1
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Tam CS, Kapoor P, Castillo JJ, Buske C, Ansell SM, Branagan AR, Kimby E, Li Y, Palomba ML, Qiu L, Shadman M, Abeykoon JP, Sarosiek S, Vos J, Yi S, Stephens D, Roos-Weil D, Roccaro AM, Morel P, Munshi NC, Anderson KC, San-Miguel J, Garcia-Sanz R, Dimopoulos MA, Treon SP, Kersten MJ. Report of consensus panel 7 from the 11th international workshop on Waldenström macroglobulinemia on priorities for novel clinical trials. Semin Hematol 2023; 60:118-124. [PMID: 37099031 DOI: 10.1053/j.seminhematol.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 04/27/2023]
Abstract
Recent advances in the understanding of Waldenström macroglobulinemia (WM) biology have impacted the development of effective novel agents and improved our knowledge of how the genomic background of WM may influence selection of therapy. Consensus Panel 7 (CP7) of the 11th International Workshop on WM was convened to examine the current generation of completed and ongoing clinical trials involving novel agents, consider updated data on WM genomics, and make recommendations on the design and prioritization of future clinical trials. CP7 considers limited duration and novel-novel agent combinations to be the priority for the next generation of clinical trials. Evaluation of MYD88, CXCR4 and TP53 at baseline in the context of clinical trials is crucial. The common chemoimmunotherapy backbones, bendamustine-rituximab (BR) and dexamethasone, rituximab and cyclophosphamide (DRC), may be considered standard-of-care for the frontline comparative studies. Key unanswered questions include the definition of frailty in WM; the importance of attaining a very good partial response or better (≥VGPR), within stipulated time frame, in determining survival outcomes; and the optimal treatment of WM populations with special needs.
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Affiliation(s)
- C S Tam
- Alfred Health, Monash University, Melbourne, Victoria, Australia.
| | | | - J J Castillo
- Harvard Medical School, Dana Farber Cancer Institute, Boston. MA
| | - C Buske
- Institute of Experimental Cancer Research, University Hospital Ulm, Ulm, Germany
| | | | | | - E Kimby
- Karolinska Institut, Stockholm, Sweden
| | - Y Li
- Baylor College of Medicine, Houston, TX
| | - M L Palomba
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - L Qiu
- National National Clinical Medical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - M Shadman
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA
| | | | - S Sarosiek
- Harvard Medical School, Dana Farber Cancer Institute, Boston. MA
| | - Jmi Vos
- Department of Hematology, Cancer Center Amsterdam/LYMMCARE, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Yi
- National National Clinical Medical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - D Stephens
- University of Utah Huntsman Cancer Institute, Salt Lake City, UT
| | - D Roos-Weil
- Sorbonne University, Hematology Unit, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | | | - P Morel
- Hematologie Clinique et Therapie Cellulaire, University Hospital Amiens Picardie, University of Picardie Jules Verne, France
| | - N C Munshi
- Institute of Experimental Cancer Research, University Hospital Ulm, Ulm, Germany
| | - K C Anderson
- Institute of Experimental Cancer Research, University Hospital Ulm, Ulm, Germany
| | - J San-Miguel
- Clinica Universidad de Navarra, CCUN, CIMA, IDISNA, CIBERONC, Navarra, Spain
| | - R Garcia-Sanz
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca, CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
| | - M A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - S P Treon
- Institute of Experimental Cancer Research, University Hospital Ulm, Ulm, Germany
| | - M J Kersten
- Tianjin Institutes of Health Science, Tianjin 301600, China
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2
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Terpos E, Branagan AR, García-Sanz R, Trotman J, Greenberger LM, Stephens DM, Morel P, Kimby E, Frustaci AM, Hatjiharissi E, San-Miguel J, Dimopoulos MA, Treon SP, Leblond V. Report of consensus panel 5 from the 11th international workshop on Waldenstrom's macroglobulinemia on COVID-19 prophylaxis and management. Semin Hematol 2023; 60:107-112. [PMID: 37099029 PMCID: PMC10050191 DOI: 10.1053/j.seminhematol.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 03/09/2023] [Indexed: 03/31/2023]
Abstract
Consensus Panel 5 (CP5) of the 11th International Workshop on Waldenstrom's Macroglobulinemia (IWWM-11; held in October 2022) was tasked with reviewing the current data on the coronavirus disease-2019 (COVID-19) prophylaxis and management in patients with Waldenstrom's Macroglobulinemia (WM). The key recommendations from IWWM-11 CP5 included the following: Booster vaccines for SARS-CoV-2 should be recommended to all patients with WM. Variant-specific booster vaccines, such as the bivalent vaccine for the ancestral Wuhan strain and the Omicron BA.4.5 strain, are important as novel mutants emerge and become dominant in the community. A temporary interruption in Bruton's Tyrosine Kinase-inhibitor (BTKi) or chemoimmunotherapy before vaccination might be considered. Patients under treatment with rituximab or BTK-inhibitors have lower antibody responses against SARS-CoV-2; thus, they should continue to follow preventive measures, including mask wearing and avoiding crowded places. Patients with WM are candidates for preexposure prophylaxis, if available and relevant to the dominant SARS-CoV-2 strains in a specific area. Oral antivirals should be offered to all symptomatic WM patients with mild to moderate COVID-19 regardless of vaccination, disease status or treatment, as soon as possible after the positive test and within 5 days of COVID-19-related symptom onset. Coadministration of ibrutinib or venetoclax with ritonavir should be avoided. In these patients, remdesivir offers an effective alternative. Patients with asymptomatic or oligosymptomatic COVID-19 should not interrupt treatment with a BTK inhibitor. Infection prophylaxis is essential in patients with WM and include general preventive measures, prophylaxis with antivirals and vaccination against common pathogens including SARS-CoV-2, influenza, and S. pneumoniae.
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Affiliation(s)
- E Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
| | - A R Branagan
- Center for Multiple Myeloma, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - R García-Sanz
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca, CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
| | - J Trotman
- Hematology Department, Concord Repatriation General Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | | | - D M Stephens
- Division of Hematology/Hematologic Malignancies Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT
| | - P Morel
- Hematology Department, University Hospital Amiens- Picardie, Amiens, France
| | - E Kimby
- Department of Medicine, Unit of Hematology, Karolinska Institutet, Stockholm, Sweden
| | - A M Frustaci
- ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milan, Italy
| | - E Hatjiharissi
- Division of Hematology, 1st Department of Internal Medicine, AHEPA University Hospital of Thessaloniki, Thessaloniki, Greece
| | - J San-Miguel
- Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Instituto de Investigación Sanitaria de Navarra, Centro de Investigación Biomédica en Red Cáncer, Pamplona, Spain
| | - M A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - S P Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA; Department of Medicine, Harvard Medical School, Boston, MA
| | - V Leblond
- Service d'Hématologie Clinique, Sorbonne University, Pitié Salpêtrière Hospital, Paris, France
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3
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D'Sa S, Matous JV, Advani R, Buske C, Castillo JJ, Gatt M, Kapoor P, Kersten MJ, Leblond V, Leiba M, Palomba ML, Paludo J, Qiu L, Sarosiek S, Shadman M, Talaulikar D, Tam CS, Tedeschi A, Thomas SK, Tohidi-Esfahani I, Trotman J, Varettoni M, Vos J, Garcia-Sanz R, San-Miguel J, Dimopoulos MA, Treon SP, Kastritis E. Report of consensus panel 2 from the 11th international workshop on Waldenström's macroglobulinemia on the management of relapsed or refractory WM patients. Semin Hematol 2023; 60:80-89. [PMID: 37147252 DOI: 10.1053/j.seminhematol.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 03/09/2023] [Indexed: 03/29/2023]
Abstract
The consensus panel 2 (CP2) of the 11th International Workshop on Waldenström's macroglobulinemia (IWWM-11) has reviewed and incorporated current data to update the recommendations for treatment approaches in patients with relapsed or refractory WM (RRWM). The key recommendations from IWWM-11 CP2 include: (1) Chemoimmunotherapy (CIT) and/or a covalent Bruton tyrosine kinase (cBTKi) strategies are important options; their use should reflect the prior upfront strategy and are subject to their availability. (2) In selecting treatment, biological age, co-morbidities and fitness are important; nature of relapse, disease phenotype and WM-related complications, patient preferences and hematopoietic reserve are also critical factors while the composition of the BM disease and mutational status (MYD88, CXCR4, TP53) should also be noted. (3) The trigger for initiating treatment in RRWM should utilize knowledge of patients' prior disease characteristics to avoid unnecessary delays. (4) Risk factors for cBTKi related toxicities (cardiovascular dysfunction, bleeding risk and concurrent medication) should be addressed when choosing cBTKi. Mutational status (MYD88, CXCR4) may influence the cBTKi efficacy, and the role of TP53 disruptions requires further study) in the event of cBTKi failure dose intensity could be up titrated subject to toxicities. Options after BTKi failure include CIT with a non-cross-reactive regimen to one previously used CIT, addition of anti-CD20 antibody to BTKi, switching to a newer cBTKi or non-covalent BTKi, proteasome inhibitors, BCL-2 inhibitors, and new anti-CD20 combinations are additional options. Clinical trial participation should be encouraged for all patients with RRWM.
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Affiliation(s)
- S D'Sa
- UCLH Centre for Waldenström Macroglobulinaemia and Related Conditions, University College London Hospitals NHS Foundation Trust, London, UK.
| | - J V Matous
- Colorado Blood Cancer Institute, Sarah Cannon Research Institute, Denver, CO
| | - R Advani
- Stanford University Medical Center, Stanford, CA
| | - C Buske
- University Hospital Ulm, Ulm, Germany
| | - J J Castillo
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - M Gatt
- Hadassah University Medical Center, Jerusalem, Israel
| | | | - M J Kersten
- Amsterdam UMC, University of Amsterdam, Department of Hematology, Cancer Center Amsterdam/LYMMCARE, Amsterdam, Netherlands
| | - V Leblond
- Groupe Hospitalier Pitié-Salpêtrière, Sorbonne University, Paris, France
| | - M Leiba
- Assuta Ashdod University Hospital; Faculty of Health Science, Ben-Gurion University of the Negev, Negev, Israel Memorial Sloan Kettering Cancer Center, New York, NY
| | - M L Palomba
- Memorial Sloan Kettering Cancer Center, New York NY US
| | | | - L Qiu
- National Clinical Medical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - S Sarosiek
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | - D Talaulikar
- ANU College of Health and Medicine, Canberra, Australia
| | - C S Tam
- Alfred Health, Monash University, Melbourne, Australia
| | - A Tedeschi
- A. O. Ospedale Niguarda Ca' Granda, Milan, Italy
| | - S K Thomas
- University of Texas, MD Anderson Cancer Center, Houston TX USA
| | - I Tohidi-Esfahani
- Concord Repatriation General Hospital, University of Sydney, Sydney, Australia
| | - J Trotman
- Concord Repatriation General Hospital, University of Sydney, Sydney, Australia
| | - M Varettoni
- Division of Hematology, Fondazione iRCCS Policlinico, San Matteo, Italy
| | - Jmi Vos
- Amsterdam UMC, University of Amsterdam, Department of Hematology, Cancer Center Amsterdam/LYMMCARE, Amsterdam, Netherlands
| | - R Garcia-Sanz
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca, CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
| | - J San-Miguel
- Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Instituto de Investigación Sanitaria de Navarra, Centro de Investigación Biomédica en Red Cáncer, Pamplona, Spain
| | - M A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - S P Treon
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - E Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
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4
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Nikolaou PE, Georgoulis A, Liacos C, Makridakis M, Efentakis P, Baltatzis G, Mavroidi B, Pelecanou M, Vlachou A, Terpos E, Vorgias CE, Dimopoulos MA, Kastritis E, Andreadou I. Understanding the molecular mosaic of cardiotoxicity of light chains in plasma cell dyscrasias and cardiac light chain amyloidosis with the use of patient derived full-length light chains. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2987] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Cardiac light chain amyloidosis (AL-CA) is a life-threatening disease and the major determinant of prognosis in AL amyloidosis. The management of heart failure (HF) in AL is challenging and gold standard therapies for HF are poorly tolerated or ineffective. Cardiac toxicity of LCs in AL-CA is poorly understood and the comparison of cardiotoxicity of LCs derived from plasma cell dyscrasias (PCDs) such as multiple myeloma (MM) and monoclonal gammopathy of undetermined significance (MGUS), will improve our understanding of the mechanisms of cardiac damage.
Purpose
We aimed to 1) genetically identify and biotechnologically produce full-length LCs from patients with AL-CA, MM, MGUS or non-clonal LCs from healthy volunteers (HV), 2) identify LCs' cardiotoxicity and 3) investigate the underlying mechanisms of cardiotoxicity in vitro.
Methods
Bone marrow derived CD138+ cells from n=7 patients with AL-CA, n=2 patients with MM and n=2 patients with MGUS and peripheral blood mononuclear cells (PBMCs) from n=2 HV were isolated for RNA extraction and characterization of the LC gene family repertoire. At the protein level, LC expression was confirmed by immunoprecipitation in patients' serum followed by top-down proteomics. The overexpressed LC genes in each patient, encoding the full-length clonal LCs were cloned and produced in Shuffle E. coli cells. Two LCs were produced from HV based on the primary protein structure similarity with the patients' LCs. Primary adult ventricular murine cardiomyocytes (pAVMCs) were isolated and exposed at various LC concentrations for evaluation of cell death and investigation of the cardiotoxicity mechanisms via gene and protein expression. LCs folding, oligomerization and amyloidogenic potential were assessed via circular dichroism (CD), SDS page and electron microscopy respectively.
Results
We successfully identified the LCs responsible for the disease and isolated the respective proteins in all cases (7 AL-CA, 2 MM, 2 MGUS and 3 HV). Despite the similarity of the LCs in conformation as beta-sheet and oligomerization mainly as dimers, 5 out of 7 AL-CA derived LCs led to a different extent of cardiotoxicity in pAVMCs compared to the HV, MM and MGUS derived LCs which did not alter cell viability. Interestingly, these 5 LCs bared the highest amyloidogenic potency. LCs induced different molecular responses leading to cardiomyocyte death. AL-CA proteins κ-type induced apoptosis and overexpression of endoplasmic reticulum stress (ERS) markers while LCs λ-type increased unfolded protein response (UPR) markers and autophagy without inducing apoptosis. All LCs of κ-type including from MM and MGUS patients led to inteleukin-6 mediated inflammation indicating that this mechanism is independent of the observed toxicity.
Conclusions
AL-CA derived LCs induce cardiotoxicity, which correlates to their amyloidogenic potential via ERS, UPR, autophagy and apoptosis which can be considered targets for cardioprotection.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): Hellenic Foundation for Research and Innovation
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Affiliation(s)
- P E Nikolaou
- National & Kapodistrian University of Athens , Athens , Greece
| | - A Georgoulis
- National & Kapodistrian University of Athens , Athens , Greece
| | - C Liacos
- National & Kapodistrian University of Athens Medical School , Athens , Greece
| | - M Makridakis
- Academy of Athens Biomedical Research Foundation , Athens , Greece
| | - P Efentakis
- National & Kapodistrian University of Athens , Athens , Greece
| | - G Baltatzis
- National & Kapodistrian University of Athens Medical School , Athens , Greece
| | - B Mavroidi
- National Center for Scientific Research Democritus , Athens , Greece
| | - M Pelecanou
- National Center for Scientific Research Democritus , Athens , Greece
| | - A Vlachou
- Academy of Athens Biomedical Research Foundation , Athens , Greece
| | - E Terpos
- National & Kapodistrian University of Athens Medical School , Athens , Greece
| | - C E Vorgias
- National & Kapodistrian University of Athens , Athens , Greece
| | - M A Dimopoulos
- National & Kapodistrian University of Athens Medical School , Athens , Greece
| | - E Kastritis
- National & Kapodistrian University of Athens Medical School , Athens , Greece
| | - I Andreadou
- National & Kapodistrian University of Athens , Athens , Greece
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5
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Patras R, Georgiopoulos G, Petropoulos I, Theodorakakou F, Delialis D, Angelidakis L, Gavriatopoulou M, Dimopoulou MA, Sianis A, Maneta E, Neofytou O, Terpos E, Dimopoulos MA, Kastritis E, Stamatelopoulos K. Sustained vasodilation after cold pressor test is an independent predictor of poor survival in primary AL amyloidosis. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1790] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Primary AL amyloidosis is a rare yet lethal systemic disorder. Dysfunction of the autonomous nervous system due to disease-related nerve infiltration is a common manifestation of AL amyloidosis. Previously published own work indicated that AL patients present sustained paradoxical vasodilation in response to sympathetic stimulus, as assessed by cold pressor test (CPT). The clinical relevance of this finding is unknown.
Purpose
We sought to investigate the relationship between CPT-induced vascular response and mortality in AL amyloidosis.
