Non-homogeneous distribution of Al3+ in doped phosphate glasses revealed by 27Al/31P solid state NMR

Solid state NMR is applied in this contribution on the xAl₂O₃-(50-x/2)Na₂O-(50-x/2)P₂O₅ composition line (with 0<x<5mol%) in order to investigate the distribution of Al³⁺ ions in Al₂O₃-doped sodium phosphate glasses. The structure was analysed by (i) ²⁷Al 1D-, 3Q-, DQ- MAS-NMR analysis and (ii) 1D ³¹P, ²⁷Al(³¹P) 2D D-HMQC MAS-NMR and 2D ³¹P R-INADEQUATE technique. The ²⁷Al NMR results confirm the presence of six-coordinated aluminate as major aluminate species and indicate that Al³⁺ ions are fully dissociated in the glass network. The ³¹P NMR data show the simultaneous presence of five different phosphate units connected to 0, 1 but also 2 Al³⁺ ions and offer a new vision of the doping mechanism by highlighting a non-homogeneous distribution of Al³⁺ ions in the phosphate matrix. This study indicates that the glass networks contain Al³⁺-rich and -poor domains and present thus a significant structural disorder beyond the local order.

The structure of Pyrex® glass investigated by correlation NMR spectroscopy

The structure of Pyrex® glass has been analysed by 1D and 2D-correlation NMR.

Intermediate length scale organisation in tin borophosphate glasses: new insights from high field correlation NMR

The structure of tin borophosphate glasses, considered for the development of low temperature sealing glasses or anode materials for Li-batteries, has been analysed at the intermediate length scale by a combination of high field standard and advanced 1D/2D nuclear magnetic resonance techniques. The nature and extent of B/P mixing were analysed using the (11)B((31)P) dipolar heteronuclear multiple quantum coherence NMR sequence and the data interpretation allowed (i) detecting the presence and analysing the nature of the B-O-P linkages, (ii) re-interpreting the 1D (31)P spectra and (iii) extracting the proportion of P connected to borate species. Interaction between the different borate species was analysed using the (11)B double quantum-simple quantum experiment to (i) investigate the presence and nature of the B-O-B linkage, (ii) assign the different borate species observed all along the composition line and (iii) monitor the borate network formation. In addition, (119)Sn static NMR was used to investigate the evolution of the chemical environment of the tin polyhedra. Altogether, the set of data allowed determining the structural units constituting the glass network and quantifying the extent of B/P mixing. The structural data were then used to explain the non-linear and unusual evolution of the glass transition temperature.

P-O-B(3) linkages in borophosphate glasses evidenced by high field (11)B/(31)P correlation NMR

The long-standing debate about the presence of P-O-B(3) linkages in glasses has been solved by high-field scalar correlation NMR. Previously suggested by dipolar NMR methods, the presence of such species has been definitively demonstrated by (11)B((31)P) J-HMQC NMR techniques. The results indicate that borophosphate networks contain P-O-B(3) bonds and thus present a higher degree of atomic homogeneity than previously thought.

Red coralline algae assessed as marine pH proxies using 11B MAS NMR

Reconstructing pH from biogenic carbonates using boron isotopic compositions relies on the assumption that only borate, and no boric acid, is present. Red coralline algae are frequently used in palaeoenvironmental reconstruction due to their widespread distribution and regular banding frequency. Prior to undertaking pH reconstructions using red coralline algae we tested the boron composition of the red coralline alga Lithothamnion glaciale using high field NMR. In bulk analysed samples, thirty percent of boron was present as boric acid. We suggest that prior to reconstructing pH using coralline algae 1) species-specific boron compositions and 2) within-skeleton special distributions of boron are determined for multiple species. This will enable site selective boron analyses to be conducted validating coralline algae as palaeo-pH proxies based on boron isotopic compositions.

(18)F-FDG-PET/CT imaging in an IL-6- and MYC-driven mouse model of human multiple myeloma affords objective evaluation of plasma cell tumor progression and therapeutic response to the proteasome inhibitor ixazomib

(18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) and computed tomography (CT) are useful imaging modalities for evaluating tumor progression and treatment responses in genetically engineered mouse models of solid human cancers, but the potential of integrated FDG-PET/CT for assessing tumor development and new interventions in transgenic mouse models of human blood cancers such as multiple myeloma (MM) has not been demonstrated. Here we use BALB/c mice that contain the newly developed iMyc(ΔEμ) gene insertion and the widely expressed H2-L(d)-IL6 transgene to demonstrate that FDG-PET/CT affords an excellent research tool for assessing interleukin-6- and MYC-driven plasma cell tumor (PCT) development in a serial, reproducible and stage- and lesion-specific manner. We also show that FDG-PET/CT permits determination of objective drug responses in PCT-bearing mice treated with the investigational proteasome inhibitor ixazomib (MLN2238), the biologically active form of ixazomib citrate (MLN9708), that is currently in phase 3 clinical trials in MM. Overall survival of 5 of 6 ixazomib-treated mice doubled compared with mice left untreated. One outlier mouse presented with primary refractory disease. Our findings demonstrate the utility of FDG-PET/CT for preclinical MM research and suggest that this method will play an important role in the design and testing of new approaches to treat myeloma.

