016] [Indexed: 10/21/2022]
Abstract
Erythropoiesis-stimulating agents (ESAs) that exert long-acting antianemia effects have been developed recently, but their mechanisms are poorly understood. Analyses reveal unique erythropoietin receptor (EPOR)-binding properties for one such ESA, the synthetic EPOR agonist peginesatide. Compared with recombinant human EPO and darbepoietin, peginesatide exhibited a slow on rate, but sustained EPOR residency and resistant displacement. In EPO-dependent human erythroid progenitor UT7epo cells, culture in peginesatide unexpectedly upmodulated endogenous cell surface EPOR levels with parallel increases in full-length EPOR-68K levels. These unique properties are suggested to contribute to the durable activity of this (and perhaps additional) dimeric peptide hematopoietic growth factor receptor agonist.
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Affiliation(s)
- Rakesh Verma
- Molecular Medicine Division, Maine Medical Center Research Institute, Scarborough, ME
| | | | | | - Don M Wojchowski
- Molecular Medicine Division, Maine Medical Center Research Institute, Scarborough, ME; Department of Medicine, Tufts University Medical Center, Boston, MA.
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