Methods
We consecutively recruited 97 newly diagnosed patients with AL amyloidosis. CPT of the brachial artery was performed before treatment initiation. All measurements were assessed using high resolution ultrasonography (14.0Mhz multifrequency linear array probe, Vivid 7 Pro; General Electric Healthcare, Milwaukee, Wisconsin, USA). The maximum vasodilation of the brachial artery was measured during the sympathetic stimulus and 3 minutes after withdrawal (sustained response). All-cause mortality was defined as the primary end-point of the study.
Results
Mean age was 66 years with prevalence of male gender. Sustained vasodilation (but not vasodilation during CPT) was associated with heart failure, NYHA stage, BNP and peripheral vascular involvement (p<0.05 for all). Sustained vasodilation after withdrawal of the sympathetic stimulus was significantly associated with mortality as assessed by Cox regression analysis (HR: 1.149, 95% CI 1.042–1.269, p=0.005). This association remained significant after adjustment for age, sex, systolic blood pressure (SBP), nerve involvement and Mayo stage (HR: 1.123, 95% CI 1.014–1.243, p=0.026). A sustained vasodilation ≥3.35% from pre-stimulus diameter was associated with shorter survival (log-rank test, p=0.022, Figure 1). No association between vasodilation during sympathetic stress and mortality was observed.
Conclusions
In AL amyloidosis, sustained paradoxical vasodilation in response to sympathetic stimulus was associated with poor survival. The clinical utility of this index of vascular autonomic dysfunction as a potential prognostic and therapeutic biomarker in AL amyloidosis merits further investigation.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- R Patras
- University of Athens Medical School, Department of Clinical Therapeutics , Athens , Greece
| | - G Georgiopoulos
- University of Athens Medical School, Department of Clinical Therapeutics , Athens , Greece
| | - I Petropoulos
- University of Athens Medical School, Department of Clinical Therapeutics , Athens , Greece
| | - F Theodorakakou
- University of Athens Medical School, Department of Clinical Therapeutics , Athens , Greece
| | - D Delialis
- University of Athens Medical School, Department of Clinical Therapeutics , Athens , Greece
| | - L Angelidakis
- University of Athens Medical School, Department of Clinical Therapeutics , Athens , Greece
| | - M Gavriatopoulou
- University of Athens Medical School, Department of Clinical Therapeutics , Athens , Greece
| | - M A Dimopoulou
- University of Athens Medical School, Department of Clinical Therapeutics , Athens , Greece
| | - A Sianis
- University of Athens Medical School, Department of Clinical Therapeutics , Athens , Greece
| | - E Maneta
- University of Athens Medical School, Department of Clinical Therapeutics , Athens , Greece
| | - O Neofytou
- University of Athens Medical School, Department of Clinical Therapeutics , Athens , Greece
| | - E Terpos
- University of Athens Medical School, Department of Clinical Therapeutics , Athens , Greece
| | - M A Dimopoulos
- University of Athens Medical School, Department of Clinical Therapeutics , Athens , Greece
| | - E Kastritis
- University of Athens Medical School, Department of Clinical Therapeutics , Athens , Greece
| | - K Stamatelopoulos
- University of Athens Medical School, Department of Clinical Therapeutics , Athens , Greece
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6
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Ikonomidis I, Kountouri A, Mitrakou A, Thymis J, Katogiannis K, Korakas E, Varlamos C, Bamias A, Thomas K, Andreadou I, Tsoumani M, Kavatha D, Antoniadou A, Dimopoulos MA, Lambadiari V. SARS-CoV-2 is associated withabnormal biomarkers of oxidative stress,and endothelial function linked with cardiovascular dysfunction four months after the infection. Eur Heart J 2022. [PMCID: PMC9619520 DOI: 10.1093/eurheartj/ehac544.153] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction COVID-19 infection has been associated with increase arterial stiffness, endothelialdysfunction, and impairment in coronary and cardiac performance. Inflammation and oxidative stress have beensuggested as possible pathophysiological mechanisms leading to vascular and endothelial deregulation afterCOVID-19 infection. Purpose The objective of our study is to evaluate premature alterations in arterial stiffness, endothelial,coronary, and myocardial function markers four months after SARS-CoV-2 infection. Methods In a case-control prospective study, we included 70 patients 4 months after COVID-19 infection, 70 age- and sex-matched untreated hypertensive patients (positive control) and 70 healthy individuals. We measured (i) perfused boundary region (PBR) of the sublingual arterial microvessels (increased PBR indicates reduced endothelial glycocalyx thickness), (ii) flow-mediated dilatation (FMD), (iii) coronary flow reserve (CFR) by Doppler echocardiography, (iv) pulse wave velocity (PWV) and central systolic blood pressure (cSBP), (v) global left and right ventricular longitudinal strain (GLS), (vi) malondialdehyde (MDA), an oxidative stress marker, thrombomodulin and von Willebrand factor as endothelial biomarkers. Results COVID-19 patients had similar CFR and FMD with hypertensives (2.48±0.41 vs 2.58±0.88, p=0.562, 5.86±2.82% vs 5.80±2.07%, p=0.872 respectively) but lower values than controls (3.42±0.65, p=0.0135, 9.06±2.11%, p=0.002 respectively). Compared to controls, both COVID-19 and hypertensives had greater PBR5–25 (2.07±0.15μm and 2.07±0.26μm p=0.8 vs 1.89±0.17μm, p=0.001), higher PWV, (12.09±2.50 vs 11.92±2.94, p=0.7 vs 10.04±1.80m/sec, p=0.036) increased cSBP (128.43±17.39 vs 135.17±16.83 vs 117.89±18.85) and impaired LV and RV GLS (−19.50±2.56% vs −19.23±2.67%, p=0.864 vs −21.98±1.51%, p=0.020 and −16.99±3.17% vs −18.63±3.20%, p=0.002 vs −20.51±2.28%, p<0.001). MDA and thrombomodulin were higher in COVID-19 patients than both hypertensives and controls (10.67±2.75 vs 1.76±0.30, p=0.003 vs 1.01±0.50nmole/L, p=0.001 and 3716.63±188.36 vs 3114.46±179.18, p=0.017 vs 2590.02±156.51pg/ml, p<0.001). COVID-19 patients displayed similar vWF values with hypertensives but higher compared with healthy controls (4018.03±474.31 vs 3756.65±293.28 vs 2079.33±855.10 ng/ml, p=0.718 and p=0.016 respectively). Conclusions SARS-CoV-2 infection is associated with oxidative stress, endothelial and vascular dysfunction, which are linked to impaired longitudinal myocardial deformation 4 months after COVID-19 infection. Funding Acknowledgement Type of funding sources: None.
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Affiliation(s)
- I Ikonomidis
- National & Kapodistrian University of Athens , Athens , Greece
| | - A Kountouri
- Attikon University Hospital, 2nd Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School , Athens , Greece
| | - A Mitrakou
- Alexandra University Hospital, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Medical School , Athens , Greece
| | - J Thymis
- National & Kapodistrian University of Athens, Attikon University Hospital, 2nd Cardiology Department , Athens , Greece
| | - K Katogiannis
- National & Kapodistrian University of Athens, Attikon University Hospital, 2nd Cardiology Department , Athens , Greece
| | - E Korakas
- Attikon University Hospital, 2nd Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School , Athens , Greece
| | - C Varlamos
- National & Kapodistrian University of Athens, Attikon University Hospital, 2nd Cardiology Department , Athens , Greece
| | - A Bamias
- Attikon University Hospital, 2nd Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School , Athens , Greece
| | - K Thomas
- Attikon University Hospital, Forth Department of Internal Medicine , Athens , Greece
| | - I Andreadou
- National & Kapodistrian University of Athens, Laboratory of Pharmacology, Faculty of Pharmacy , Athens , Greece
| | - M Tsoumani
- National & Kapodistrian University of Athens, Laboratory of Pharmacology, Faculty of Pharmacy , Athens , Greece
| | - D Kavatha
- Attikon University Hospital, Forth Department of Internal Medicine , Athens , Greece
| | - A Antoniadou
- Attikon University Hospital, Forth Department of Internal Medicine , Athens , Greece
| | - M A Dimopoulos
- Alexandra University Hospital, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Medical School , Athens , Greece
| | - V Lambadiari
- Attikon University Hospital, 2nd Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School , Athens , Greece
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7
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Dimopoulos MA, Moreau P, Terpos E, Mateos MV, Zweegman S, Cook G, Delforge M, Hájek R, Schjesvold F, Cavo M, Goldschmidt H, Facon T, Einsele H, Boccadoro M, San-Miguel J, Sonneveld P, Mey U. Corrigendum to "Corrigendum to 'Multiple myeloma: EHA-ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up'": [Ann Oncol Volume 33, Issue 1, January 2022, Page 117]. Ann Oncol 2022; 33:988. [PMID: 35810138 DOI: 10.1016/j.annonc.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- M A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - P Moreau
- Department of Hematology, University Hospital Hôtel-Dieu, Nantes, France
| | - E Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - M V Mateos
- University Hospital of Salamanca, IBSAL, Cancer Research Center, Salamanca, Spain
| | - S Zweegman
- Department of Hematology, Amsterdam, UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - G Cook
- Leeds Cancer Centre and University of Leeds, Leeds, UK
| | - M Delforge
- Department of Hematology, University Hospital Leuven, Leuven, Belgium
| | - R Hájek
- Faculty of Medicine, University Hospital Ostrava, Ostrava, Czech Republic
| | - F Schjesvold
- Oslo Myeloma Center, Oslo, University Hospital, Oslo; KG Jebsen Center for B Cell Malignancies, University of Oslo, Oslo, Norway
| | - M Cavo
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy; Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - H Goldschmidt
- University Hospital Heidelberg, Internal Medicine V and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - T Facon
- Hôpital Claude Huriez, Lille University Hospital, Lille, France
| | - H Einsele
- Department of Internal Medicine II, University Hospital Wurzburg, Wurzburg, Germany
| | - M Boccadoro
- Division of Hematology, University of Torino, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - J San-Miguel
- Clinica Universidad de Navarra, CIMA, IDISNA, CIBERONC, Pamplona, Spain
| | - P Sonneveld
- Erasmus Medical Center Cancer Institute, Rotterdam, Netherlands
| | - U Mey
- Department of Oncology and Hematology, Kantonsspital Graubünden, Chur, Switzerland
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8
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Jaccard A, Bridoux F, Roeloffzen W, Minnema MC, Bergantim R, Hájek R, João C, Cibeira MT, Palladini G, Schönland S, Merlini G, Milani P, Dimopoulos MA, Ravichandran S, Hegenbart U, Agis H, Gros B, Asra A, Dergarabetian E, Magarotto V, Leonidakis A, Cheliotis G, Sonneveld P, Wechalekar A, Kastritis E. P1714: HEALTHCARE RESOURCE UTILIZATION IN PATIENTS WITH LIGHT CHAIN AMYLOIDOSIS IN EUROPE. Hemasphere 2022. [PMCID: PMC9429565 DOI: 10.1097/01.hs9.0000849712.10352.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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9
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Katogiannis K, Ikonomidis I, Thymis J, Mitrakou A, Kountouri A, Stamoulis K, Korakas E, Varlamos C, Andreadou I, Tsoumani M, Bamias A, Thomas K, Antoniadou A, Dimopoulos MA, Lambadiari V. Association of COVID-19 with impaired endothelial glycocalyx, vascular function and myocardial efficiency four months after infection. Eur Heart J Cardiovasc Imaging 2022. [PMCID: PMC9383395 DOI: 10.1093/ehjci/jeab289.065] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Aims
SARS-CoV-2 infection may lead to endothelial and vascular dysfunction. We
investigated alterations of arterial stiffness, endothelial coronary and myocardial
function markers four months after COVID-19 infection.
Methods
In a case-control prospective study, we included 100 patients four months after COVID-19 infection, 50 age- and sex-matched healthy individuals. We measured a) pulse wave velocity (PWV), b) flow-mediated dilation (FMD) of brachial artery, c) coronary Flow Reserve (CFR) by Doppler echocardiography d) left ventricular (LV) global longitudinal strain (GLS), e) left ventricular myocardial work index, constructive work, wasted work and work efficiency and e) von-Willenbrand factor and thrombomodulin as endothelial biomarkers.
Results
COVID-19 patients had lower CFR and FMD values than controls (2.39 ± 0.39 vs 3.31 ± 0.59, p = 0.0122, 5.12 ± 2.95% vs 8.12 ± 2.23%, p = 0.006 respectively). Compared to controls, COVID-19 patients had higher PWV (PWVc-f 12.32 ± 2.44 vs 10.11 ± 1.85 m/sec, p = 0.033) and impaired LV GLS (-19.11 ± 2.14% vs -20.41 ± 1.61%, p = 0.001). Compared to controls, COVID-19 patients had higher myocardial work index, and wasted work (2067.7 ± 325.9 mmHg% vs 1929.4 ± 312.7 mmHg%, p = 0.026, 104.6 ± 58.9 mmHg% vs 75.1 ± 52.6 mmHg%, p = 0.008, respectively), while myocardial efficiency was lower (94.8 ± 2.5% vs 96.06 ± 2.3%, p = 0.008). and thrombomodulin were higher in COVID-19 patients than controls (3716.63 ± 188.36 vs 2590.02 ± 156.51pg/ml, p < 0.001). MDA was higher in COVID-19 patients than controls (10.55 ± 2.45 vs 1.01 ± 0.50 nmole/L, p = 0.001). Residual cardiovascular symptoms at 4 months were associated with oxidative stress markers. Myocardial work efficiency was related with PWV (F=-0.309, p = 0.016) and vWillenbrand (F=-0.541, p = 0.037). Myocardial wasted work was related with PWV (F = 0.255, p = 0.047) and vWillenbrand (F = 0.610, p = 0.016).
Conclusions
SARS-CoV-2 may cause vascular dysfunction, followed by a waste of cardiac work, in order to compensate for increased arterial stiffness 4 months after infection.
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Affiliation(s)
- K Katogiannis
- National & Kapodistrian University of Athens, Attikon University Hospital, 2nd Cardiology Department, Athens, Greece
| | - I Ikonomidis
- National & Kapodistrian University of Athens, Attikon University Hospital, 2nd Cardiology Department, Athens, Greece
| | - J Thymis
- National & Kapodistrian University of Athens, Attikon University Hospital, 2nd Cardiology Department, Athens, Greece
| | - A Mitrakou
- National & Kapodistrian University of Athens, Alexandra Hospital, Department of Clinical Therapeutics, Athens, Greece
| | - A Kountouri
- Attikon University Hospital, 2nd Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - K Stamoulis
- National & Kapodistrian University of Athens, Attikon University Hospital, 2nd Cardiology Department, Athens, Greece
| | - E Korakas
- Attikon University Hospital, 2nd Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - C Varlamos
- National & Kapodistrian University of Athens, Attikon University Hospital, 2nd Cardiology Department, Athens, Greece
| | - I Andreadou
- National and Kapodistrian University of Athens, Faculty of Pharmacy, Laboratory of Pharmacology, Athens, Greece
| | - M Tsoumani
- National and Kapodistrian University of Athens, Faculty of Pharmacy, Laboratory of Pharmacology, Athens, Greece
| | - A Bamias
- Attikon University Hospital, 2nd Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - K Thomas
- National and Kapodistrian University of Athens, Attikon University Hospital, 4th Department of Internal Medicine, Athens, Greece
| | - A Antoniadou
- National and Kapodistrian University of Athens, Attikon University Hospital, 4th Department of Internal Medicine, Athens, Greece
| | - MA Dimopoulos
- National & Kapodistrian University of Athens, Alexandra Hospital, Department of Clinical Therapeutics, Athens, Greece
| | - V Lambadiari
- Attikon University Hospital, 2nd Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
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10
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Ikonomidis I, Katogiannis K, Mitrakou A, Kountouri A, Thymis J, Korakas E, Varlamos C, Andreadou I, Tsoumani M, Bamias A, Kazakou P, Grigoropoulou S, Kavatha D, Dimopoulos MA, Lambadiari V. Association of COVID-19 with impaired endothelial glycocalyx, coronary flow and longitudinal strain four months after infection. Eur Heart J Cardiovasc Imaging 2022. [DOI: 10.1093/ehjci/jeab289.313] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Aims
SARS-CoV-2 infection may lead to endothelial and vascular dysfunction. We
investigated alterations of arterial stiffness, endothelial coronary and myocardial
function markers four months after COVID-19 infection.
Methods
In a case-control prospective study, we included 100 patients four months after COVID-19 infection, 50 age- and sex-matched healthy individuals. We measured a) perfused boundary region (PBR) of the sublingual arterial microvessels (increased PBR indicates reduced endothelial glycocalyx thickness), b) flow-mediated dilation (FMD), c) coronary Flow Reserve (CFR) by Doppler echocardiography d) pulse wave velocity (PWV) e) global left (LV) and right (RV) ventricular longitudinal strain (GLS), f) malondialdehyde (MDA), an oxidative stress marker, von-Willenbrand factor and thrombomodulin as endothelial biomarkers.