Cell-cycle characteristics - alterable determinants of remission duration in a study of 179 standard risk newly diagnosed patients with acute myeloid-leukemia

Prognostic factors were related to remission duration among 179 standard risk newly diagnosed acute myeloid leukemia (AML) patients who received identical induction and consolidation therapies. Following a bromodeoxyuridine infusion, labeling indices of bone marrow aspirate/biopsy, durations of S-phase and cell cycle (Tc) were determined. Patients with slowly cycling myeloblasts had longer remissions (Log rank p=0.03) than those with rapidly cycling myeloblasts. Multivariate analysis demonstrated that both WBC and Tc contributed to remission duration (p=0.01 and 0.005 respectively). Patients with slowly proliferating leukemias have longer remissions probably due to slower regrowth of leukemia between chemotherapy courses.

Clinical-grade myeloma Ag pre-loaded DC vaccines retain potency after cryopreservation

BACKGROUND

The use of myeloma Ag-loaded mature DC vaccines, cryopreserved in single-use aliquots, is an attractive immunotherapeutic strategy. In this study we investigated the retention of phenotype, viability and potency of DC vaccines after freezing and thawing.

METHODS

Plastic-adherent monocytes, derived from a steady-state leukapheresis, were cultured in serum-free media containing GM-CSF and IL-4. DC were loaded on day 6 with myeloma lysate (ML) or idiotype (Id) Ag and keyhole limpet hemocyanin (KLH), induced to mature on day 7 with CD40-ligand and cryopreserved on day 9. Seventeen clinical-scale cultures were evaluated for DC yield, recovery and immunophenotype after potency was validated with allogeneic mixed lymphocyte culture and Ag presentation assays.

RESULTS

We produced 88 individual vaccines from 17 clinical-scale cultures. Median DC yield at harvest was 131 x 10(6) (range 37-375 x 10(6)) and median recovery of viable DC after thawing was 69% (range 11-100%). We confirmed viability (7AAD-), phenotype (CD14-, CD83+/CD40+, CD83+/CD80+, CD83+/CD86+, CD83+/CD54+, HLA-DR++) and the ability of the DC to present Ag and stimulate allogeneic T cells post-thawing.

DISCUSSION

We have validated a serum-free culture system for the production of DC. Cryopreservation did not interfere with DC activity, allowed time for rigorous quality control (QC) and flexible scheduling of intranodal vaccination, and reduced the time to prepare multiple vaccines.

Measurement of through-space connectivities between spin-1/2 and quadrupolar nuclei in solid-state NMR: the TEDOR-MQMAS method

We present the transferred echo double-resonance multiple-quantum MAS (TEDOR-MQMAS) method that allows to analyze under high resolution the through-bond connectivities between spin-1/2 and quadrupolar nuclei. This method avoids some of the limitations related to the spin-lock of half-integer quadrupolar nuclei under MAS. However, the losses observed during the TEDOR transfer are related to the T'(2) constants, and they may thus be more important than those observed during the CP-MAS transfer, which are related to T(1rho) > T'(2).

High-dose melphalan (MEL) based autotransplants (AT) for multiple myeloma (MM): The Arkansas experience since 1989 in more than 2,800 patients

