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Ladbury CJ, Sanchez JF, Chowdhury A, Palmer J, Liu A, Stein A, Htut M, Farol L, Cai JL, Somlo G, Rosenzweig M, Wong JYC, Sahebi F. Phase I Study of Bortezomib, Fludarabine, and Melphalan, with or without Total Marrow Irradiation as Conditioning for Allogeneic Hematopoietic Stem Cell Transplantation in Patients with High-Risk or Relapsed/Refractory Multiple Myeloma. Int J Radiat Oncol Biol Phys 2023; 117:S107-S108. [PMID: 37784283 DOI: 10.1016/j.ijrobp.2023.06.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Though outcomes of patients with multiple myeloma (MM) have improved, cure remains elusive. Allogeneic hematopoietic stem cell transplantation (allo-sCT) is associated with a lower relapse rate, but its role is hindered due to toxicities. We hypothesized that targeted total body irradiation in the form of total marrow irradiation (TMI) could safely facilitate allo-SCT via an improved toxicity profile. Therefore, we conducted a phase I study to investigate the safety and feasibility of a bortezomib (BTZ), fludarabine (FLU), and melphalan (MEL), with or without TMI, prior to allo-SCT for patients with high-risk (HR) or relapsed/refractory (R/R) MM. MATERIALS/METHODS Between 2012 and 2018 this study enrolled patients with HR or R/R MM on one of two strata, each comprising BTZ dose-escalation cohorts. Patients aged 18-60 with no prior radiation (RT) received TMI at 900 cGy (in 6 fractions delivered twice-daily), FLU, and MEL conditioning, with BTZ added in the second cohort (stratum I). Patients aged 18-70 with prior RT received FLU, MEL, and BTZ, without TMI (stratum II). The primary endpoint was feasibility of escalating doses of BTZ, with or without TMI, defined using a 3+3 design. Dose-limiting toxicity (DLT) was defined as any Grade 3+ Bearman toxicity or prolonged CTCAE v4.0 Grade 4+ neutropenia. Secondary endpoints included treatment response, time to neutrophil and platelet engraftment, incidence of acute (a) and chronic (c) graft-versus-host disease (GVHD), progression-free-survival (PFS), and overall survival (OS). RESULTS Eight patients were enrolled on stratum I. One of three patients in the first cohort of stratum I experienced DLT, which led to expansion to three more patients with no DLT. Cohort 2 enrolled only 2 patients due to low accrual, with BTZ added at 0.5 mg/m2; neither experienced DLT. Nine patients were enrolled on stratum II. Three patients were enrolled on cohort 1 (BTZ 0.5 mg/m2) and none experienced DLT. Three were enrolled on cohort 2 (bortezomib 0.7 mg/m2), and one experienced DLT. Therefore, the cohort expanded to three more patients. One more patient experienced DLT and 0.5 mg/m2 was considered the maximum tolerated dose. There were no primary or secondary graft failures. Complete response was achieved in 7 and 4 patients in strata I and II, respectively. Median follow-up for all patients was 30.7 months (mos) and was 99.8 mos for surviving patients. Median overall survival (OS) on strata I and II were 44.5 mos and 21.6 mos, respectively. Median PFS on strata I and II were 18.1 mos and 8.9 mos, respectively. In strata I, 5 patients developed Grade 2+ aGVHD and 8 developed extensive cGVHD. In strata II, 4 patients developed Grade 2+ aGVHD and 6 developed extensive cGVHD. CONCLUSION The TMI 900 cGy, FLU, and MEL conditioning regimen is considered safe as conditioning for allo-SCT and may warrant further investigation due to favorable response rates and survival; the conditioning regimen of FLU, MEL, and BTZ (0.7 mg/m2) is associated with unacceptable toxicities.
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Affiliation(s)
- C J Ladbury
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA
| | - J F Sanchez
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - A Chowdhury
- Division of Biostatistics, City of Hope National Medical Center, Duarte, CA
| | - J Palmer
- Division of Biostatistics, City of Hope National Medical Center, Duarte, CA
| | - A Liu
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA
| | - A Stein
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - M Htut
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - L Farol
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - J L Cai
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - G Somlo
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - M Rosenzweig
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - J Y C Wong
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA
| | - F Sahebi
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
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Stein A, Al Malki M, Yang D, Liu A, Han C, Palmer J, Dandapani S, Farol L, Hui S, Marcucci G, Nakamura R, Pullarkat V, Rosenthal J, Salhotra A, Spielberger R, Forman S, Wong J. Total Marrow and Lymphoid Irradiation to 20 Gy Combined With Post-Transplant Cyclophosphamide Graft vs. Host Disease (GvHD) Prophylaxis is Associated With Low Non-Relapse Mortality Rates and Favorable GvHD-Free/Relapse-Free Survival in AML. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Krishnan A, Wang S, Htut M, Farol L, Palmer J, Quazi I, Forman S, Tsai N, Forman S. Cyclophosphamide Priming with Intravenous Plerixafor and GCSF Mobilization for Multiple Myeloma. Biol Blood Marrow Transplant 2012. [DOI: 10.1016/j.bbmt.2011.12.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Stein A, Wong J, O'Donnell M, Synder D, Palmer J, Tsai NC, Parker P, Farol L, Spielberger R, Sahebi F, Kogut N, Forman S. Phase I Trial of Escalated Doses of Targeted Marrow Radiation Delivered By Tomotherapy Combined With Etoposide and Cyclophosphamide; an Allogeneic HCT Preparative Regimen for Patients With Advanced Leukemia. Biol Blood Marrow Transplant 2011. [DOI: 10.1016/j.bbmt.2010.12.285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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