Results
COVID-19 patients had lower CFR and FMD values than controls (2.39 ± 0.39 vs 3.31 ± 0.59, p = 0.0122, 5.12 ± 2.95% vs 8.12 ± 2.23%, p = 0.006 respectively). Compared to controls, COVID-19 had greater PBR5-25 (2.11 ± 0.14μm vs 1.87 ± 0.16μm, p = 0.002), higher PWV (PWVc-f 12.32 ± 2.44 vs 10.11 ± 1.85 m/sec, p = 0.033) and impaired LV and RV GLS (-19.11 ± 2.14% vs -20.41 ± 1.61%, p = 0.001 and -16.45 ± 3.33% vs -20.11 ± 2.48%, p < 0.001). MDA and thrombomodulin were higher in COVID-19 patients than controls (10.55 ± 2.45 vs 1.01 ± 0.50 nmole/L, p = 0.001 and 3716.63 ± 188.36 vs 2590.02 ± 156.51pg/ml, p < 0.001). Residual cardiovascular symptoms at 4 months were associated with oxidative stress and endothelial dysfunction markers.
Conclusions
SARS-CoV-2 may cause endothelial and vascular dysfunction linked to
impaired cardiac performance four months after infection.
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Affiliation(s)
- I Ikonomidis
- National & Kapodistrian University of Athens, Attikon University Hospital, 2nd Cardiology Department, Athens, Greece
| | - K Katogiannis
- National & Kapodistrian University of Athens, Attikon University Hospital, 2nd Cardiology Department, Athens, Greece
| | - A Mitrakou
- National & Kapodistrian University of Athens, Alexandra Hospital, Department of Clinical Therapeutics, Athens, Greece
| | - A Kountouri
- Attikon University Hospital, 2nd Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - J Thymis
- National & Kapodistrian University of Athens, Attikon University Hospital, 2nd Cardiology Department, Athens, Greece
| | - E Korakas
- Attikon University Hospital, 2nd Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - C Varlamos
- National & Kapodistrian University of Athens, Attikon University Hospital, 2nd Cardiology Department, Athens, Greece
| | - I Andreadou
- National and Kapodistrian University of Athens, Faculty of Pharmacy, Laboratory of Pharmacology, Athens, Greece
| | - M Tsoumani
- National and Kapodistrian University of Athens, Faculty of Pharmacy, Laboratory of Pharmacology, Athens, Greece
| | - A Bamias
- Attikon University Hospital, 2nd Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - P Kazakou
- National and Kapodistrian University of Athens, Attikon University Hospital, 4th Department of Internal Medicine, Athens, Greece
| | - S Grigoropoulou
- National and Kapodistrian University of Athens, Attikon University Hospital, 4th Department of Internal Medicine, Athens, Greece
| | - D Kavatha
- National and Kapodistrian University of Athens, Attikon University Hospital, 4th Department of Internal Medicine, Athens, Greece
| | - MA Dimopoulos
- National & Kapodistrian University of Athens, Alexandra Hospital, Department of Clinical Therapeutics, Athens, Greece
| | - V Lambadiari
- Attikon University Hospital, 2nd Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
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11
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Dimopoulos MA, Moreau P, Terpos E, Mateos MV, Zweegman S, Cook G, Delforge M, Hájek R, Schjesvold F, Cavo M, Goldschmidt H, Facon T, Einsele H, Boccadoro M, San-Miguel J, Sonneveld P, Mey U. Corrigendum to 'Multiple myeloma: EHA-ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up': [Ann Oncol 2021; 32(3): 309-322]. Ann Oncol 2021; 33:117. [PMID: 34857439 DOI: 10.1016/j.annonc.2021.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- M A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - P Moreau
- Department of Hematology, University Hospital Hôtel-Dieu, Nantes, France
| | - E Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - M V Mateos
- University Hospital of Salamanca, IBSAL, Cancer Research Center, Salamanca, Spain
| | - S Zweegman
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - G Cook
- Leeds Cancer Centre and University of Leeds, Leeds, UK
| | - M Delforge
- Department of Hematology, University Hospital Leuven, Leuven, Belgium
| | - R Hájek
- Faculty of Medicine, University Hospital Ostrava, Ostrava, Czech Republic
| | - F Schjesvold
- Oslo Myeloma Center, Oslo University Hospital, Oslo; KG Jebsen Center for B Cell Malignancies, University of Oslo, Oslo, Norway
| | - M Cavo
- Seràgnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
| | - H Goldschmidt
- University Hospital Heidelberg, Internal Medicine V and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - T Facon
- Hôpital Claude Huriez, Lille University Hospital, Lille, France
| | - H Einsele
- Department of Internal Medicine II, University Hospital Wurzburg, Wurzburg, Germany
| | - M Boccadoro
- Division of Hematology, University of Torino, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - J San-Miguel
- Clinica Universidad de Navarra, CIMA, IDISNA, CIBERONC, Pamplona, Spain
| | - P Sonneveld
- Erasmus Medical Center Cancer Institute, Rotterdam, Netherlands
| | - U Mey
- Department of Oncology and Hematology, Kantonsspital Graubünden, Chur, Switzerland
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12
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Liontos M, Andrikopoulou A, Koutsoukos K, Markellos C, Skafida E, Fiste O, Kaparelou M, Thomakos N, Haidopoulos D, Rodolakis A, Dimopoulos MA, Zagouri F. Neutrophil-to-lymphocyte ratio and chemotherapy response score as prognostic markers in ovarian cancer patients treated with neoadjuvant chemotherapy. J Ovarian Res 2021; 14:148. [PMID: 34724958 PMCID: PMC8561989 DOI: 10.1186/s13048-021-00902-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/13/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) is the recommended approach in patients with advanced epithelial ovarian cancer (EOC). However, most patients eventually relapse despite the initial high response rate to chemotherapy. Neutrophil-to-lymphocyte ratio is a well-known biomarker that reflects severe inflammation, critical illness, and mortality in various diseases. Chemotherapy response score (CRS) and neutrophil-to-lymphocyte ratio (NLR) have been identified as potential biomarkers of platinum resistance and disease prognosis. We retrospectively evaluated 132 patients with stage IIIc or IV ovarian/fallopian tube/primary peritoneal cancer who had received NACT followed by IDS from 01/01/2003 to 31/12/2018. CRS was assessed on omental specimens collected from IDS according to ICCR guidelines. RESULTS Median age was 64.57 years (SD: 9.72; range 39.2-87.1). Most ovarian tumors were serous epithelial (90.9%; 120/132). An elevated NLR (defined as > 3) was observed in 72% (95/132) of patients in contrast with 28% (37/132) of patients characterized by low NLR status. Median PFS (mPFS) and median overall survival (mOS) were 13.05 months (95% CI: 11.42-14.67)) and 34.69 months (95% CI: 23.26-46.12) respectively. In univariate analysis, CRS3 score was significantly associated with prolonged mPFS (CRS1/2: 12.79 months vs CRS3: 17.7 months; P = 0.008). CRS score was not associated with mOS (P = 0.876). High NLR was not significantly associated with mPFS (P = 0.128), however it was significantly associated with poor mOS (P = 0.012). In multivariate analysis, only performance of surgery maintained its statistical significance with both PFS (P = 0.001) and OS (P = 0.008). CONCLUSION NLR could serve as a useful predictor of OS but not PFS in ovarian cancer patients receiving NACT. In accordance with our previous study, CRS score at omentum was found to be associated with PFS but not OS in ovarian cancer patients treated with NACT and IDS.
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Affiliation(s)
- M Liontos
- Department of Clinical Therapeutics, Alexandra General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - A Andrikopoulou
- Department of Clinical Therapeutics, Alexandra General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - K Koutsoukos
- Department of Clinical Therapeutics, Alexandra General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - C Markellos
- Department of Clinical Therapeutics, Alexandra General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - E Skafida
- Department of Clinical Therapeutics, Alexandra General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - O Fiste
- Department of Clinical Therapeutics, Alexandra General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - M Kaparelou
- Department of Clinical Therapeutics, Alexandra General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - N Thomakos
- Department of Obstetrics and Gynecology, Alexandra General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - D Haidopoulos
- Department of Obstetrics and Gynecology, Alexandra General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - A Rodolakis
- Department of Obstetrics and Gynecology, Alexandra General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - M A Dimopoulos
- Department of Clinical Therapeutics, Alexandra General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - F Zagouri
- Department of Clinical Therapeutics, Alexandra General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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13
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Efentakis P, Lamprou S, Makridakis M, Barla I, Nikolaou PE, Christodoulou A, Dimitriou C, Kastritis E, Gakiopoulou C, Gikas E, Vlachou A, Thomaidis N, Dimopoulos MA, Terpos E, Andreadou I. Mineralocorticoid receptor signaling is implicated in carfilzomib-induced increase in blood pressure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.3416] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Carfilzomib (Cfz), an irreversible proteasome inhibitor, is a first line antineoplastic agent indicated for relapsed/refractory multiple myeloma, with its clinical use being hampered by cardiovascular adverse effects. Hypertension, is the most common cardiovascular side effect of Cfz, remaining of unknown pathogenicity.
Purpose
Considering that management of Cfz-related hypertension remains an unmet clinical need and that renal function plays a pivotal role in blood pressure regulation we sought to investigate the renal contribution in Cfz-induced hypertension.
Methods
We have previously established a translational model of Cfz-induced cardiomyopathy, based on clinically applicable dose regimens and we have concluded that two and four dose protocols successfully resemble the clinical observations in vivo. Herein, sixty C57Bl/6 male mice (12–14 weeks old) were randomized to: 1. Two doses Protocol: i. Control (N/S 0.9%), ii. Cfz (8mg/kg) for two consecutive days; and 2. Four doses Protocol: i. Control (N/S 0.9%), ii. Cfz (8mg/kg) for seven days intraperitoneally. Systolic (SBP) and diastolic blood pressure (DBP) were measured by tail cuffs; the latter protocol was repeated and urine collection was performed via metabolic cages studies. Renal samples were collected for histological, proteomic, metabolomic and molecular signaling analyses. Finally, eplerenone, a mineralocorticoid receptor (MR) blocker, was orally co-administered with Cfz to the mice daily (165 mg/kg) in the four doses protocol.
Results
Cfz increased SBP only in the four doses protocol (78.50±2.05 vs 68.20±0.73 in the Control group, **P<0.01). Histological evaluation of the kidneys revealed a juxtaglomerular apparatus hyperplasia (JAH) in the same dose regimen. Proteomic analysis presented that metabolic and transport of small molecules pathways were differentially regulated in the Cfz treated murine kidneys. Metabolomic analysis revealed an increase in urea cycle metabolites (L-Alanine, L-Glutamine, glutamate, aspartate) and taurine content in the kidneys. Additionally, mice presented decreased diuresis without any differences in other metabolic parameters. In parallel an upregulation of β-ENaC expression and activation of MR/SGK-1 signaling in the kidneys was observed, indicating that Cfz activates MR signaling. Co-administration of eplerenone and Cfz, restored diuresis, decreased SBP and inhibited MR/SGK-1 signaling in the kidneys.
Conclusions
Activation of MR signaling by Cfz in the kidneys orchestrates renal water/salt retention and drives an increase in blood pressure in vivo. Histological and metabolomic analyses present that Cfz induces an acute kidney injury and a tonicity increase. Eplerenone reversed Cfz-induced blood pressure increase and restored diuresis by inhibiting MR/SGK-1 signaling. Therefore, MR blockade emerges as a potent therapeutic approach against Cfz-related cardiovascular adverse events.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- P Efentakis
- School of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - S Lamprou
- School of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - M Makridakis
- Academy of Athens Biomedical Research Foundation, Athens, Greece
| | - I Barla
- National & Kapodistrian University of Athens, Chemistry, Athens, Greece
| | - P.-E Nikolaou
- School of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - A Christodoulou
- School of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - C Dimitriou
- Academy of Athens Biomedical Research Foundation, Athens, Greece
| | - E Kastritis
- National & Kapodistrian University of Athens Medical School, Athens, Greece
| | - C Gakiopoulou
- National & Kapodistrian University of Athens Medical School, Athens, Greece
| | - E Gikas
- National & Kapodistrian University of Athens, Chemistry, Athens, Greece
| | - A Vlachou
- Academy of Athens Biomedical Research Foundation, Athens, Greece
| | - N Thomaidis
- National & Kapodistrian University of Athens, Chemistry, Athens, Greece
| | - M A Dimopoulos
- National & Kapodistrian University of Athens Medical School, Athens, Greece
| | - E Terpos
- National & Kapodistrian University of Athens Medical School, Athens, Greece
| | - I Andreadou
- School of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
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14
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Stamatelopoulos K, Delialis D, Bampatsias D, Tselegkidi ME, Petropoulos I, Theodorakakou F, Gavriatopoulou M, Patras R, Pamboucas C, Kanakakis J, Ikonomidis I, Terpos E, Trougakos IP, Dimopoulos MA, Kastritis E. Peripheral vascular involvement in transthyretin cardiac amyloidosis. A comparative analysis with AL amyloidosis. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1798] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The pattern of peripheral vascular involvement in the wild type transthyretin-related cardiac amyloidosis (ATTRwt) and its diagnostic utility in differentiating this infiltrating cardiomyopathy from light chain (AL) cardiac amyloidosis (AL-CA) and heart failure with preserved ejection fraction (HFpEF) of different origin have not been explored.
Aims
To characterize the pattern of peripheral vascular involvement in ATTRwt and evaluate its value in differentiating ATTRwt from AL-CA and HFpEF.
Methods
Newly diagnosed patients with ATTRwt (n=42) were consecutively recruited from our amyloidosis center. These patients were matched 1:1 for age and sex to patients with AL-CA (n=32) and subjects without amyloidosis (n=32) and also matched 2:1 to HFpEF patients (n=16). All subjects underwent a series of non-invasive vascular examinations for the assessment of: 1. subclinical carotid atherosclerosis with B-mode ultrasonography, 2. Arterial stiffness with measurement of carotid-femoral pulse wave velocity, 3. Reactive vasodilation with flow-mediated dilation (FMD) and 4. Aortic blood pressures and arterial wave reflections with augmentation index (AI) and return time of reflected wave (Tr).
Results
ATTRwt patients had lower peripheral (pBP) and aortic blood pressure (aBP) markers compared to non-AL controls (p<0.05 for all). ATTRwt grouping was an independent determinant of these markers, after adjustment for cardiovascular risk factors (CVRF), including history of hypertension, hyperlipidemia and diabetes, glomerular filtration rate, body mass index and smoking status (core model). ATTRwt had lower aDBP and increased Tr compared to AL subjects. In a comparison between ATTRwt and AL patients with cardiac involvement, AI and Tr were higher and FMD lower in ATTRwt patients. ATTRwt was an independent determinant of these markers, after adjustment for the core model (p<0.05 for all). Compared to HFpEF, patients with ATTRwt had lower peripheral and central BP and higher Tr (p<0.05 for all). By ROC analysis, Tr provided high diagnostic value for ATTRwt vs. AL-CA (Area Under the Curve, AUC=0.809, CI: 0.65–0.96) and for ATTRwt vs combined AL-CA and HFpEF (AUC=0.880, CI: 0.79–0.97). Finally, AI was closely correlated with posterior (Spearman's Rho=−0.30) and intraventricular wall thickness (Rho=−0.329) and left ventricular global longitudinal strain (Rho=−0.4) and lower cDBP with higher Gilmore and New York Heart Association stage (p<0.05).
Conclusion
ATTRwt patients present differential characteristics of peripheral vascular function and aortic hemodynamics as compared to AL, HFpEF and healthy controls. The clinical value of these characteristics merit further investigation since differential diagnosis among amyloidosis types is clinically challenging, while it may have prognostic implications.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
| | - D Delialis
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - D Bampatsias
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - M E Tselegkidi
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - I Petropoulos
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - F Theodorakakou
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - M Gavriatopoulou
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - R Patras
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - C Pamboucas
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - J Kanakakis
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - I Ikonomidis
- Attikon University Hospital, Second Cardiology Department, Athens, Greece
| | - E Terpos
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - I P Trougakos
- National & Kapodistrian University of Athens, Department of Cell Biology and Biophysics, Faculty of Biology, Athens, Greece
| | - M A Dimopoulos
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - E Kastritis
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
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15
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Makris N, Laina A, Georgiopoulos G, Gavriatopoulou M, Papanagnou E, Eleutherakis-Papaiakovou E, Fotiou D, Dialoupi I, Migkou M, Roussou M, Terpos E, Trougakos I, Dimopoulos MA, Kastritis E, Stamatelopoulos K. Global deterioration of cardiovascular mechanics by carfilzomib treatment is associated with proteasome activity in patients with relapsed multiple myeloma. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0749] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Carfilzomib (CFZ) is a second generation irreversible proteasome inhibitor that has been shown to improve overall survival in patients with relapsed or refractory multiple myeloma (MM) but is associated with cardiac toxicity in MM. Because ubiquitin-proteasome system (UPS) is involved in cardiovascular homeostasis exploring the effects of proteasome inhibition on cardiac mechanics, in a clinical setting, would provide novel insight of the clinical role of UPS in cardiovascular disease.