8043

Background: The dose-response effect for MEL has been safely exploited through the use of AT. Long-term follow-up studies from large centers are critical to understand who benefits most and who should be considered for alternative treatment approaches. Methods: 2,836 patients receiving at least one MEL AT were considered. Kaplan-Meier analysis was used to estimate median event-free survival (EFS) and overall survival (OS). Cox regression was used to evaluate independent prognostic factors of EFS and OS from AT. Results: Of the 2,836 patients, 979 were enrolled into front-line Total Therapy protocols 1/2/3 (TT); 1,064 were entered on protocols for previously treated patients (non-TT); and 793 were treated off protocol (non-P). Overall median EFS and OS from 1st AT are 31mo and 53 mo; 10-yr EFS and OS were 19% and 24%; 15% survived >15 yr. The 5 strongest favorable OS features included TT (HR 0.46, p<0.001), absence of cytogenetic abnormalities (no CA) (HR 0.48, p<0.001), B2M <3 mg/L (HR 0.46, p<0.001), albumin >=3g/dL (HR 0.45, p<0.001) and platelet count >=100.000/microL (HR 0.41, p<.001), so that 10-yr OS rates were 58% with 5, 24% with 4, 16% with 3, 4% with 2 and 0% with =<1 favorable parameter (p<0.0001). The corresponding median durations of EFS were 80 mo, 37 mo, 27 mo, 18 mo and 7 mo (p<0.0001). Conclusion: This large single institution experience demonstrates that > 10 yr OS can be accomplished in over one-half of the 16% of all patients presenting without CA, with low levels of B2M and albumin, high platelet count and receiving TT. The worst constellation affected 3% of all patients presenting with at most 1 good-risk feature whose 5-yr survival was only 7%. These data should serve as guidepost for MM investigators and patients alike, against which newer treatments should be measured.

No significant financial relationships to disclose.

Phase II study of total therapy 3 (TT3) with added bortezomib (V) for multiple myeloma (MM)

8020

Background: Building on the success of TT2 with OS exceeding a median of 8 yr, TT3 incorporated V into induction and consolidation/maintenance of melphalan (MEL)-based tandem transplants. Methods: Newly diagnosed patients with MM up to age 75 yr (>59 yr, 47%) were enrolled in TT3, consisting of 2 cycles of V, thalidomide, dexamethasone, cisplatin, adriamycin, cyclophosphamide, etoposide (VTD-PACE) as induction prior to and as consolidation after MEL transplants, followed by maintenance with monthly VTD in year 1 and TD in years 2 and 3. The primary endpoint was complete response (CR). Results: 303 eligible patients were accrued between 02/04 and 07/06; median follow-up is 19 mo. Tandem transplants were completed in 84% with TT3 and 66% with TT2 (p<0.0001) with similar 12-mo TRM (4% v 5%). At 24 mo, 84% v 68% achieved n-CR including 59% v 44% CR (both p<0.0001). 24-mo EFS is superior (83% v 75%, p=0.02; <65 yr: 86% v 76%, p=0.008) while 24-mo OS is still similar (86% v 85%, p=0.44; <65 yr: 88% v 85%, p=0.16). In gene array-based high-risk MM, 24-mo EFS was 62% v 27% (p=0.006) and 24-mo OS was 74% v 43% (p=0.06). Independent adverse parameters for OS with TT3 were LDH>=190 U/L (27%; HR=3.78, p=0.002), high-risk gene array (14%; HR=3.30, p=0.006) and age >=65 yr (29%; HR=2.23, p=0.044). Compared to the T arm of TT2, fewer patients in TT3 experienced grade >2 tremor (3% v 13%, p<0.001), constipation (6% v 14%, p=0.002), syncope (1% v 12%, p<0.001) and thrombo-embolic events (27% v 38%, p=0.004). Conclusion: Compared to TT2, added V and shortened induction in TT3 increased tandem transplant compliance, effected higher CR and n-CR rates and extended EFS with a strong trend for superior OS in high-risk MM in patients <65 yr. TT3 toxicity was reduced in comparison with the T arm of TT2.

No significant financial relationships to disclose.

A phase I trial of AVN944 in patients with advanced hematologic malignancies

14026

Background: AVN-944 is an inhibitor of inosine monophosphate dehydrogenase (IMPDH), an enzyme that catalyzes the rate- limiting step in guanine nucleotide synthesis, and induces apoptosis in malignant hematopoietic cell lines in vitro. Methods: This phase I study employed open-label dose escalations in patients (pts) with relapsed, refractory hematologic cancers with safety, pharmacokinetic (PK), pharmacodynamic, & efficacy endpoints. Between 12/05 and 1/07 a total of 70 cycles of AVN944 at 25 (7pts), 50 (6pts), 75 (7pts), 100 (7pts) or 125 mg (3pts) b.i.d. orally X 21d every 28d were administered to 30 pts with AML (12), ALL (2), CLL (3), and multiple myeloma (13). Peripheral blood mononuclear cell (PBMC) or leukemic blast samples were obtained from all pts pre and post-receiving AVN944 to determine effects on GTP pools, IMPDH activity, and to correlate these changes to response in a 32-gene set that relates directly to cellular pathways dependent upon guanine nucleotide biosynthesis. Results: Pharmacokinetics were dose proportional with mean Tmax=1 hour, T1/2=1.5 hours, Cmax=2800 ng/ml and AUC=7228 hr.ng/ml at the 100 mg b.i.d. dose. Toxicities were generally mild-moderate and/or not attributed to AVN944. Twelve serious adverse events (SAEs) occurred in 8 pts; 7 of 8 had AML. No SAEs was attributed to AVN944. DLT was not seen. No protocol defined responses were seen. Twelve of 24 assessable pts had stable disease of 2 to 10 months duration. Changes in the gene expression set correlated with disease stability. Conclusions: AVN944 is well tolerated with oral b.i.d. dosing. Stabilization of disease was observed in half of the pts. Gene expression correlated with stable versus progressive disease.