Aim
To gain a thorough understanding of proteasome inhibition on myocardial mechanics in a clinical setting.
Methods
We prospectively evaluated 48 patients with relapsed or refractory MM and an indication to receive CFZ treatment [median age: 67.5, interquartile range (64–73), 66.7% men]. All patients underwent cardiac ultrasonography at an initial visit, at the first day of the 3rd month (C3D1, n=25) and at the last day of cycle 6 (C6D16, n=48). Pulse wave velocity (PWV) was used to assess arterial stiffness and calculate arterial-ventricular coupling (VAC) by the ratio (PWV/global longitudinal strain (GLS)). Carfilzomib was administered at 27mg/m2 on days 1 (C1D1) and 2 (C1D2) of cycle 1 and at 56mg/m2 thereafter. Blood was drawn at baseline, C3D1 and C6D16 to measure proteasome activity (PrA). Patients were followed up for carfilzomib–related cardiovascular adverse events.
Results
Regarding systolic function, between baseline and C6D16, we noticed deterioration in left ventricular ejection fraction (LVEF) (57.7±5.4% vs 56.1±7.19%, p=0.022), GLS (−20.51±2.78 vs −18.88±3.45%, p=0.003), S wave of LV longitudinal strain rate and radial strain (p<0.05 for both). Markers of LV diastolic function also deteriorated at 6 months including early diastolic (Ea) mitral annular velocity (7.27±1.83cm/sec vs 6.7±1.64cm/sec, p=0.008) and E wave of LV longitudinal strain rate (1.1±0.37sec-1 vs 0.95±0.36sec-1, p=0.010). Left atrial volume (LAV) and index (LAVi) increased both at 3 and 6 months (p<0.05). Peak LA strain at reservoir phase (peak atrial longitudinal strain, PALS) was also decreased at 6th and 3rd month measurements (p<0.05), whereas LA strain rate at reservoir function (s wave) was decreased, compared to baseline, only at 6th month (p=0.001). RV longitudinal strain also decreased between 3rd and 6th month (p=0.039). Furthermore, PWV/GLS also deteriorated at 6 months (−0.56±0.13 vs −0.64±0.21, p=0.001). By linear mixed models analysis, we found that changes in proteasome activity were associated with changes in PWV/GLS (p=0.017), LAV (p=0.015) and LAVi (p=0.009), and PALS (p=0.014).
Conclusion
CFZ treatment was associated with global deterioration of markers of myocardial systolic and diastolic function and VAC. The observed association of changes in proteasome activity with VAC and left atrial function and structure supports a direct effect of proteasome inhibition on the cross-talk between LV and arterial function and LV diastolic function.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Amgen
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Affiliation(s)
- N Makris
- Alexandra University Hospital, Athens, Greece
| | - A Laina
- Alexandra University Hospital, Athens, Greece
| | | | | | - E.D Papanagnou
- National & Kapodistrian University of Athens, Department of Cell Biology and Biophysics, Faculty of Biology, Athens, Greece
| | | | - D Fotiou
- Alexandra University Hospital, Athens, Greece
| | - I Dialoupi
- Alexandra University Hospital, Athens, Greece
| | - M Migkou
- Alexandra University Hospital, Athens, Greece
| | - M Roussou
- Alexandra University Hospital, Athens, Greece
| | - E Terpos
- Alexandra University Hospital, Athens, Greece
| | - I.P Trougakos
- National & Kapodistrian University of Athens, Department of Cell Biology and Biophysics, Faculty of Biology, Athens, Greece
| | | | - E Kastritis
- Alexandra University Hospital, Athens, Greece
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16
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Laina A, Georgiopoulos G, Makris N, Gavriatopoulou M, Papanagnou E, Eleutherakis-Papaiakovou E, Fotiou D, Dialoupi I, Migkou M, Roussou M, Terpos E, Trougakos I, Dimopoulos MA, Kastritis E, Stamatelopoulos K. Aortic hemodynamic parameters as predictors of incident or deteriorating hypertension during carfilzomib therapy in patients with relapsed multiple myeloma. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2854] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Carfilzomib (CFZ) improves survival in relapsed/refractory multiple myeloma but is associated with cardiovascular adverse events, among which hypertension is commonly reported.
Purpose
To evaluate aortic hemodynamics as possible predictors for CFZ-associated hypertension.
Methods
In a prospective study of 48 patients treated with Kd (CFZ 20/56 mg/m2 and dexamethasone) followed until disease progression or cycle 6 for a median of 10 months, patients underwent peripheral hemodynamic assessment, including applanation tonometry, which allows estimation of aortic blood pressure and arterial wave reflections and assessment of pulse wave velocity, which allows estimation of aortic stiffness. Hemodynamic parameters were examined at baseline and at pre-specified time points before and 24 hours after drug infusion.
Results
Thirteen patients (27.1%) developed hypertension or merited more intensive anti-hypertensive treatment (grade I or II: 6.25%, grade III: 20.8%). Patients with new onset or worsening hypertension had increased aortic [130±12.9 mmHg versus 115±16.7 mmHg, p=0.004] and peripheral systolic blood pressure (SBP) [145±15.7 mmHg versus 130±19.5 mmHg, p=0.001] at baseline. Patients distributed at highest tertile of baseline aortic SBP (log-rank test p=0.0001, Figure) or baseline peripheral SBP (log-rank test p=0.002) had significantly higher risk for CFZ associated hypertension as compared to those distributed at lower tertiles. After adjustment for age, gender and baseline hypertension, increased aortic [HR=8.0, 95% CIs 2.4–26.6, p=0.001] and peripheral SBP [HR=4.85, 95% CIs 1.53–15.4, p=0.007] remained significantly associated with hypertension. After adjustment for both baseline peripheral and aortic SBP in the same multivariable core model, aortic SBP was the only independent predictor of the study outcome (p=0.041). Accordingly, baseline aortic SBP was associated with higher discriminative value as compared to peripheral SBP [AUC: 0.819, 95% CIs 0.722–0.916 versus 0.724, 95% CIs 0.570–0.878, respectively]. Further adjustment for all cardiotoxicity risk factors using forced inclusion in non-parsimonious multivariable Cox regression models, revealed that increased aortic and peripheral SBP remained independent predictors of hypertensive events (p<0.05 for both).
Conclusion
Baseline aortic hemodynamics are associated with hypertension during CFZ treatment. Aortic SBP at baseline was the strongest predictor of CFZ-associated hypertensive adverse events, suggesting that an initial assessment of aortic blood pressure may facilitate discrimination of patients in need of close monitoring during treatment.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): Funding from the Hellenic Foundation for Research and Innovation (HFRI) and the General Secretariat for Research and Technology (GSRT), under grant agreement No [1285].
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Affiliation(s)
- A Laina
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - G Georgiopoulos
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - N Makris
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - M Gavriatopoulou
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - E Papanagnou
- National & Kapodistrian University of Athens, Department of Cell Biology and Biophysics, Faculty of Biology, Athens, Greece
| | | | - D Fotiou
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - I Dialoupi
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - M Migkou
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - M Roussou
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - E Terpos
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - I Trougakos
- National & Kapodistrian University of Athens, Department of Cell Biology and Biophysics, Faculty of Biology, Athens, Greece
| | - M A Dimopoulos
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - E Kastritis
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
| | - K Stamatelopoulos
- University of Athens Medical School, Department of Clinical Therapeutics, Athens, Greece
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17
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Andrikopoulou A, Korakiti AM, Apostolidou K, Dimopoulos MA, Zagouri F. Immune checkpoint inhibitor administration during pregnancy: a case series. ESMO Open 2021; 6:100262. [PMID: 34487972 PMCID: PMC8426195 DOI: 10.1016/j.esmoop.2021.100262] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/07/2021] [Accepted: 08/12/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitors have been widely implemented in current clinical practice. Although cancer occurs in ∼1 out of 1000 pregnancies, treatment remains challenging. Until now, limited data exist regarding immunotherapy administration during pregnancy. This systemic review aims to synthesize all available data from immunotherapy administration in pregnant women and evaluate the efficacy and safety of immunotherapy during pregnancy. PATIENTS AND METHODS Eligible studies were identified by a search of the PubMed Medline database and Food and Drug Administration Adverse Events Reporting System Public Dashboard for the period 1 January 2000 to 1 April 2021; the algorithm consisted of a predefined combination of the words 'immunotherapy', 'cancer' and 'pregnancy'. PRISMA guidelines were applied in this study. RESULTS Overall, seven articles (seven pregnancies, nine neonates) were retrieved. The mean duration of immunotherapy administration was 9.8 weeks [standard deviation (SD): 11.27; median: 7.0; range: 1-32]. In all cases specified, melanoma was the malignancy reported. The mean gestational age at delivery was 30.4 weeks (SD: 5.03; median: 32.0; range: 24-38), whereas the mean weight of neonates at delivery was 1267 g (SD: 412.0; median: 1400; range: 590-1701). Only one neonate was born term at 38 weeks of pregnancy (11.1%; 1/9). Complications during pregnancy were observed in 71.4% of cases: intrauterine growth restriction (three cases), HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) (one case), placental insufficiency (one case) and low fetal heart rate (one case). The mean progression-free survival and overall survival were 16.0 and 25.2 months, respectively. CONCLUSION The administration of immune checkpoint inhibitors during pregnancy is associated with increased incidence of pregnancy complications, prematurity and low birth weight. The administration of these regimens is not recommended during gestation. Whenever applied, close monitoring of the mother and the fetus is required.
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Affiliation(s)
- A Andrikopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - A M Korakiti
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - K Apostolidou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - M A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - F Zagouri
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
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18
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Dimopoulos MA, Moreau P, Terpos E, Mateos MV, Zweegman S, Cook G, Delforge M, Hájek R, Schjesvold F, Cavo M, Goldschmidt H, Facon T, Einsele H, Boccadoro M, San-Miguel J, Sonneveld P, Mey U. Multiple myeloma: EHA-ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up †. Ann Oncol 2021; 32:309-322. [PMID: 33549387 DOI: 10.1016/j.annonc.2020.11.014] [Citation(s) in RCA: 272] [Impact Index Per Article: 90.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/12/2020] [Accepted: 11/15/2020] [Indexed: 02/07/2023] Open
Affiliation(s)
- M A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - P Moreau
- Department of Hematology, University Hospital Hôtel-Dieu, Nantes, France
| | - E Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - M V Mateos
- University Hospital of Salamanca, IBSAL, Cancer Research Center, Salamanca, Spain
| | - S Zweegman
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - G Cook
- Leeds Cancer Centre and University of Leeds, Leeds, UK
| | - M Delforge
- Department of Hematology, University Hospital Leuven, Leuven, Belgium
| | - R Hájek
- Faculty of Medicine, University Hospital Ostrava, Ostrava, Czech Republic
| | - F Schjesvold
- Oslo Myeloma Center, Oslo University Hospital, Oslo; KG Jebsen Center for B Cell Malignancies, University of Oslo, Oslo, Norway
| | - M Cavo
- Seràgnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
| | - H Goldschmidt
- University Hospital Heidelberg, Internal Medicine V and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - T Facon
- Hôpital Claude Huriez, Lille University Hospital, Lille, France
| | - H Einsele
- Department of Internal Medicine II, University Hospital Wurzburg, Wurzburg, Germany
| | - M Boccadoro
- Division of Hematology, University of Torino, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - J San-Miguel
- Clinica Universidad de Navarra, CIMA, IDISNA, CIBERONC, Pamplona, Spain
| | - P Sonneveld
- Erasmus Medical Center Cancer Institute, Rotterdam, Netherlands
| | - U Mey
- Department of Oncology and Hematology, Kantonsspital Graubünden, Chur, Switzerland
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19
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Tsironis G, Liontos M, Kyriazoglou A, Koutsoukos K, Tsiara A, Kaparelou M, Zakopoulou R, Cohen A, Skafida E, Fontara S, Zagouri F, Bamias A, Dimopoulos MA. Axitinib as a third or further line of treatment in renal cancer: a single institution experience. BMC Urol 2020; 20:60. [PMID: 32487200 PMCID: PMC7265645 DOI: 10.1186/s12894-020-00618-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 04/21/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Kidney cancer is a lethal neoplasm that affects several thousands of people every year. Renal cell carcinoma (RCC) is the most common histologic type. Recent developments in the therapeutic approach include antiangiogenic targeted approaches and Immunotherapy. Thus, the therapeutic algorithm of RCC patients and the survival outcomes have changed dramatically. METHODS Herein we present a retrospective study of the patients treated in our Department with an antiangiogenic agent -Axitinib, a tyrosine kinase inhibitor- as a third or further line treatment. Statistical analysis was performed with SPSS, including the available clinicopathological data of the patients included. RESULTS Axitinib was found to be active in patients who received this treatment beyond second line. The toxicity profile of this regimen did not reveal any unknown adverse events. CONCLUSIONS Our real world data reflect that axitinib is a safe and effective option, even beyond the second line.
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Affiliation(s)
- G Tsironis
- Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
| | - M Liontos
- Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
| | - A Kyriazoglou
- Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece.
| | - K Koutsoukos
- Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
| | - A Tsiara
- Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
| | - M Kaparelou
- Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
| | - R Zakopoulou
- Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
| | - A Cohen
- Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
| | - E Skafida
- Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
| | - S Fontara
- 1st Department of Radiology, Aretaieio University hospital, Athens, Greece
| | - F Zagouri
- Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
| | - A Bamias
- Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
| | - M A Dimopoulos
- Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
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20
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Bringhen S, Milan A, D'Agostino M, Ferri C, Wäsch R, Gay F, Larocca A, Offidani M, Zweegman S, Terpos E, Goldschmidt H, Cavo M, Ludwig H, Driessen C, Auner HW, Caers J, Gramatzki M, Dimopoulos MA, Boccadoro M, Einsele H, Sonneveld P, Engelhardt M. Prevention, monitoring and treatment of cardiovascular adverse events in myeloma patients receiving carfilzomib A consensus paper by the European Myeloma Network and the Italian Society of Arterial Hypertension. J Intern Med 2019; 286:63-74. [PMID: 30725503 DOI: 10.1111/joim.12882] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The novel proteasome inhibitor carfilzomib alone or in combination with other agents is already one of the standard therapies for relapsed and/or refractory multiple myeloma (MM) patients and produces impressive response rates in newly diagnosed MM as well. However, carfilzomib-related cardiovascular adverse events (CVAEs) - including hypertension (all grades: 12.2%; grade ≥3: 4.3%), heart failure (all grades: 4.1%; grade ≥3: 2.5%) and ischemic heart disease (all grades: 1.8%; grade ≥3: 0.8%) - may lead to treatment suspensions. At present, there are neither prospective studies nor expert consensus on the prevention, monitoring and treatment of CVAEs in myeloma patients treated with carfilzomib. METHODS An expert panel of the European Myeloma Network in collaboration with the Italian Society of Arterial Hypertension and with the endorsement of the European Hematology Association aimed to provide recommendations to support health professionals in selecting the best management strategies for patients, considering the impact on outcome and the risk-benefit ratio of diagnostic and therapeutic tools, thereby achieving myeloma response with novel combination approaches whilst preventing CVAEs. RESULTS Patients scheduled to receive carfilzomib need a careful cardiovascular evaluation before treatment and an accurate follow-up during treatment. CONCLUSIONS A detailed clinical assessment before starting carfilzomib treatment is essential to identify patients at risk for CVAEs, and accurate monitoring of blood pressure and of early signs and symptoms suggestive of cardiac dysfunction remains pivotal to safely administer carfilzomib without treatment interruptions or dose reductions.