[Table: see text]

International uniform response criteria for multiple myeloma

New uniform response criteria are required to adequately assess clinical outcomes in myeloma. The European Group for Blood and Bone Marrow Transplant/International Bone Marrow Transplant Registry criteria have been expanded, clarified and updated to provide a new comprehensive evaluation system. Categories for stringent complete response and very good partial response are added. The serum free light-chain assay is included to allow evaluation of patients with oligo-secretory disease. Inconsistencies in prior criteria are clarified making confirmation of response and disease progression easier to perform. Emphasis is placed upon time to event and duration of response as critical end points. The requirements necessary to use overall survival duration as the ultimate end point are discussed. It is anticipated that the International Response Criteria for multiple myeloma will be widely used in future clinical trials of myeloma.

High CR and near-CR rate with bortezomib incorporated into up-front therapy of multiple myeloma with tandem transplants

7519

Background: Tandem autotransplants have increased complete response (CR) rates and extended event-free survival (EFS) and overall survival (OS) in multiple myeloma (MM). Because of its remarkable efficacy in end-stage disease and to further increase CR and thereby improving EFS and OS, bortezomib (Velcade, V) was incorporated into Total Therapy 3 (TT3), both with DT-PACE combination chemotherapy (dex, thalidomide, cis-platin, adriamycin, cyclophosphamide, etoposide) as induction prior to and consolidation after transplant. Methods: TT3 has accrued 247 of a target population of 300 patients; median follow-up is 16 months. Twenty-seven percent of patients were 65 yr and older; cytogenetic abnormalities (CA) were present in 31% and inter-phase FISH-based deletion 13 in 42%. Results: Median times to 1st and 2nd transplants were 3 mo and 5 mo, with projected completion rates of 95% and 82%. The cumulative frequency of CR plus near-CR was 50% at 6 mo, 75% at 12 mo, reaching 80% at 18 mo. Blood stem cells were readily procured, yielding ≥20 million CD34 cells/kg in > 95%. At 12 mo, 91% are alive and 89% event-free. Relapse has occurred in 29 patients, whose distinguishing features included age ≥ 65 yr (48% vs 24%, p = .005), abnormal cytogenetics (CA, 48% vs. 29%, p = .03) and LDH > ULN (48% vs 23%, p = .004). Among 21 deaths, baseline features were: creatinine >4 mg/dL in 4; age ≥ 65 yr in 11; PS > 3 in 5 and PS > 2 in 4; CRP > 10 mg/L in 9 patients. Conclusions: Introducing V in TT3 as part of combination chemotherapy is safe, permits robust stem cell collection and induces remarkably high CR plus near-CR rates. High-risk MM features such as CA and LDH, defined in Total Therapies 1 and 2, also appeared detrimental with TT3.

[Table: see text]

Effect on survival of treatment associated deep vein thrombosis in newly diagnosed multiple myeloma patients

7549

Background: Cancer patients experiencing thromboembolic disease have a poor prognosis. We report the effect on survival of treatment-associated DVT in myeloma patients. Methods: 668 newly diagnosed patients with progressive or symptomatic MM were enrolled in our Total Therapy 2 study, which included induction phase with VAD, DCEP, CAD and DCEP followed by high dose chemotherapy and tandem transplants. Patients were randomly assigned to receive Thalidomide or not during the whole treatment. Both arms otherwise received identical chemotherapy. Patients were followed and when clinically indicated underwent radiological studies to confirm a suspected DVT. If present, they were treated with low-molecular weight heparin followed by warfarin. Results: With a median follow up of 47 months a total of 158 patients experienced DVT; the median age was 57 years, 59% were male, 24% were IgA, 197 patients (30%) had abnormal cytogenetics (CA) including 100 patients with deletion of chromosome 13. The baseline characteristics were balanced between patients with and without DVT, with the exception of female gender, which was more prominent in the non DVT group (32% vs 46%, p = .018) on thalidomide, whereas CRP ≥ 8 mg/dl (57% vs 33%, p = .001), and IL6 > 9 pg/ml (47% vs 14%, p < .001) were more frequently observed in the DVT group on no thalidomide. Within each arm of the trial no significant differences in prognostic factors for survival (chromosomal abnormalities, low albumin level, β2-microglobulin, CRP) were seen. DVT status did not affect EFS (p = .3) or OS (p = .3) for the entire group, but a statistically longer EFS (p = .03) was observed in patients who developed a thromboembolic episode in the non thalidomide arm. No effect on survival (EFS p = .3; OS p = .95) was seen in the thalidomide arm. Conclusions: Development of DVT in newly diagnosed myeloma patients treated with chemotherapy ± thalidomide, does not affect overall survival. Patients not exposed to thalidomide who developed thrombosis during chemotherapy had significantly longer EFS. Our observation supports a survival benefit associated with anticoagulation therapy in cancer patients.

[Table: see text]

Malignant pleural effusion of multiple myeloma: prognostic factors and outcome

Malignant pleural effusion (MPE) in multiple myeloma (MM) is rare. Approximately 80 cases have been reported. To delineate optimal treatment and prognostic variables in these patients, we reviewed 11 MM patients with MPE. MPE developed at median of 12 months from diagnosis of MM. All the patients had high-risk disease based on complex karyotypic abnormalities including deletions of chromosome-13 (n=9), elevated beta-2 microglobulin (B2M) (n=9), high C-reactive protein (CRP) (n=8), high plasma cell labeling index (n=5) or high LDH (n=5). A significant increase in B2M, LDH, and CRP was observed at the onset of MPE. The initial diagnosis of MPE was based on positive cytology (n=9), pleural fluid cIg/DNA (n=9) or pleural fluid cytogenetics (n=4). Pleural tissue infiltration was found on pleural biopsy and autopsy in one patient each. Systemic chemotherapy comprising dexamethasone, cyclophosphamide, etoposide and cisplatin (DCEP) (n=7) and pleurodesis (n=7) were effective in resolving MPE but survival was short. High dose chemotherapy with peripheral blood stem cell support for MPE in six patients conferred no clear survival advantage. These patients died at median of four months from onset of MPE. Patients with bone marrow complex karyotypic abnormalities including deletion-13 (n=9) had a shorter (median--18 months) overall survival compared to patients with normal cytogenetics (median--38 months). MPE in patients with MM is often associated with high-risk disease including deletion 13 chromosomal abnormality and heralds a poor prognosis despite aggressive local and systemic treatment.

Autologous stem cell transplantation followed by consolidation chemotherapy for patients with multiple myeloma

Although high-dose therapy and autologous stem cell transplant (ASCT) is superior to conventional chemotherapy for treatment of myeloma, most patients relapse and the time to relapse depends upon the initial prognostic factors. The administration of non-cross-resistant chemotherapies during the post-transplant period may delay or prevent relapse. We prospectively studied the role of consolidation chemotherapy (CC) after single autologous peripheral blood stem cell transplant (auto-PBSCT) in 103 mostly newly diagnosed myeloma patients (67 patients were < or =6 months from the initial treatment). Patients received conditioning with BCNU, melphalan+/-gemcitabine and auto-PBSCT followed by two cycles of the DCEP+/-G regimen (dexamethasone, cyclophosphamide, etoposide, cisplatin+/-gemcitabine) at 3 and 9 months post-transplant and alternating with two cycles of DPP regimen (dexamethasone, cisplatin, paclitaxel) at 6 and 12 months post-transplant. With a median follow-up of 61.2 months, the median event-free survival (EFS) and overall survival (OS) are 26 and 54.1 months, respectively. The 5-year EFS and OS are 23.1 and 42.5%, respectively. Overall, 51 (49.5%) patients finished all CC, suggesting that a major limitation of this approach is an inability to deliver all planned treatments. In order to improve results following autotransplantation, novel agents or immunologic approaches should be studied in the post-transplant setting.