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Affiliation(s)
- S Bringhen
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - A Milan
- Department of Medical Sciences, Internal Medicine and Hypertension Division, AOU Città della Salute e della Scienza di Torino, Rete Oncologica Piemontese, University of Torino, Torino, Italy
| | - M D'Agostino
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - C Ferri
- University of L'Aquila, MeSVA Department - San Salvatore Hospital, Division of Internal Medicine & Nephrology, Coppito, Italy
| | - R Wäsch
- Department of Medicine I, Hematology, Oncology & Stem Cell Transplantation, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - F Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - A Larocca
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - M Offidani
- Clinica di Ematologia, AOU Ospedali Riuniti di Ancona, Ancona, Italy
| | - S Zweegman
- Amsterdam UMC, Vrije Universiteit Amsterdam, VU University Medical Center, Department of Hematology, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - E Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - H Goldschmidt
- University Clinic Heidelberg, Internal Medicine V and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - M Cavo
- 'Seràgnoli' Institute of Hematology and Medical Oncology, University of Bologna, Bologna, Italy
| | - H Ludwig
- 1. Medical Department and Oncology, Wilhelminenspital Wien, Vienna, Austria
| | - C Driessen
- Department of Oncology and Hematology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - H W Auner
- Faculty of Medicine, Department of Medicine, Imperial College London, London, UK
| | - J Caers
- Department of Hematology, Domaine University Liege, Liege, Belgium
| | - M Gramatzki
- Division of Stem Cell Transplantation and Immunotherapy, University of Kiel, Kiel, Germany
| | - M A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - M Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - H Einsele
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - P Sonneveld
- Department of Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - M Engelhardt
- Department of Medicine I, Hematology, Oncology & Stem Cell Transplantation, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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21
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Kastritis E, Leblond V, Dimopoulos MA, Kimby E, Staber P, Kersten MJ, Tedeschi A, Buske C. Waldenström's macroglobulinaemia: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2019; 30:860-862. [PMID: 30520968 DOI: 10.1093/annonc/mdy466] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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22
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Kastritis E, Leblond V, Dimopoulos MA, Kimby E, Staber P, Kersten MJ, Tedeschi A, Buske C. Waldenström's macroglobulinaemia: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2018; 29:iv270. [PMID: 30285219 DOI: 10.1093/annonc/mdy322] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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23
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Kastritis E, Leblond V, Dimopoulos MA, Kimby E, Staber P, Kersten MJ, Tedeschi A, Buske C. Waldenström's macroglobulinaemia: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2018; 29:iv41-iv50. [PMID: 29982402 DOI: 10.1093/annonc/mdy146] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- E Kastritis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - V Leblond
- Department of Hematology, Pitié Salpêtrière Hospital, Pierre and Marie Curie University, UPMC GRC11-GRECHY, Paris, France
| | - M A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - E Kimby
- Division of Hematology, Department of Medicine at Huddinge, Karolinska Institute and University Hospital, Stockholm, Sweden
| | - P Staber
- Division of Hematology and Hemostaseology, Department of Internal Medicine I, Vienna General Hospital, Vienna, Austria
| | - M J Kersten
- Department of Hematology, Academic Medical Center
- LYMMCARE (Lymphoma and Myeloma Center Amsterdam), Amsterdam, The Netherlands
| | - A Tedeschi
- Department of Haematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - C Buske
- Comprehensive Cancer Center Ulm, Institute of Experimental Cancer Research, University Hospital Ulm, Ulm, Germany
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24
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Kremastiotis G, Efentakis P, Varela A, Davos CH, Papanagnou ED, Trougakos IP, Kastritis E, Kanaki Z, Iliodromitis EK, Klinakis A, Dimopoulos MA, Terpos E, Andreadou I. P4787Investigating the molecular mechanisms of carfilzomib-induced cardiotoxicity and the emerging role of metformin as a prophylactic therapy. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p4787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- G Kremastiotis
- School of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - P Efentakis
- School of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - A Varela
- Biomedical Research Foundation Academy of Athens, Athens, Greece
| | - C H Davos
- Biomedical Research Foundation Academy of Athens, Athens, Greece
| | - E.-D Papanagnou
- Faculty of Biology, National and Kapodistrian University of Athens, Athens, Greece
| | - I P Trougakos
- Faculty of Biology, National and Kapodistrian University of Athens, Athens, Greece
| | - E Kastritis
- Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Z Kanaki
- Biomedical Research Foundation Academy of Athens, Athens, Greece
| | - E K Iliodromitis
- 2nd Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - A Klinakis
- Biomedical Research Foundation Academy of Athens, Athens, Greece
| | - M A Dimopoulos
- Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - E Terpos
- Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - I Andreadou
- School of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
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25
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Anastasiou M, Oikonomou E, Zagouri F, Siasos G, Antonopoulos AS, Tsalamandris S, Papakostas P, Psaltopoulou T, Bamias A, Dimopoulos MA, Tousoulis D. P1577Cancer therapeutic related vaso- and cardio-toxicity in patients receiving chemotherapy for breast cancer. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- M Anastasiou
- Hippokration Hospital, University of Athens, 1st Department of Cardiology, Athens, Greece
| | - E Oikonomou
- Hippokration Hospital, University of Athens, 1st Department of Cardiology, Athens, Greece
| | - F Zagouri
- Alexandra University Hospital, Department of Clinical Therapeutics, University of Athens Medical School, Athens, Greece
| | - G Siasos
- Hippokration Hospital, University of Athens, 1st Department of Cardiology, Athens, Greece
| | - A S Antonopoulos
- Hippokration Hospital, University of Athens, 1st Department of Cardiology, Athens, Greece
| | - S Tsalamandris
- Hippokration Hospital, University of Athens, 1st Department of Cardiology, Athens, Greece
| | - P Papakostas
- Hippokration General Hospital, Department of Internal Medicine, Athens, Greece
| | - T Psaltopoulou
- National & Kapodistrian University of Athens, Department of Hygiene, Epidemiology and Medical Statistics, Athens, Greece
| | - A Bamias
- Alexandra University Hospital, Department of Clinical Therapeutics, University of Athens Medical School, Athens, Greece
| | - M A Dimopoulos
- Alexandra University Hospital, Department of Clinical Therapeutics, University of Athens Medical School, Athens, Greece
| | - D Tousoulis
- Hippokration Hospital, University of Athens, 1st Department of Cardiology, Athens, Greece
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26
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Ludwig H, Delforge M, Facon T, Einsele H, Gay F, Moreau P, Avet-Loiseau H, Boccadoro M, Hajek R, Mohty M, Cavo M, Dimopoulos MA, San-Miguel JF, Terpos E, Zweegman S, Garderet L, Mateos MV, Cook G, Leleu X, Goldschmidt H, Jackson G, Kaiser M, Weisel K, van de Donk NWCJ, Waage A, Beksac M, Mellqvist UH, Engelhardt M, Caers J, Driessen C, Sonneveld P. Prevention and management of adverse events of Novel agents in multiple myeloma: A consensus of the european myeloma network. Leukemia 2017:leu2017353. [PMID: 29251284 DOI: 10.1038/leu.2017.353] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 11/23/2017] [Accepted: 11/30/2017] [Indexed: 11/08/2022]
Abstract
During the last few years, several new drugs have been introduced for treatment of patients with multiple myeloma, which have significantly improved treatment outcome. All of these novel substances differ at least in part in their mode of action from similar drugs of the same drug class, or are representatives of new drugs classes, and as such present with very specific side effect profiles. In this review, we summarize these adverse events, provide information on their prevention, and give practical guidance for monitoring of patients and for management of adverse events.Leukemia accepted article preview online, 18 December 2017. doi:10.1038/leu.2017.353.
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Affiliation(s)
- H Ludwig
- Wilhelminen Cancer Research Institute, Vienna, Austria
| | - M Delforge
- Stem Cell Biology and Embryology Unit, Department of Development and Regeneration, Catholic University Leuven, Leuven, Belgium
| | - T Facon
- Department of Hematology, Lille University Hospital, Lille, France
| | - H Einsele
- Department of Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - F Gay
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - P Moreau
- Department of Hematology, University Hospital, University of Nantes, Nantes, France
| | - H Avet-Loiseau
- Centre de Recherches en Cancerologie de Toulouse CRCT, Institut National de la Sante et de la Recherche Medicale, Université Toulouse, Toulouse, France
| | - M Boccadoro
- Division of Hematology, Citta della Salute e della Scienza, University of Torino, Torino, Italy
| | - R Hajek
- Faculty of Medicine, University Hospital Ostrava, University of Ostrava, Ostrava, Czech Republic
| | - M Mohty
- Department of Haematology, Saint Antoine Hospital, University Pierre and Marie Curie, and INSERM UMRs 938, Paris, France
| | - M Cavo
- a 'Seràgnoli' Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
| | - M A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - J F San-Miguel
- Department of Hematology, Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona, Spain
| | - E Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - S Zweegman
- Department of Hematology, VU University Medical Center, Amsterdam, Netherlands
| | - L Garderet
- Department of Haematology, Saint Antoine Hospital, University Pierre and Marie Curie, and INSERM UMRs 938, Paris, France
| | - M-V Mateos
- Hospital Universitario de Salamanca, Instituto Biosanitario de Salamanca (IBSAL), Salamanca, Spain
| | - G Cook
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - X Leleu
- Service d'Hématologie et Thérapie Cellulaire, PRC, and Inserm CIC1402, Hospital de la Miléterie, Poitiers, France
| | - H Goldschmidt
- National Center for Tumor Diseases, Heidelberg Medical University, Heidelberg, Germany
| | - G Jackson
- Department of Hematology, Newcastle University, Newcastle, UK
| | - M Kaiser
- Myeloma Group, The Institute of Cancer Research ICR, London, UK
| | - K Weisel
- Department of Hematology and Oncology, University of Tuebingen, Tuebingen, Germany
| | - N W C J van de Donk
- Department of Hematology, VU University Medical Center, Amsterdam, Netherlands
| | - A Waage
- Department of Hematology, St Olavs Hospital, and IKOM, NTNU, Trondheim, Norway
| | - M Beksac
- Department of Medicine, Ankara University, Ankara, Turkey
| | - U H Mellqvist
- Department of Hematology Sahlgrenska Hospital, Gothenburg, Sweden
| | - M Engelhardt
- Department of Hematology and Oncology, University of Freiburg Medical Center, Freiburg, Germany
| | - J Caers
- Department of Hematology, University Hospital of Liège, Liège, Belgium
| | - C Driessen
- Department of Oncology and Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - P Sonneveld
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
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27
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Terpos E, Christoulas D, Gavriatopoulou M, Dimopoulos MA. Mechanisms of bone destruction in multiple myeloma. Eur J Cancer Care (Engl) 2017; 26. [PMID: 28940410 DOI: 10.1111/ecc.12761] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2017] [Indexed: 02/02/2023]
Abstract
Osteolytic bone disease is a frequent complication of multiple myeloma, resulting in skeletal complications that are a significant cause of morbidity and mortality. It is the result of an increased activity of osteoclasts, which is not followed by reactive bone formation by osteoblasts. Recent studies have revealed novel molecules and pathways that are implicated in osteoclast activation and osteoblast inhibition. Among them, the most important include the receptor activator of nuclear factor-kappa B ligand/osteoprotegerin pathway, the macrophage inflammatory proteins and the activin-A that play a crucial role in osteoclast stimulation in myeloma, while the wingless-type (Wnt) signalling inhibitors (sclerostin and dickkopf-1) along with the growth factor independence-1 are considered the most important factors for the osteoblast dysfunction of myeloma patients. Finally, the role of osteocytes, which is the key cell for normal bone remodelling, has also revealed during the last years through their interaction with myeloma cells that leads to their apoptosis and the release of RANKL and sclerostin maintaining bone loss in these patients. This review focuses on the latest available data for the mechanisms of bone destruction in multiple myeloma.
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Affiliation(s)
- E Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Alexandra General Hospital, Athens, Greece
| | - D Christoulas
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Alexandra General Hospital, Athens, Greece
| | - M Gavriatopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Alexandra General Hospital, Athens, Greece
| | - M A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Alexandra General Hospital, Athens, Greece
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28
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Moreau P, San Miguel J, Sonneveld P, Mateos MV, Zamagni E, Avet-Loiseau H, Hajek R, Dimopoulos MA, Ludwig H, Einsele H, Zweegman S, Facon T, Cavo M, Terpos E, Goldschmidt H, Attal M, Buske C. Multiple myeloma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017; 28:iv52-iv61. [PMID: 28453614 DOI: 10.1093/annonc/mdx096] [Citation(s) in RCA: 455] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- P Moreau
- Haematology Department, University Hospital Hôtel-Dieu, Nantes, France
| | - J San Miguel
- Clinica Universidad de Navarra, CIMA, IDISNA, Pamplona, Spain
| | - P Sonneveld
- Erasmus Medical Center Institute, Rotterdam, The Netherlands
| | - M V Mateos
- University Hospital of Salamanca, IBSAL, Salamanca, Spain
| | - E Zamagni
- Seragnoli Institute of Hematology, School of Medicine, Bologna University, Bologna, Italy
| | - H Avet-Loiseau
- The Cancer Research Center of Toulouse, CRCT, INSERM U 1037, Toulouse, France
| | - R Hajek
- Faculty of Medicine, University Hospital Ostrava, Ostrava, Czech Republic
| | - M A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, University of Athens, Athens, Greece
| | - H Ludwig
- Wilhelminen Cancer Research Institute, Wilhelminenspital, Vienna, Austria
| | - H Einsele
- Department of Internal Medicine II, University Hospital Wuerzburg, Wuerzburg, Germany
| | - S Zweegman
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - T Facon
- University Hospital Huriez, Lille, France
| | - M Cavo
- Seragnoli Institute of Hematology, School of Medicine, Bologna University, Bologna, Italy
| | - E Terpos
- Department of Clinical Therapeutics, School of Medicine, University of Athens, Athens, Greece
| | - H Goldschmidt
- Department of Medicine, University of Heidelberg, Heidelberg
| | - M Attal
- The Cancer Research Center of Toulouse, CRCT, INSERM U 1037, Toulouse, France
| | - C Buske
- Comprehensive Cancer Center Ulm and Department of Internal Medicine III, Institute of Experimental Cancer Research, University Hospital, Ulm, Germany
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29
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Kastritis E, Gavriatopoulou M, Roussou M, Fotiou D, Ziogas DC, Migkou M, Eleutherakis-Papaiakovou E, Panagiotidis I, Kanellias N, Psimenou E, Papadopoulou E, Pamboucas C, Manios E, Gakiopoulou H, Ntalianis A, Tasidou A, Giannouli S, Terpos E, Dimopoulos MA. Addition of cyclophosphamide and higher doses of dexamethasone do not improve outcomes of patients with AL amyloidosis treated with bortezomib. Blood Cancer J 2017; 7:e570. [PMID: 28622303 PMCID: PMC5520394 DOI: 10.1038/bcj.2017.47] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/05/2017] [Accepted: 02/15/2017] [Indexed: 01/11/2023] Open
Abstract
Bortezomib, in combination with dexamethasone (VD) or with the addition of cyclophosphamide (VCD), is highly effective in patients with amyloid light-chain (AL) amyloidosis. Currently, VCD is considered as a primary regimen for patients with AL, but it is not clear whether the addition of cyclophosphamide to VD further and significantly improves efficacy, given the substantial activity of bortezomib itself. We retrospectively compared the outcomes of 101 patients with AL amyloidosis who received VD (n=59) or VCD (n=42) in two consecutive periods. Early mortality after adjustment for Mayo stage was similar. On intent to treat, a hematologic response rate was 68% for patients treated with VD and 78% for VCD (P=0.26), while complete response+very good partial response (CR+VGPR) rate was 47.5% and 35%, respectively. Higher doses of dexamethasone or twice-weekly bortezomib were not associated with significantly higher CR+VGPR rates. Organ responses occurred in similar rates between the two groups. Median survival was similar (33 vs 36 months, P=0.45) even after adjustment for Mayo stage and dose and schedule of bortezomib and dexamethasone. In conclusion, bortezomib even with low doses of dexamethasone is effective for the treatment of AL amyloidosis; higher doses of dexamethasone and addition of cyclophosphamide do not seem to have a profound effect on efficacy and survival.
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Affiliation(s)
- E Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - M Gavriatopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - M Roussou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - D Fotiou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - D C Ziogas
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - M Migkou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - E Eleutherakis-Papaiakovou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - I Panagiotidis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - N Kanellias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - E Psimenou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - E Papadopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - C Pamboucas
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - E Manios
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - H Gakiopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - A Ntalianis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - A Tasidou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - S Giannouli
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - E Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - M A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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30
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Moreau P, Joshua D, Chng WJ, Palumbo A, Goldschmidt H, Hájek R, Facon T, Ludwig H, Pour L, Niesvizky R, Oriol A, Rosiñol L, Suvorov A, Gaidano G, Pika T, Weisel K, Goranova-Marinova V, Gillenwater HH, Mohamed N, Aggarwal S, Feng S, Dimopoulos MA. Impact of prior treatment on patients with relapsed multiple myeloma treated with carfilzomib and dexamethasone vs bortezomib and dexamethasone in the phase 3 ENDEAVOR study. Leukemia 2017; 31:115-122. [PMID: 27491641 PMCID: PMC5220137 DOI: 10.1038/leu.2016.186] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 06/22/2016] [Indexed: 01/15/2023]
Abstract
The randomized phase 3 ENDEAVOR study (N=929) compared carfilzomib and dexamethasone (Kd) with bortezomib and dexamethasone (Vd) in relapsed multiple myeloma (RMM). We performed a subgroup analysis from ENDEAVOR in patients categorized by number of prior lines of therapy or by prior treatment. Median progression-free survival (PFS) for patients with one prior line was 22.2 months for Kd vs 10.1 months for Vd, and median PFS for patients with ⩾2 prior lines was 14.9 months for Kd vs 8.4 months for Vd. For patients with prior bortezomib exposure, the median PFS was 15.6 months for Kd vs 8.1 months for Vd, and for patients with prior lenalidomide exposure the median PFS was 12.9 months for Kd vs 7.3 months for Vd. Overall response rates (Kd vs Vd) were 81.9 vs 65.5% (one prior line), 72.0 vs 59.7% (⩾2 prior lines), 71.2 vs 60.3% (prior bortezomib) and 70.1 vs 59.3% (prior lenalidomide). The safety profile in the prior lines subgroups was qualitatively similar to that in the broader ENDEAVOR population. In RMM, outcomes are improved when receiving treatment with carfilzomib compared with bortezomib, regardless of the number of prior therapy lines or prior exposure to bortezomib or lenalidomide.