Clonal cytogenetic changes and myeloma relapse after reduced intensity conditioning allogeneic transplantation

To identify a correlation between metaphase cytogenetics and relapse after reduced intensity conditioning (RIC) allotransplant for patients with multiple myeloma, data on 60 patients (median age 52) who received grafts from a sibling (n = 49) or unrelated donor (n = 11) were analyzed. Fifty-three patients (88%) showed chromosomal abnormalities (CA) before the allotransplant, including 42 with abnormalities involving 13q (CA13). Twenty-two patients (41%) relapsed post-allotransplant at a median of 165 days. Of these, 11 patients showed abnormal cytogenetics at the time of post-allotransplant relapse at a median of 167 days. Of 54 patients who developed graft-versus-host disease, relapse occurred in 19 of 48 patients (43%) with CA present before RCI allotransplant, versus 1 of 6 without CA (17%) (P = 0.06). Loss of CA before RIC allotransplant and disease status > PR after RIC allotransplant were significantly associated with a lower risk of post-allotransplant relapse with cytogenetic abnormalities; 5.2 vs 36%, and 18 vs 53%, (both P < 0.05), respectively. The current data suggests that myeloma associated with persistent clonal cytogenetic abnormalities is an entity which most likely escapes the effects of a graft versus myeloma activity, maybe because of acquisition of resistance to immunologic manipulations.

18F-fluorodeoxyglucose positron emission tomography contributes to the diagnosis and management of infections in patients with multiple myeloma: a study of 165 infectious episodes

PURPOSE

Correctly identifying infection in cancer patients can be challenging. Limited data suggest that positron emission tomography (PET) using fluorine-18 fluorodeoxyglucose (FDG) may be useful for diagnosing infection. To determine the role of FDG-PET in the diagnosis of infection in patients with multiple myeloma (MM).

PATIENTS AND METHODS

The medical records of 248 patients who had FDG-PET performed for MM staging or infection work-up revealing increased uptake at extramedullary sites and/or bones and joints that would be atypical for MM between October 2001 and May 2004 were reviewed to identify infections and evaluate FDG-PET contribution to patient outcome.

RESULTS

One hundred sixty-five infections were identified in 143 adults with MM. Infections involved the respiratory tract [99; pneumonia (93), sinusitis (six)], bone, joint and soft tissues [26; discitis (10), osteomyelitis (nine), septic arthritis (one), cellulitis (six)], vascular system [18; septic thrombophlebitis (nine), infection of implantable catheter (eight), septic emboli (one)], gastrointestinal tract [12; colitis (seven), abdominal abscess (three), and diverticulitis and esophagitis (one each)], and dentition [periodontal abscess (10)]. Infections were caused by bacteria, mycobacteria, fungi, and viruses. FDG-PET detected infection even in patients with severe neutropenia and lymphopenia (30 episodes). The FDG-PET findings identified infections not detectable by other methods (46 episodes), determined extent of infection (32 episodes), and led to modification of work-up and therapy (55 episodes). Twenty silent, but clinically relevant, infections were detected among patients undergoing staging FDG-PET.

CONCLUSION

In patients with MM, FDG-PET is a useful tool for diagnosing and managing infections even in the setting of severe immunosuppression.

High-dose cyclophosphamide with or without etoposide for mobilization of peripheral blood progenitor cells in patients with multiple myeloma: efficacy and toxicity

The purpose of the study was to examine the yield of CD34(+) cells, response rates, and toxicity of high-dose cyclophosphamide with or without etoposide in patients with multiple myeloma. In total, 77 myeloma patients received either cyclophosphamide 4.5 g/m(2) (n=28) alone or with etoposide 2 g/m(2) (n=49) in a nonrandomized manner, followed by G-CSF 10 microg/kg/day for the purpose of stem cell mobilization. The effects of various factors on CD34(+) cell yield, response rate and engraftment were explored. A median of 22.39 x 10(6) CD34(+) cells/kg were collected on the first day of leukapheresis (range 0.59-114.71 x 10(6)/kg) in 71 (92%) of patients. Greater marrow plasma cell infiltration (P=0.02) or prior radiation therapy (P=0.02) adversely affected CD34(+) cell yield. In total, 45% of patients receiving cyclophosphamide and 56% of those receiving cyclophosphamide/etoposide had at least a minimum response by EBMT criteria. In all, 25% of patients who received cyclophosphamide alone vs 75.5% of patients who received combined chemotherapy required hospitalization mainly for treatment of neutropenic fever. Cyclophosphamide alone is associated with impressive CD34(+) cell yields and clear antimyeloma activity. The addition of etoposide resulted in increased toxicity without significant improvement in CD34(+) cell yield or response rates.

Psychosocial adjustment and quality of life among multiple myeloma patients undergoing evaluation for autologous stem cell transplantation

Stem cell transplantation has assumed a prominent place in the treatment of multiple myeloma, but relative to patients with other malignancies there is surprisingly little information about the adjustment difficulties and quality-of-life changes that these patients experience. This study examined psychosocial and functional deficits among myeloma patients assessed at a uniform period during their initial diagnostic evaluation, prior to beginning protocols at a transplant center. Validated self-report measures and clinician rating scales were used to assess 213 patients. Outcomes evaluated included emotional distress (Hospital Anxiety and Depression Scale, Brief Symptom Inventory), depression (Hamilton Depression Rating Scale), physical functioning, pain, and energy (SF-12). A significant proportion of patients experienced compromised psychosocial and physical functioning. Roughly one-third reported clinically elevated levels of distress, anxiety, and depression. In all, 59% scored below age-adjusted norms for daily physical functioning, 58% reported at least moderate levels of pain, and over 80% noted at least moderate fatigue. Clinical and demographic correlates of these outcomes were examined. These findings are among the first to characterize quality-of-life outcomes among myeloma patients in the transplant setting, and indicate that many patients experience considerable supportive care needs even prior to beginning aggressive regimens. Results highlight the importance of early screening.

Autologous stem cell transplantation followed by consolidation chemotherapy for relapsed or refractory Hodgkin's lymphoma

Relapse remains a major cause of treatment failure after autotransplantation (auto-PBSCT) for Hodgkin's disease (HD). The administration of non-crossresistant therapies during the post-transplant period may delay or prevent relapse. We prospectively studied the role of consolidation chemotherapy (CC) after auto-PBSCT in 37 patients with relapsed or refractory HD. Patients received high-dose gemcitabine-BCNU-melphalan and auto-PBSCT followed by involved-field radiation and up to four cycles of the DCEP-G regimen, which consisted of dexamethasone, cyclophosphamide, etoposide, cisplatin, gemcitabine given at 3 and 9 months post transplant alternating with a second regimen (DPP) of dexamethasone, cisplatin, paclitaxel at 6 and 12 months post transplant. The probabilities of event-free survival (EFS) and overall survival (OS) at 2.5 years were 59% (95% CI=42-76%) and 86% (95% CI=71-99%), respectively. In all, 17 patients received 54 courses of CC and 15 were surviving event free (2.5 years, EFS=87%). There were no treatment-related deaths during or after the CC phase. Post-transplant CC is feasible and well tolerated. The impact of this approach on EFS should be evaluated in a larger, randomized study.

High-level expression of cancer/testis antigen NY-ESO-1 and human granulocyte-macrophage colony-stimulating factor in dendritic cells with a bicistronic retroviral vector

Tumor-specific genes delivered to dendritic cells (DCs) have been used for the generation of cytotoxic T cells (CTLs), but their application has been limited on the one hand by low viral titers resulting in low transduction efficiency and poor protein production, and on the other hand by immunogenicity of the selectable marker and poor viability of the DCs. We addressed these limitations by creating a multipurpose master vector (pMV) and cloning the tumor gene NY-ESO-1, which is highly expressed in more than 50% of advanced myeloma patients. pMV was constructed from a Moloney murine leukemia virus (Mo-MuLV)-based retroviral backbone with the following features: (1) an extended packaging signal to achieve high viral titers, (2) a splice acceptor region to facilitate protein production, (3) a nonimmunogenic selectable marker, dihydrofolate reductase-L22Y (DHFR(L22Y)), to exclude the generation of CTLs against the selectable marker, (4) an internal ribosomal entry site between the tumor-specific gene (NY-ESO-1) and the selectable marker DHFR(L22Y) for coexpression of two heterologous gene products from a single bicistronic mRNA, minimizing the possibility of differential expression of these two genes, and (5) human granulocyte-macrophage colony-stimulating factor (hGM-CSF) cDNA driven by the human T-lymphotropic virus promoter to enhance DC function and viability. Recombinant virus of pMV-NY-ESO-1 was generated with vesicular stomatitis virus G envelope protein (VSV-G) in the GP2-293 cell line for efficient transduction. We present evidence that the DC phenotype is unaltered after transduction and that more than 85% of DCs express NY-ESO-1, which secrete approximately 40 ng of GM-CSF per 10(6) DCs.

Dialysis-dependent renal failure in patients with myeloma can be reversed by high-dose myeloablative therapy and autotransplant

To evaluate the role of high-dose melphalan and autologous transplant (AT) in reversing dialysis-dependent renal failure, 59 patients still on dialysis at the time of AT were analyzed. A total of 37 patients had been on dialysis < or =6 months. A 5-year event-free and overall survival rate of all patients after AT was 24 and 36%, respectively. Of 54 patients evaluable for renal function improvement, 13 (24%) became dialysis independent at a median of 4 months after AT (range: 1-16). Dialysis duration < or =6 months prior to first AT and pre-transplant creatinine clearance >10 ml/min were significant for renal function recovery: 12 of 36 (33%) < or =6 months vs one of 18 patients (6%) >6 months on dialysis recovered renal function; 10 of 26 (38%) with >10 ml/min vs three of 28 (11%) with < or =10 ml/min of creatinine clearance (both P<0.05). Quality of response after autotransplant was also significant: 12 of 31 (39%) being greater than partial remission after AT vs one of 21 patients (5%) attaining partial remission or less became independent of dialysis (P<0.05). Our data suggest that significant renal failure can be reversible and AT should be considered early in the disease course.