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Affiliation(s)
- P Moreau
- University of Nantes, Nantes, France
| | - D Joshua
- Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - W-J Chng
- National University Cancer Institute, National University Health System; Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | | | | | - R Hájek
- University Hospital Ostrava, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - T Facon
- CHRU Lille Hôpital Claude Huriez, Lille, France
| | - H Ludwig
- Wilhelminen Cancer Research Institute, Wilhelminenspital, Vienna, Austria
| | - L Pour
- University Hospital Brno, Brno, Czech Republic
| | - R Niesvizky
- Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - A Oriol
- Institut Català d'Oncologia, Institut Josep Carreras, Hospital Germans Trias i Pujol, Barcelona, Spain
| | - L Rosiñol
- Hospital Clínic de Barcelona, Barcelona, Spain
| | - A Suvorov
- Hematological Department, First Republican Clinical Hospital of Udmurtia, Izhevsk, Russia
| | - G Gaidano
- Division of Hematology, Department of Translational Medicine, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy
| | - T Pika
- Department of Hematooncology, University Hospital Olomouc, Olomouc, Czech Republic
| | - K Weisel
- Universitätsklinikum Tübingen, Tübingen, Germany
| | - V Goranova-Marinova
- University Multiprofile Hospital for Active Treatment ‘Sv. Georgi' and Medical University, Plovdiv, Bulgaria
| | - H H Gillenwater
- Onyx Pharmaceuticals, Inc., an Amgen subsidiary, South San Francisco, CA, USA
| | - N Mohamed
- Onyx Pharmaceuticals, Inc., an Amgen subsidiary, South San Francisco, CA, USA
| | - S Aggarwal
- Onyx Pharmaceuticals, Inc., an Amgen subsidiary, South San Francisco, CA, USA
| | - S Feng
- Onyx Pharmaceuticals, Inc., an Amgen subsidiary, South San Francisco, CA, USA
| | - M A Dimopoulos
- National and Kapodistrian University of Athens, Athens, Greece
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31
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Spanoudakis E, Papoutselis M, Terpos E, Dimopoulos MA, Tsatalas C, Margaritis D, Rahemtulla A, Kotsianidis I, Karadimitris A. Overexpression of RANKL by invariant NKT cells enriched in the bone marrow of patients with multiple myeloma. Blood Cancer J 2016; 6:e500. [PMID: 27834938 PMCID: PMC5148055 DOI: 10.1038/bcj.2016.108] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- E Spanoudakis
- Department of Haematology, Democritus University of Thrace, Alexandroupolis, Greece
| | - M Papoutselis
- Department of Haematology, Democritus University of Thrace, Alexandroupolis, Greece
| | - E Terpos
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece
| | - M A Dimopoulos
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece
| | - C Tsatalas
- Department of Haematology, Democritus University of Thrace, Alexandroupolis, Greece
| | - D Margaritis
- Department of Haematology, Democritus University of Thrace, Alexandroupolis, Greece
| | - A Rahemtulla
- Centre for Haematology, Department of Medicine, Hammersmith Hospital, Imperial College London, London, UK
| | - I Kotsianidis
- Department of Haematology, Democritus University of Thrace, Alexandroupolis, Greece
| | - A Karadimitris
- Centre for Haematology, Department of Medicine, Hammersmith Hospital, Imperial College London, London, UK
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Hájek R, Masszi T, Petrucci MT, Palumbo A, Rosiñol L, Nagler A, Yong KL, Oriol A, Minarik J, Pour L, Dimopoulos MA, Maisnar V, Rossi D, Kasparu H, Van Droogenbroeck J, Yehuda DB, Hardan I, Jenner M, Calbecka M, Dávid M, de la Rubia J, Drach J, Gasztonyi Z, Górnik S, Leleu X, Munder M, Offidani M, Zojer N, Rajangam K, Chang YL, San-Miguel JF, Ludwig H. A randomized phase III study of carfilzomib vs low-dose corticosteroids with optional cyclophosphamide in relapsed and refractory multiple myeloma (FOCUS). Leukemia 2016; 31:107-114. [PMID: 27416912 PMCID: PMC5220126 DOI: 10.1038/leu.2016.176] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 03/16/2016] [Accepted: 04/28/2016] [Indexed: 02/07/2023]
Abstract
This randomized, phase III, open-label, multicenter study compared carfilzomib monotherapy against low-dose corticosteroids and optional cyclophosphamide in relapsed and refractory multiple myeloma (RRMM). Relapsed and refractory multiple myeloma patients were randomized (1:1) to receive carfilzomib (10-min intravenous infusion; 20 mg/m2 on days 1 and 2 of cycle 1; 27 mg/m2 thereafter) or a control regimen of low-dose corticosteroids (84 mg of dexamethasone or equivalent corticosteroid) with optional cyclophosphamide (1400 mg) for 28-day cycles. The primary endpoint was overall survival (OS). Three-hundred and fifteen patients were randomized to carfilzomib (n=157) or control (n=158). Both groups had a median of five prior regimens. In the control group, 95% of patients received cyclophosphamide. Median OS was 10.2 (95% confidence interval (CI) 8.4-14.4) vs 10.0 months (95% CI 7.7-12.0) with carfilzomib vs control (hazard ratio=0.975; 95% CI 0.760-1.249; P=0.4172). Progression-free survival was similar between groups; overall response rate was higher with carfilzomib (19.1 vs 11.4%). The most common grade ⩾3 adverse events were anemia (25.5 vs 30.7%), thrombocytopenia (24.2 vs 22.2%) and neutropenia (7.6 vs 12.4%) with carfilzomib vs control. Median OS for single-agent carfilzomib was similar to that for an active doublet control regimen in heavily pretreated RRMM patients.
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Affiliation(s)
- R Hájek
- University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - T Masszi
- St István and St László Hospital of Budapest, Budapest, Hungary
| | | | | | - L Rosiñol
- Hospital Clínic de Barcelona, Barcelona, Spain
| | - A Nagler
- Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - K L Yong
- University College London Cancer Institute, London, UK
| | - A Oriol
- Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Barcelona, Spain
| | - J Minarik
- University Hospital Olomouc and Medical Faculty of Palacky, University Olomouc, Olomouc, Czech Republic
| | - L Pour
- University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - M A Dimopoulos
- National and Kapodistrian University of Athens, Athens, Greece
| | - V Maisnar
- Charles University Teaching Hospital, Hradec Králové, Czech Republic
| | - D Rossi
- Amedeo Avogadro University of Eastern Piedmont, Novara, Italy
| | - H Kasparu
- Hospital Elisabethinen Linz, Linz, Austria
| | | | - D B Yehuda
- Hadassah Medical Center, Jerusalem, Israel
| | - I Hardan
- Meir Medical Center, Kfar-Saba, Israel
| | - M Jenner
- Southampton General Hospital, Hampshire, UK
| | - M Calbecka
- Nicolaus Copernicus Hospital, Toruń, Poland
| | - M Dávid
- University of Pécs, Pécs, Hungary
| | - J de la Rubia
- University Hospital La Fe and Universidad Católica de València 'San Vicente Mártir', València, Spain
| | - J Drach
- Medical University of Vienna, Vienna, Austria
| | - Z Gasztonyi
- Petz Aladár Megyei Oktató Kórház, Vasvári Pál, Hungary
| | - S Górnik
- Zamojski Szpital Niepubliczny, Zamosc, Poland
| | - X Leleu
- Hopital Huriez, CHRU, Lille, France
| | - M Munder
- University Medicine Mainz, Mainz, Germany
| | - M Offidani
- Clinica di Ematologia Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, Ancona, Italy
| | - N Zojer
- Center for Oncology, Hematology with Outpatient Department and Palliative Care, Wilhelminenspital, Vienna, Austria
| | - K Rajangam
- Onyx Pharmaceuticals, Inc., an Amgen subsidiary, South San Francisco, CA, USA
| | - Y-L Chang
- Onyx Pharmaceuticals, Inc., an Amgen subsidiary, South San Francisco, CA, USA
| | - J F San-Miguel
- Clínica Universidad de Navarra-CIMA-IDISNA, Navarra, Spain
| | - H Ludwig
- Wilhelminen Cancer Research Institute, Vienna, Austria
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Dimopoulos MA, Kastritis E, Ghobrial IM. Waldenström's macroglobulinemia: a clinical perspective in the era of novel therapeutics. Ann Oncol 2016; 27:233-40. [PMID: 26598544 PMCID: PMC4722893 DOI: 10.1093/annonc/mdv572] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 11/09/2015] [Accepted: 11/16/2015] [Indexed: 12/20/2022] Open
Abstract
Waldenström's macroglobulinemia (WM) is a rare, low-grade malignancy with no established standard of care. Rituximab regimens are most commonly used, supported by their efficacy in hematologic malignancies, including WM. A growing number of investigational regimens for WM have been evaluated in phase II clinical trials, including single-agent and combination strategies that include newer-generation monoclonal antibodies (ofatumumab and alemtuzumab), proteasome inhibitors (bortezomib and carfilzomib), immunomodulatory agents (thalidomide and lenalidomide), phosphoinositide 3-kinase/protein kinase B (Akt)/mammalian target of rapamycin pathway inhibitors (everolimus and perifosene), a Bruton's tyrosine kinase inhibitor (ibrutinib), and a histone deacetylase inhibitor (panobinostat). Other novel agents are in early-stage development for WM. International treatment guidelines for WM suggest suitable regimens in the newly diagnosed and relapsed/refractory settings, in accordance with patient age, disease presentation, and efficacy and safety profiles of particular drugs. These factors must be considered when choosing appropriate therapy for individual patients with WM, to maximize response and prolong survival, while minimizing the risk of adverse events. This review article provides a clinical perspective of the modern management of patients with WM, in the context of available trial data for novel regimens and recently updated treatment guidelines.
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Affiliation(s)
- M A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - E Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - I M Ghobrial
- Medical Oncology, Dana Farber Cancer Center, Boston, MA, USA
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Dimopoulos MA, Sonneveld P, Siegel D, Palumbo A, San-Miguel J. Carfilzomib and pomalidomide in patients with relapsed and/or refractory multiple myeloma with baseline risk factors. Ann Oncol 2015. [PMID: 26216385 DOI: 10.1093/annonc/mdv325] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
While survival times have increased over the last decade, most patients with multiple myeloma (MM) eventually relapse and become refractory to therapy. The treatment of patients with relapsed and/or refractory MM is frequently further complicated by the presence of pre-existing comorbidities that arise from an advanced disease state and of toxicities stemming from prior antimyeloma treatment. Carfilzomib and pomalidomide have recently been approved for the treatment of patients with relapsed and refractory MM. While these agents represent important additions to the available treatment options, the identification of patients who may best benefit from the use of each of therapy is still being investigated. A number of patient-related and disease-related factors may impact treatment efficacy and/or tolerability, and the clinical presentation and medical history of each patient must be carefully considered to optimize treatment. Here, we review results from carfilzomib and pomalidomide clinical trials in patients with relapsed and/or refractory MM who also have baseline comorbidities or treatment-induced or disease-induced complications (including the presence of renal impairment, cardiac risk factors, peripheral neuropathy, or high-risk chromosomal abnormalities) to evaluate the safety and efficacy of the two agents in these difficult-to-treat patients and to provide treatment recommendations specific to each scenario.
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Affiliation(s)
- M A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - P Sonneveld
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | - D Siegel
- John Theurer Cancer Center, Hackensack, USA
| | - A Palumbo
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - J San-Miguel
- Centre of Applied Medical Research, Clinica Universidad de Navarra, Navarra, Spain
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Dimopoulos MA, Swern AS, Li JS, Hussein M, Weiss L, Nagarwala Y, Baz R. Efficacy and safety of long-term treatment with lenalidomide and dexamethasone in patients with relapsed/refractory multiple myeloma. Blood Cancer J 2014; 4:e257. [PMID: 25382609 PMCID: PMC4571985 DOI: 10.1038/bcj.2014.77] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 09/16/2014] [Indexed: 11/29/2022] Open
Abstract
Data from two randomized pivotal, phase 3 trials evaluating the combination of lenalidomide and dexamethasone in relapsed/refractory multiple myeloma (RRMM) were pooled to characterize the subset of patients who achieved long-term benefit of therapy (progression-free survival ⩾ 3 years). Patients with long-term benefit of therapy (n = 45) had a median duration of treatment of 48.1 months and a response rate of 100%. Humoral improvement (uninvolved immunoglobulin A) was more common in patients with long-term benefit of therapy (79% vs 55%; P = 0.002). Significant predictors of long-term benefit of therapy in multivariate analysis were age < 65 years (P = 0.03), β2-microglobulin <2.5 mg/l (P = 0.002) and fewer prior therapies (P = 0.002). The exposure-adjusted incidence rate (EAIR) of grade 3-4 neutropenia was lower in patients with long-term benefit of therapy (13.9 vs 38.2 per 100 patient-years). The EAIR for invasive second primary malignancy was the same in patients with long-term benefit of therapy and other patients (1.7 per 100 patient-years). These findings indicate that patients with RRMM can experience long-term benefit with lenalidomide and dexamethasone treatment with manageable side effects.
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Affiliation(s)
- M A Dimopoulos
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece
| | - A S Swern
- Department of Biostatistics, Celgene Corporation, Summit, NJ, USA
| | - J S Li
- Department of Biostatistics, Celgene Corporation, Summit, NJ, USA
| | - M Hussein
- Department of Medical Affairs, Celgene Corporation, Summit, NJ, USA
| | - L Weiss
- Department of Drug Safety, Celgene Corporation, Summit, NJ, USA
| | - Y Nagarwala
- Department of Medical Affairs, Celgene Corporation, Summit, NJ, USA
| | - R Baz
- Department of Hematologic Malignancies, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Thilakarathne P, Palumbo A, Diels J, Delforge M, van Sanden S, Mateos MV, Chirita O, Dimopoulos MA, van de Velde H, San Miguel JF. Inverse Probability of Censoring Weighted Analysis to Adjust the Treatment Effect on Overall Survival for Subsequent Therapy: A Case Study in a Clinical Trial in Multiple Myeloma. Value Health 2014; 17:A546. [PMID: 27201769 DOI: 10.1016/j.jval.2014.08.1770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
| | | | - J Diels
- Janssen Pharmaceutica N. V., Beerse, Belgium
| | - M Delforge
- University Hospital Leuven, Leuven, Belgium
| | - S van Sanden
- EMEA HEMAR Analytics, Janssen EMEA, Beerse, Belgium
| | - M V Mateos
- Hospital Universitario de Salamanca, Salamanca, Spain
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Dimopoulos MA, Leleu X, Palumbo A, Moreau P, Delforge M, Cavo M, Ludwig H, Morgan GJ, Davies FE, Sonneveld P, Schey SA, Zweegman S, Hansson M, Weisel K, Mateos MV, Facon T, Miguel JFS. Expert panel consensus statement on the optimal use of pomalidomide in relapsed and refractory multiple myeloma. Leukemia 2014; 28:1573-85. [PMID: 24496300 PMCID: PMC4131249 DOI: 10.1038/leu.2014.60] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 01/16/2014] [Accepted: 01/21/2014] [Indexed: 11/24/2022]
Abstract
In this report, a panel of European myeloma experts discuss the role of pomalidomide in the treatment of relapsed and refractory multiple myeloma (RRMM). Based on the available evidence, the combination of pomalidomide and low-dose dexamethasone is a well-tolerated and effective treatment option for patients with RRMM who have exhausted treatment with lenalidomide and bortezomib. The optimal starting dose of pomalidomide is 4 mg given on days 1-21 of each 28-day cycle, whereas dexamethasone is administered at a dose of 40 mg weekly (reduced to 20 mg for patients aged >75 years). The treatment should continue until evidence of disease progression or unacceptable toxicity. Dose-modification schemes have been established for patients who develop neutropenia, thrombocytopaenia and other grade 3-4 adverse events during pomalidomide therapy. Guidance on the prevention and management of infections and venous thromboembolism is provided, based on the available clinical evidence and the experience of panel members. The use of pomalidomide in special populations, such as patients with advanced age, renal impairment or unfavourable cytogenetic features, is also discussed.
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Affiliation(s)
| | - X Leleu
- Service des Maladies du Sang, Hôpital Huriez, CHRU Lille, Lille, France
| | - A Palumbo
- Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliera S Giovanni Battista, Turin, Italy
| | - P Moreau
- Service d'Hematologie, CHU, Nantes, France
| | - M Delforge
- University Hospital Leuven, Leuven, Belgium
| | - M Cavo
- Seràgnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
| | - H Ludwig
- 1st Department of Internal Medicine, Center for Oncology and Hematology, Wilhelminenhospital, Vienna, Austria
| | - G J Morgan
- Institute of Cancer Research, Royal Marsden Hospital, London, UK
| | - F E Davies
- Institute of Cancer Research, Royal Marsden Hospital, London, UK
| | - P Sonneveld
- Department of Hematology, University Hospital Rotterdam, Rotterdam, The Netherlands
| | - S A Schey
- Department of Haemato-oncology, King's College Hospital and King's College London, London, UK
| | - S Zweegman
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - M Hansson
- Department of Hematology, Skåne University Hospital, Lund University, Lund, Sweden
| | - K Weisel
- University of Tuebingen, Tuebingen, Germany
| | - M V Mateos
- Hospital Universitario de Salamanca, CIC, IBMCC (USAL-CSIC), Salamanca, Spain
| | - T Facon
- Service des Maladies du Sang, Hôpital Huriez, CHRU Lille, Lille, France
| | - J F S Miguel
- Clinica Universidad de Navarra, Centro Investigaciones Medicas Aplicada (CIMA), Pamplona, Spain
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Gkotzamanidou M, Sfikakis PP, Kyrtopoulos SA, Bamia C, Dimopoulos MA, Souliotis VL. Chromatin structure, transcriptional activity and DNA repair efficiency affect the outcome of chemotherapy in multiple myeloma. Br J Cancer 2014; 111:1293-304. [PMID: 25051404 PMCID: PMC4183844 DOI: 10.1038/bjc.2014.410] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 05/15/2014] [Accepted: 06/30/2014] [Indexed: 01/20/2023] Open
Abstract
Background: Melphalan is one of the most active chemotherapeutic agents in the treatment of multiple myeloma (MM). However, the mechanism underlying differential patient responses to melphalan therapy is unknown. Methods: Chromatin structure, transcriptional activity and DNA damage response signals were examined following ex vivo treatment with melphalan of both malignant bone marrow plasma cells (BMPCs) and peripheral blood mononuclear cells (PBMCs) of MM patients, responders (n=57) or non-responders (n=28) to melphalan therapy. PBMCs from healthy controls (n=25) were also included in the study. Results: In both BMPCs and PBMCs, the local chromatin looseness, transcriptional activity and repair efficiency of the transcribed strand (TS) were significantly higher in non-responders than in responders and lowest in healthy controls (all P<0.05). Moreover, we found that melphalan-induced apoptosis inversely correlated with the repair efficiency of the TS, with the duration of the inhibition of mRNA synthesis, phosphorylation of p53 at serine 15 and apoptosis rates being higher in responders than in non-responders (all P<0.001). Conclusions: Our findings provide a mechanistic basis for the link between DNA repair efficiency and response to melphalan therapy. Interestingly, the observation of these phenomena in PBMCs provides a novel approach for the prediction of response to anti-myeloma therapy.
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Affiliation(s)
- M Gkotzamanidou
- 1] Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA [2] Department of Clinical Therapeutics, University of Athens School of Medicine, 11528 Athens, Greece
| | - P P Sfikakis
- First Department of Propedeutic Medicine, University of Athens School of Medicine, 11527 Athens, Greece
| | - S A Kyrtopoulos
- Institute of Biology, Medicinal Chemistry and Biotechnology, National Hellenic Research Foundation, 48 Vassileos Constantinou Avenue, 11635 Athens, Greece
| | - C Bamia
- Department of Hygiene, Epidemiology and Medical Statistics, University of Athens School of Medicine, 11527 Athens, Greece
| | - M A Dimopoulos
- Department of Clinical Therapeutics, University of Athens School of Medicine, 11528 Athens, Greece
| | - V L Souliotis
- Institute of Biology, Medicinal Chemistry and Biotechnology, National Hellenic Research Foundation, 48 Vassileos Constantinou Avenue, 11635 Athens, Greece
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Ocio EM, Richardson PG, Rajkumar SV, Palumbo A, Mateos MV, Orlowski R, Kumar S, Usmani S, Roodman D, Niesvizky R, Einsele H, Anderson KC, Dimopoulos MA, Avet-Loiseau H, Mellqvist UH, Turesson I, Merlini G, Schots R, McCarthy P, Bergsagel L, Chim CS, Lahuerta JJ, Shah J, Reiman A, Mikhael J, Zweegman S, Lonial S, Comenzo R, Chng WJ, Moreau P, Sonneveld P, Ludwig H, Durie BGM, Miguel JFS. New drugs and novel mechanisms of action in multiple myeloma in 2013: a report from the International Myeloma Working Group (IMWG). Leukemia 2014; 28:525-42. [PMID: 24253022 PMCID: PMC4143389 DOI: 10.1038/leu.2013.350] [Citation(s) in RCA: 182] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 10/23/2013] [Accepted: 11/07/2013] [Indexed: 01/08/2023]
Abstract
Treatment in medical oncology is gradually shifting from the use of nonspecific chemotherapeutic agents toward an era of novel targeted therapy in which drugs and their combinations target specific aspects of the biology of tumor cells. Multiple myeloma (MM) has become one of the best examples in this regard, reflected in the identification of new pathogenic mechanisms, together with the development of novel drugs that are being explored from the preclinical setting to the early phases of clinical development. We review the biological rationale for the use of the most important new agents for treating MM and summarize their clinical activity in an increasingly busy field. First, we discuss data from already approved and active agents (including second- and third-generation proteasome inhibitors (PIs), immunomodulatory agents and alkylators). Next, we focus on agents with novel mechanisms of action, such as monoclonal antibodies (MoAbs), cell cycle-specific drugs, deacetylase inhibitors, agents acting on the unfolded protein response, signaling transduction pathway inhibitors and kinase inhibitors. Among this plethora of new agents or mechanisms, some are specially promising: anti-CD38 MoAb, such as daratumumab, are the first antibodies with clinical activity as single agents in MM. Moreover, the kinesin spindle protein inhibitor Arry-520 is effective in monotherapy as well as in combination with dexamethasone in heavily pretreated patients. Immunotherapy against MM is also being explored, and probably the most attractive example of this approach is the combination of the anti-CS1 MoAb elotuzumab with lenalidomide and dexamethasone, which has produced exciting results in the relapsed/refractory setting.
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Affiliation(s)
- E M Ocio
- Department of Hematology, University Hospital and Cancer Research Center, University of Salamanca-IBSAL, IBMCC (USAL-CSIC), Salamanca, Spain
| | - P G Richardson
- Department of Medicine, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - S V Rajkumar
- Department of Hematology, Mayo Clinic, Rochester, MN, USA
| | - A Palumbo
- Department of Hematology, University of Torino, Torino, Italy
| | - M V Mateos
- Department of Hematology, University Hospital and Cancer Research Center, University of Salamanca-IBSAL, IBMCC (USAL-CSIC), Salamanca, Spain
| | - R Orlowski
- Department of Lymphoma/Myeloma, MD Anderson Cancer Center, Houston, TX, USA
| | - S Kumar
- Department of Hematology, Mayo Clinic, Rochester, MN, USA
| | - S Usmani
- M.I.R.T. UAMS, Little Rock, AR, USA
| | - D Roodman
- Director of Hematology/Oncology, Indiana University, Indianapolis, IN, USA
| | - R Niesvizky
- Department of Hematology, Weill Cornell Medical College, New York, NY, USA
| | - H Einsele
- Department of Internal Medicine, University of Wurzburg, Wurzburg, Germany
| | - K C Anderson
- Department of Medicine, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - M A Dimopoulos
- School of Medicine, University of Athens, Athens, Greece
| | - H Avet-Loiseau
- Department of Hematology, University of Toulouse, Toulouse, France
| | - U-H Mellqvist
- Department of Medicine, Section of Hematology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - I Turesson
- Department of Medicine, Section of Hematology, Skane University Hospital, Malmo, Sweden
| | - G Merlini
- Department of Molecular Medicine, Univeristy of Pavia, Pavia, Italy
| | - R Schots
- Department of Clinical Hematology and Stem Cell Laboratory, University Ziekenhuis, Brussels, Belgium
| | - P McCarthy
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - L Bergsagel
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ, USA
| | - C S Chim
- Department of Hematology, Queen Mary Hospital, Hong Kong
| | - J J Lahuerta
- Department of Hematology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - J Shah
- Department of Lymphoma/Myeloma, MD Anderson Cancer Center, Houston, TX, USA
| | - A Reiman
- Department of Oncology, University of New Brunswick, Saint John Regional Hospital, St John, NB, Canada
| | - J Mikhael
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ, USA
| | - S Zweegman
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - S Lonial
- Department of Hematology and Medical Oncology, Shanghai Chang Zheng Hospital, Atlanta, GA, USA
| | - R Comenzo
- Department of Hematology, Tufts Medical School, Boston, MA, USA
| | - W J Chng
- Department of Hematology Oncology, National University Cancer Institute, Singapore
| | - P Moreau
- Department of Hematology, University Hospital, Nantes, France
| | - P Sonneveld
- Department of Hematology, Erasmus MC, Rotterdam, The Netherlands
| | - H Ludwig
- Department of Medicine, Center for Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria
| | | | - J F S Miguel
- 1] Department of Hematology, University Hospital and Cancer Research Center, University of Salamanca-IBSAL, IBMCC (USAL-CSIC), Salamanca, Spain [2] Department of Clinical and Translational Medicine, University of Navarra, Pamplona, Spain
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Kotoula V, Lilakos K, Timotheadou E, Dimopoulos MA, Christodoulou C, Pentheroudakis G, Gogas H, Charalambous E, Papadopoulou K, Gkakou C, Lakis S, Kalogeras KT, Pectasides D, Fountzilas G. Abstract P4-04-10: Clinically relevant tumor mutation profiles in patients with triple negative breast cancer (TNBC). Cancer Res 2013. [DOI: 10.1158/0008-5472.sabcs13-p4-04-10] [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: 11/16/2022]
Abstract
Abstract
TNBC account for ∼15% of breast cancers and are most difficult to treat. However, TNBC patient outcome is very heterogeneous. In an effort to characterize the biological characteristics of TNBC, we examined 190 routinely diagnosed tumor tissues from early high-risk breast cancer patients treated with adjuvant chemotherapy (anthracyclines and/or taxanes). Highly multiplexed PCR primer pools were designed for 43 genes previously implicated in TNBC with Ion Ampliseq optimized for FFPE samples. Upon library construction and clonal amplification, amplicons were massively sequenced on Ion Proton PI chips and base-called (Torrent Suite 3.6). Variants were called and annotated (Ion Reporter 1.6), and accepted for analysis upon stringent read quality filtering at p<0.001. Informative results were obtained in 183 cases (96.3%). Deleterious and hot-spot mutations (Ingenuity and Oncomine databases) were observed in 39/43 genes, and were more frequent in TP53 (77%), CDH1 (29%), PIK3CA (16.4%), ARID1B (10.4%). TP53 was affected as a single gene in 55/183 (30%) of the cases. Most TNBC (103/183, 56.3%) were mutant in more than one genes; double deleterious/damaging TP53 mutations were observed in 59 (32.2%) tumors at relatively high incidence; and, 29 (15.8%) tumors had extremely variable mutation profiles with >4 mutations per sample, most of them at low incidence but still indicative of dynamic clonal expansion. CDH1 mutations seldom occurred alone (2% of all tumors) and were probably non-founders, while mutations in some genes, e.g., AKT1 (9/12) and ARID1B (13/19) preferentially occurred in CDH1mutant tumors (p<0.001). In comparison to the 12 patients with tumors free of mutations in any of the genes tested (no events up to 120 mo after treatment start), patients with tumors bearing any number of mutations (n = 171) had significantly shorter disease-free survival (DFS, median: 56 mo, log-rank p = 0.031). Mutations in single genes were not significantly associated with disease outcome. The 29 patients with tumors bearing >4 mutations had longer median DFS (91 mo) as compared to those with 1 mutation (n = 68, median DFS 46.5 mo) or with 4 mutations (n = 21, median DFS 39 mo) (HR: 0.4; 95%CI: 0.2-0.8; Wald's p = 0.010). In comparison to patients with TP53&CDH1 non-mutant tumors (n = 26, median DFS 62 mo), patients with TP53mutant/CDH1non-mutant tumors relapsed significantly earlier (n = 103, median DFS 48 mo, HR 3.9, 95%CI 1.2-12.9, Wald's p = 0.023) and tended to have shorter overall survival. CDH1mutant/TP53non-mutant and tumors mutated in both genes did not show such associations (interaction Wald's p = 0.044). No interactive effects on patient outcome were observed between mutation markers and treatment with taxanes, adjuvant radiotherapy, or with standard clinicopathologic parameters. In conclusion, TNBC may be assigned as a TP53 disease. However, the present data underline the need for a broad assessment of tumor mutational profiles, including non-founder mutations, since they may interfere with patient outcome upon standard treatments. The application of targeted parallel sequencing on routinely processed FFPE tissue samples seems feasible and may help in assessing clinically relevant genomic variant profiles of these highly intra- and inter-heterogeneous tumors.
Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-04-10.
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Affiliation(s)
- V Kotoula
- Hellenic Cooperative Oncology Group (HeCOG), Athens, Greece
| | - K Lilakos
- Hellenic Cooperative Oncology Group (HeCOG), Athens, Greece
| | - E Timotheadou
- Hellenic Cooperative Oncology Group (HeCOG), Athens, Greece
| | - MA Dimopoulos
- Hellenic Cooperative Oncology Group (HeCOG), Athens, Greece
| | | | | | - H Gogas
- Hellenic Cooperative Oncology Group (HeCOG), Athens, Greece
| | - E Charalambous
- Hellenic Cooperative Oncology Group (HeCOG), Athens, Greece
| | - K Papadopoulou
- Hellenic Cooperative Oncology Group (HeCOG), Athens, Greece
| | - C Gkakou
- Hellenic Cooperative Oncology Group (HeCOG), Athens, Greece
| | - S Lakis
- Hellenic Cooperative Oncology Group (HeCOG), Athens, Greece
| | - KT Kalogeras
- Hellenic Cooperative Oncology Group (HeCOG), Athens, Greece
| | - D Pectasides
- Hellenic Cooperative Oncology Group (HeCOG), Athens, Greece
| | - G Fountzilas
- Hellenic Cooperative Oncology Group (HeCOG), Athens, Greece
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Ludwig H, Miguel JS, Dimopoulos MA, Palumbo A, Garcia Sanz R, Powles R, Lentzsch S, Ming Chen W, Hou J, Jurczyszyn A, Romeril K, Hajek R, Terpos E, Shimizu K, Joshua D, Hungria V, Rodriguez Morales A, Ben-Yehuda D, Sondergeld P, Zamagni E, Durie B. International Myeloma Working Group recommendations for global myeloma care. Leukemia 2013; 28:981-92. [DOI: 10.1038/leu.2013.293] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 09/17/2013] [Accepted: 09/23/2013] [Indexed: 12/31/2022]
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Terpos E, Christoulas D, Kastritis E, Roussou M, Migkou M, Eleutherakis-Papaiakovou E, Gavriatopoulou M, Gkotzamanidou M, Kanellias N, Manios E, Papadimitriou C, Dimopoulos MA. VTD consolidation, without bisphosphonates, reduces bone resorption and is associated with a very low incidence of skeletal-related events in myeloma patients post ASCT. Leukemia 2013; 28:928-34. [PMID: 24045498 DOI: 10.1038/leu.2013.267] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 09/11/2013] [Indexed: 01/17/2023]
Abstract
We prospectively evaluated the effect of bortezomib, thalidomide and dexamethasone (VTD) consolidation on bone metabolism of 42 myeloma patients who underwent an autologous stem cell transplantation (ASCT). VTD started on day 100 post ASCT; patients received four cycles of VTD (first block), were followed without treatment for 100 days and then received another four VTD cycles (second block). During this 12-month period, bisphosphonates were not administered. Best response included stringent complete remission (sCR) in 15 (35.7%) patients, complete response (CR) in 13 (30.9%), vgPR in 7 (16.6%), PR in 4 (9.5%), while 3 (7.1%) patients developed a progressive disease (PD). Importantly, 33.3% and 47.6% of patients improved their status of response after the first and second VTD block, respectively. VTD consolidation resulted in a significant reduction of circulating C-terminal cross-linking telopeptide of collagen type I (CTX), soluble receptor activator of the nuclear factor-kappa B ligand (sRANKL) and osteocalcin (OC), whereas bone-specific alkaline phosphatase (bALP) remained stable compared with pre-VTD values. During the study period, only one patient with a PD developed a skeletal-related event (that is, radiation to bone). The median time to progression (TTP) after ASCT was 34 months and the median time of next treatment was 40 months. We conclude that VTD consolidation post ASCT reduces bone resorption and is associated with a very low incidence of skeletal-related events (SREs) despite the absence of bisphosphonates; the later do not appear to be necessary in this context.