Transplantation as salvage therapy for high-risk patients with myeloma in relapse

Patients with myeloma relapsing after tandem transplant have a poor survival and treatment options are limited. The role of additional salvage transplant procedures for these patients is unknown. To evaluate the benefit and identify prognostic factors, the outcome of 76 consecutive patients with recurrent myeloma after tandem transplant receiving salvage transplants (ST) was analyzed. Prior to ST, 23 patients (30%) had shown chemosensitive response to preceding salvage chemotherapy: two complete remissions (CR); eight near CRs (nCR: only immunofixation positive); 13 partial remissions (PR >or=75% reduction in M protein). Fifty received an autologous transplant, 22 a sibling-matched allogeneic transplant, and four a matched-unrelated allogeneic transplant. Overall response after ST was 59%: eight CRs (11%); 14 nCRs (18%); 23 PRs (30%). Overall survival (OS) at 2 years was 19%; 2 year event-free survival rate (EFS) 7%. On univariate analysis for survival, only pre-transplant chemosensitive relapse (P < 0.05), serum albumin >3 g/dl (P = 0.001), normal LDH (P = 0.04), and long interval between the second transplant and relapse/progression were significant beneficial factors. In a Cox proportional hazard model, chemosensitive relapse, and albumin >3 g/dl were significant for better OS: hazard ratio (HR) 1.4, 1.7, respectively, while normal LDH, and absence of CA13 were significant for better EFS: HR 1.8, 1.7, respectively. Patients with albumin >3 g/dl who had chemosensitive disease before ST (n = 16) had a median survival of 16 months, compared to 7 months (n = 34) and 2 months (n = 26) for patients with only one (n = 34) or no favorable prognostic factors (n = 28), respectively (P < 0.001). Their survival at 2 years post-ST was 43%, 17% and 11%, respectively. Our study suggests further transplantation should only be considered in the setting of a clinical trial in patients with favorable prognostic factors.

Clinical activity of arsenic trioxide for the treatment of multiple myeloma

Arsenic has been used since ancient times as a therapeutic agent. However, until recently its use in modern medicine has been restricted to the treatment of a limited number of parasitic infections. In the early 1990s, reports from China described impressive results with arsenic trioxide in patients with de novo, relapsed, and refractory acute promyelocytic leukemia (APL). Other investigators subsequently confirmed these results leading to approval of its use for relapsed or refractory APL in the United States. Investigations of this agent have demonstrated that its efficacy in APL and preclinical tumor models is dependent upon a number of mechanisms, including induction of apoptosis, effects on cellular differentiation, cell cycling, and tumor angiogenesis. Subsequent preclinical studies showed significant activity of arsenic trioxide in multiple myeloma (MM). Based on this, in a phase II trial, we have evaluated the activity of arsenic trioxide in 14 patients with relapsed MM, refractory to conventional salvage therapy. With the dose and schedule used, treatment with arsenic trioxide produced responses in three patients and prolonged stable disease in a fourth patient, with the longest response lasting 6 weeks. Although treatment was reasonably well tolerated, in these patients with extensive prior therapy, 11 developed cytopenia, five associated with infectious complications and three developed deep vein thromboses. The results of this small trial support further investigation of this novel drug for the treatment of patients with relapsed or refractory MM.

Separating graft-versus-tumor from graft-versus-host reactions

The full therapeutic potential of allogeneic stem cell transplantation, through its immunologically mediated graft-versus-tumor effect, in patients with hematologic malignancies is greatly compromised by the occurrence of graft-versus-host disease. Unfortunately, the use of non-selective immunosuppressive agents to reduce the incidence and severity of graft-versus-host disease is associated with severe immune compromise of the host and most likely a greater relapse risk of the underlying malignancy. Many attempts have been made to clinically separate these two effects. A critical overview of the published experience is the focus of this report. As the effector cells responsible for the two reactions are largely unknown, the limited success of the various approaches used is not surprising. A more thorough understanding of the antigenic stimuli involved in the initiation of the two reactions and of the molecular pathways through which the cytotoxic effects of T-cells are mediated is essential for abrogating graft-versus-host disease while preserving the graft-versus-tumor effect.