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Affiliation(s)
- E Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - D Christoulas
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - E Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - M Roussou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - M Migkou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - E Eleutherakis-Papaiakovou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - M Gavriatopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - M Gkotzamanidou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - N Kanellias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - E Manios
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - C Papadimitriou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - M A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
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Bamias A, Tzannis K, Beuselinck B, Oudard S, Escudier B, Diosynopoulos D, Papazisis K, Lang H, Wolter P, de Guillebon E, Stravodimos K, Chrisofos M, Fountzilas G, Elaidi RT, Dimopoulos MA, Bamia C. Development and validation of a prognostic model in patients with metastatic renal cell carcinoma treated with sunitinib: a European collaboration. Br J Cancer 2013; 109:332-41. [PMID: 23807171 PMCID: PMC3721408 DOI: 10.1038/bjc.2013.341] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 06/07/2013] [Accepted: 06/09/2013] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Accurate prediction of outcome for metastatic renal cell carcinoma (mRCC) patients receiving targeted therapy is essential. Most of the available models have been developed in patients treated with cytokines, while most of them are fairly complex, including at least five factors. We developed and externally validated a simple model for overall survival (OS) in mRCC. We also studied the recently validated International Database Consortium (IDC) model in our data sets. METHODS The development cohort included 170 mRCC patients treated with sunitinib. The final prognostic model was selected by uni- and multivariate Cox regression analyses. Risk groups were defined by the number of risk factors and by the 25th and 75th percentiles of the model's prognostic index distribution. The model was validated using an independent data set of 266 mRCC patients (validation cohort) treated with the same agent. RESULTS Eastern Co-operative Oncology Group (ECOG) performance status (PS), time from diagnosis of RCC and number of metastatic sites were included in the final model. Median OS of patients with 1, 2 and 3 risk factors were: 24.7, 12.8 and 5.9 months, respectively, whereas median OS was not reached for patients with 0 risk factors. Concordance (C) index for internal validation was 0.712, whereas C-index for external validation was 0.634, due to differences in survival especially in poor-risk populations between the two cohorts. Predictive performance of the model was improved after recalibration. Application of the mRCC International Database Consortium (IDC) model resulted in a C-index of 0.574 in the development and 0.576 in the validation cohorts (lower than those recently reported for this model). Predictive ability was also improved after recalibration in this analysis. Risk stratification according to IDC model showed more similar outcomes across the development and validation cohorts compared with our model. CONCLUSION Our model provides a simple prognostic tool in mRCC patients treated with a targeted agent. It had similar performance with the IDC model, which, however, produced more consistent survival results across the development and validation cohorts. The predictive ability of both models was lower than that suggested by internal validation (our model) or recent published data (IDC model), due to differences between observed and predicted survival among intermediate and poor-risk patients. Our results highlight the importance of external validation and the need for further refinement of existing prognostic models.
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Affiliation(s)
- A Bamias
- Department of Clinical Therapeutics, University of Athens, Athens, Greece.
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Zorzou MP, Efstathiou E, Galani E, Bozas G, Kastritis E, Papadimitriou C, Dimopoulos MA, Bamias A. Carboplatin Hypersensitivity Reactions: A Single Institution Experience. J Chemother 2013; 17:104-10. [PMID: 15828452 DOI: 10.1179/joc.2005.17.1.104] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Carboplatin-related hypersensitivity reactions, frequently encountered in the heavily pretreated subpopulation of patients with gynecologic malignancies, can be severe and even potentially lethal-precluding these patients from an effective salvage treatment. We describe our experience in the management of such reactions and the application of a pretreatment protocol with corticosteroids, antihistamines and a slow infusion rate in order to safely re-administer carboplatin to the above patients. From 1998 to 2004, twenty patients developed an allergic reaction to carboplatin. Sixteen of them (80%) suffered from ovarian cancer. Upon resolution of the acute reaction, thirteen patients were pretreated according to our protocol and were re-exposed to carboplatin. Fifteen patients experienced the reaction during second-line carboplatin-based treatment and 5 patients after 3 or more regimens. Fifteen of the reactions (75%) were severe. Thirteen patients were re-treated with carboplatin after the application of our protocol, all of them successfully, even though 10 patients (77%) experienced minor symptoms during subsequent courses. On the contrary, only one of the 6 patients who were re-treated without the application of the protocol was able to receive further platinum-based treatment. In conclusion, pretreatment with corticosteroids, antihistamines and a slower infusion rate may make re-treatment possible in patients having experienced hypersensitivity to carboplatin.
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Affiliation(s)
- M P Zorzou
- Department of Clinical Therapeutics, Medical School, University of Athens, Athens, Greece
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45
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Gavalas NG, Tsiatas M, Tsitsilonis O, Politi E, Ioannou K, Ziogas AC, Rodolakis A, Vlahos G, Thomakos N, Haidopoulos D, Terpos E, Antsaklis A, Dimopoulos MA, Bamias A. VEGF directly suppresses activation of T cells from ascites secondary to ovarian cancer via VEGF receptor type 2. Br J Cancer 2013; 107:1869-75. [PMID: 23169339 PMCID: PMC3504940 DOI: 10.1038/bjc.2012.468] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background: Vascular endothelial growth factor action in tumour angiogenesis is well characterised; nevertheless, it functions as a key element in the promotion of the immune system’s evasion by tumours. We sought to investigate the possible direct effect of VEGF on T-cell activation and through which type of VEGF receptor it exerts this effect on cells isolated from ovarian cancer patients’ ascites. Methods: T cells isolated from the ascites of ovarian cancer patients were cultured with anti-CD3 and IL-2, with or without VEGF for 14 days and the number of viable T cells was counted. Cytotoxic activity of cultured T cells and expression of VEGF receptor-2 (VEGFR-2), was assayed. Results: The addition of VEGF in cultures significantly reduced the number and proliferation rate of T cells in a dose-dependent manner and CD3+ T cells expressed VEGFR-2 on their surface upon activation. Experiments with specific anti-VEGFR-2 antibodies revealed that the direct suppressive effect of VEGF on T-cell proliferation is mediated by VEGFR-2. We also showed that VEGF significantly reduced the cytotoxic activity of T cells. Conclusion: Our study showed that ascites-derived T cells secrete VEGF and express VEGFR-2 upon activation. Vascular endothelial growth factor directly suppresses T-cell activation via VEGFR-2.
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Affiliation(s)
- N G Gavalas
- Department of Clinical Therapeutics, Medical School, University of Athens, Alexandra Hospital, 80 Vas. Sofias Avenue, 115 28 Athens, Greece
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Kyrtsonis MC, Koulieris E, Maltezas D, Tzenou T, Harding S, Kastritis E, Kafassi N, Bartzis V, Efthymiou A, Bitsanis K, Gavriatopoulou M, Terpos E, Kalpadakis C, K. Angelopoulou M, P. Vassilakopoulos T, R. Bradwell A, Beris P, A. Pangalis G, Panayiotidis P, A. Dimopoulos M. Prognostic Contribution of the New Immunoglobulin (Ig) Biomarkers (Freelite™ and Hevylite™) in Waldenstrom’s Macroglobulinemia (WM). ACTA ACUST UNITED AC 2012. [DOI: 10.5923/j.ajmms.20120206.05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Fernández de Larrea C, Kyle RA, Durie BGM, Ludwig H, Usmani S, Vesole DH, Hajek R, San Miguel JF, Sezer O, Sonneveld P, Kumar SK, Mahindra A, Comenzo R, Palumbo A, Mazumber A, Anderson KC, Richardson PG, Badros AZ, Caers J, Cavo M, LeLeu X, Dimopoulos MA, Chim CS, Schots R, Noeul A, Fantl D, Mellqvist UH, Landgren O, Chanan-Khan A, Moreau P, Fonseca R, Merlini G, Lahuerta JJ, Bladé J, Orlowski RZ, Shah JJ. Plasma cell leukemia: consensus statement on diagnostic requirements, response criteria and treatment recommendations by the International Myeloma Working Group. Leukemia 2012; 27:780-91. [PMID: 23288300 DOI: 10.1038/leu.2012.336] [Citation(s) in RCA: 229] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Plasma cell leukemia (PCL) is a rare and aggressive variant of myeloma characterized by the presence of circulating plasma cells. It is classified as either primary PCL occurring at diagnosis or as secondary PCL in patients with relapsed/refractory myeloma. Primary PCL is a distinct clinic-pathological entity with different cytogenetic and molecular findings. The clinical course is aggressive with short remissions and survival duration. The diagnosis is based upon the percentage (≥ 20%) and absolute number (≥ 2 × 10(9)/l) of plasma cells in the peripheral blood. It is proposed that the thresholds for diagnosis be re-examined and consensus recommendations are made for diagnosis, as well as, response and progression criteria. Induction therapy needs to begin promptly and have high clinical activity leading to rapid disease control in an effort to minimize the risk of early death. Intensive chemotherapy regimens and bortezomib-based regimens are recommended followed by high-dose therapy with autologous stem cell transplantation if feasible. Allogeneic transplantation can be considered in younger patients. Prospective multicenter studies are required to provide revised definitions and better understanding of the pathogenesis of PCL.
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Affiliation(s)
- C Fernández de Larrea
- Amyloidosis and Myeloma Unit, Department of Hematology, IDIBAPS, Hospital Clinic de Barcelona, Barcelona, Spain.
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48
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Bamias A, Dafni U, Karadimou A, Timotheadou E, Aravantinos G, Psyrri A, Xanthakis I, Tsiatas M, Koutoulidis V, Constantinidis C, Hatzimouratidis C, Samantas E, Visvikis A, Chrisophos M, Stravodimos K, Deliveliotis C, Eleftheraki A, Pectasides D, Fountzilas G, Dimopoulos MA. Prospective, open-label, randomized, phase III study of two dose-dense regimens MVAC versus gemcitabine/cisplatin in patients with inoperable, metastatic or relapsed urothelial cancer: a Hellenic Cooperative Oncology Group study (HE 16/03). Ann Oncol 2012; 24:1011-7. [PMID: 23136231 DOI: 10.1093/annonc/mds583] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The combinations of methotrexate, vinblastine, Adriamycin, cisplatin (Pharmanell, Athens, Greece) (MVAC) or gemcitabine, cisplatin (GC) represent the standard treatment of advanced urothelial cancer (UC). Dose-dense (DD)-MVAC has achieved longer progression-free survival (PFS) than the conventional MVAC. However, the role of GC intensification has not been studied. We conducted a randomized, phase III study comparing a DD-GC regimen with DD-MVAC in advanced UC. PATIENTS AND METHODS One hundred and thirty patients were randomly assigned between DD-MVAC: 66 (M 30 mg/m(2), V 3 mg/m(2), A 30 mg/m(2), C 70 mg/m(2) q 2 weeks) and DD-GC 64 (G 2500 mg/m(2), C 70 mg/m(2) q 2 weeks). The median follow-up was 52.1 months (89 events). RESULTS The median overall survival (OS) and PFS were 19 and 8.5 months for DD-MVAC and 18 and 7.8 months for DD-GC (P = 0.98 and 0.36, respectively). Neutropenic infections were less frequent for DD-GC than for DD-MVAC (0% versus 8%). More patients on DD-GC received at least six cycles of treatment (85% versus 63%, P = 0.011) and the discontinuation rate was lower for DD-GC (3% versus 13%). CONCLUSIONS Although DD-GC was not superior to DD-MVAC, it was better tolerated. DD-GC could be considered as a reasonable therapeutic option for further study in this patient population. Clinical Trial Number ACTRN12610000845033, www.anzctr.org.au.
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Affiliation(s)
- A Bamias
- Department of Clinical Therapeutics, Alexandra Hospital, Athens University Medical School, Athens, Greece.
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Terpos E, Kastritis E, Christoulas D, Gkotzamanidou M, Eleutherakis-Papaiakovou E, Kanellias N, Papatheodorou A, Dimopoulos MA. Circulating activin-A is elevated in patients with advanced multiple myeloma and correlates with extensive bone involvement and inferior survival; no alterations post-lenalidomide and dexamethasone therapy. Ann Oncol 2012; 23:2681-2686. [PMID: 22492699 DOI: 10.1093/annonc/mds068] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Activin-A is a transforming growth factor -β superfamily member, which seems to be implicated in the biology of osteolytic disease in multiple myeloma. DESIGN AND METHODS Circulating activin-A was evaluated in 98 newly diagnosed myeloma patients (85 with symptomatic disease), in 40 patients with relapsed myeloma before and after four cycles of lenalidomide and dexamethasone (RD), in 27 healthy controls and in 10 monoclonal gammopathy of undetermined significance patients. RESULTS Patients with newly diagnosed symptomatic myeloma had increased circulating activin-A compared with controls (P < 0.001), while patients with relapsed disease had elevated activin-A even compared with symptomatic patients at diagnosis (P < 0.001). High activin-A correlated with advanced International Staging System stage (P = 0.002), increased bone resorption (P < 0.001) and extensive bone disease (P = 0.03). Low levels of activin-A (<442 pg/ml) were associated with superior median overall survival: not reached versus 59 months (P = 0.04), while activin-A inversely correlated with survival as a continuous variable (P < 0.001). RD did not alter circulating activin-A after four cycles of treatment, even in responders. CONCLUSIONS High circulating activin-A correlates with advanced features of myeloma, supporting the rationale for the use of activin-A antagonists, such as sotatercept in myeloma. The inability of RD to reduce activin-A reveals RD as a good candidate for combination therapies with activin-A antagonists in myeloma.
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Affiliation(s)
- E Terpos
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece.
| | - E Kastritis
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece
| | - D Christoulas
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece
| | - M Gkotzamanidou
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece
| | | | - N Kanellias
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece
| | - A Papatheodorou
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece
| | - M A Dimopoulos
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece
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Dimopoulos MA, Kastritis E, Michalis E, Tsatalas C, Michael M, Pouli A, Kartasis Z, Delimpasi S, Gika D, Zomas A, Roussou M, Konstantopoulos K, Parcharidou A, Zervas K, Terpos E. The International Scoring System (ISS) for multiple myeloma remains a robust prognostic tool independently of patients' renal function. Ann Oncol 2012; 23:722-729. [PMID: 21652580 DOI: 10.1093/annonc/mdr276] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND The International Staging System (ISS) is the most widely used staging system for patients with multiple myeloma (MM). However, serum β2-microglobulin increases in renal impairment (RI) and there have been concerns that ISS-3 stage may include 'up-staged' MM patients in whom elevated β2-microglobulin reflects the degree of renal dysfunction rather than tumor load. PATIENTS AND METHODS In order to assess the impact of RI on the prognostic value of ISS, we analyzed 1516 patients with symptomatic MM and the degree of RI was classified according to the Kidney Disease Outcomes Quality Initiative-Chronic Kidney Disease (CKD) criteria. RESULTS Forty-eight percent patients had stages 3-5 CKD while 29% of patients had ISS-1, 38% had ISS-2 and 33% ISS-3. The frequency and severity of RI were more common in ISS-3 patients. RI was associated with inferior survival in univariate but not in multivariate analysis. When analyzed separately, ISS-1 and ISS-2 patients with RI had inferior survival in univariate but not in multivariate analysis. In ISS-3 MM patients, RI had no prognostic impact either in univariate or multivariate analysis. Results were similar, when we analyzed only patients with Bence-Jones >200 mg/day. CONCLUSIONS ISS remains unaffected by the degree of RI, even in patients with ISS-3, which includes most patients with renal dysfunction.
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Affiliation(s)
- M A Dimopoulos
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens.
| | - E Kastritis
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens
| | - E Michalis
- Department of Hematology, 'G. Gennimatas' Hospital, Athens
| | - C Tsatalas
- Department of Haematology, Democritus University of Thrace Medical School, Alexandroupolis, Greece
| | - M Michael
- Department of Haematology, Nicosia General Hospital, Nicosia, Cyprus
| | - A Pouli
- Department of Hematology, 'Saint Savvas' Anticancer Hospital, Athens
| | - Z Kartasis
- Department of Hematology, Chalkis General Hospital, Chalkis
| | - S Delimpasi
- Department of Hematology, 'Evangelismos' Hospital, Athens
| | - D Gika
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens
| | - A Zomas
- Fourth Department of Internal Medicine, 'Attikon' University Hospital, Athens
| | - M Roussou
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens
| | - K Konstantopoulos
- First Department of Medicine, University of Athens School of Medicine, Athens
| | - A Parcharidou
- Third Department of Internal Medicine, Red Cross Hospital 'Korgialenio Benakio', Athens
| | - K Zervas
- Department of Hematology, 'Theagenion' Cancer Center, Thessaloniki, Greece
| | - E Terpos
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens
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