Bortezomib In Multiple Myeloma Patients Research Articles

Expanding therapeutic utility of carfilzomib for breast cancer therapy by novel albumin-coated nanocrystal formulation

Carfilzomib (CFZ) is the second-in-class proteasome inhibitor with much improved efficacy and safety profiles over bortezomib in multiple myeloma patients. In expanding the utility of CFZ to solid cancer therapy, the poor aqueous solubility and in vivo instability of CFZ are considered major drawbacks. We investigated whether a nanocrystal (NC) formulation can address these issues and enhance anticancer efficacy of CFZ against breast cancer. The surface of NC was coated with albumin in order to enhance the formulation stability and drug delivery to tumors via interactions with albumin-binding proteins located in and near cancer cells. The novel albumin-coated NC formulation of CFZ (CFZ-alb NC) displayed improved metabolic stability and enhanced cellular interactions, uptake and cytotoxic effects in breast cancer cells in vitro. Consistently, CFZ-alb NC showed greater anticancer efficacy in a murine 4T1 orthotopic breast cancer model than the currently used cyclodextrin-based formulation. Overall, our results demonstrate the potential of CFZ-alb NC as a viable formulation for breast cancer therapy.

Comparison of Peripheral Neuropathy Between the Original and a Generic Bortezomib in Multiple Myeloma Patients

Comparison of Peripheral Neuropathy Between the Original and a Generic Bortezomib in Multiple Myeloma Patients

Efficacy and Safety of Bortezomib in Multiple Myeloma Patients with Hepatitis B: A Multicenter Retrospective Study.

Background:The efficacy and safety evidence of bortezomib in multiple myeloma (MM) patients with hepatitis B is vacant. This study aimed to investigate the efficacy and safety of bortezomib in MM patients with hepatitis B in China.Methods:From 2006 to 2011, 739 newly diagnosed MM patients were screened for serum hepatitis B virus (HBV) biomarkers. HBV-infected patients were followed for HBV reactivation by monitoring of serum alanine transaminase (ALT) and HBV DNA load. The pattern of HBV reactivation in relation to bortezomib was evaluated. Seven hundred thirty-nine MM patients were included in this study.Results:The prevalence of MM patients infected with HBV was 3.4% (n = 25), of which 17 cases were treated with bortezomib. Bortezomib had no significant influence on liver function (ALT before and after treatment: 36.69 ± 8.90 U/L vs. 11.31 ± 2.74 U/L, P = 0.19) and HBV DNA of MM patients with HBV (detectable HBV DNA percentage: 5.9% vs. 11.8%, P = 0.12).Conclusions:Bortezomib can be used safely and effectively in MM patients with hepatitis B. HBV prophylaxis and surveillance are recommended during the MM treatment.

Varicella-zoster virus-specific cell-mediated immunity and herpes zoster development in multiple myeloma patients receiving bortezomib- or thalidomide-based chemotherapy

BackgroundThe incidence of herpes zoster is substantial during bortezomib treatment in patients with multiple myeloma (MM). ObjectivesThis study aimed to elucidate the effect of chemotherapy with or without bortezomib in MM patients on their herpes zoster incidence and varicella zoster virus (VZV)-specific cell-mediated immunity (CMI). Study designPeripheral blood mononuclear cells were collected at baseline and after 1 month of bortezomib-based or thalidomide-based chemotherapy and then analyzed using VZV-specific interferon-gamma (IFN-γ) enzyme-linked immunospot (ELISPOT) assay. The clinical data from these patients were analyzed in relation to the ELISPOT results. ResultsOf 58 patients analyzed, 39 patients received bortezomib and the other 19 patients, thalidomide. Among them, 5 patients developed herpes zoster during chemotherapy; all 5 were being treated with the bortezomib-based regimen and were not receiving prophylactic anti-viral agents. The median onset of herpes zoster was 32 days (range, 15–95 days) from the initiation of chemotherapy. Among patients who received bortezomib therapy, acyclovir prophylaxis significantly reduced the risk for herpes zoster (100-day cumulative incidence, 0% vs. 49.5%; p<0.001). Spot-forming cell (SFC) counts in the IFN-γ ELISPOT assay decreased from baseline after bortezomib (p=0.011) or thalidomide (p=0.096) treatment. Patients with baseline SFCs greater than 20/106 mononuclear cells exhibited significantly higher incidence of herpes zoster (100-day cumulative incidence, 34.8% vs. 0%; p=0.040). ConclusionsBortezomib treatment significantly reduced VZV-specific CMI, and high baseline SFC counts in patients receiving this treatment without acyclovir prophylaxis were associated with a significantly increased risk for herpes zoster.

Subcutaneous bortezomib in multiple myeloma patients induces similar therapeutic response rates as intravenous application but it does not reduce the incidence of peripheral neuropathy.

ObjectiveSubcutaneous (SC) application of bortezomib has been recently introduced as a new application route in multiple myeloma (MM) patients. We performed an analysis to compare the outcomes of bortezomib-based therapy in multiple myeloma (MM) patients treated using either intravenous (IV) or subcutaneous (SC) route of administration.Patients and methodsDuring January 2012 through December 2013, we performed a retrospective analysis of 446 patients with MM treated with bortezomib-based regimens (either once weekly – 63% or twice weekly – 27%) in both, the first line setting, and in relapse, with separate analysis of patients undergoing autologous stem cell transplantation. We assessed the response rates and toxicity profiles in both, IV and SC route of bortezomib administration.ResultsThe response rates in both IV and SC arm were similar with overall response rate 71.7% vs 70.7%, complete remissions in 13.9% vs 8.6%, very good partial remissions in 30.8% vs 34.5% and partial remissions in 27% vs 27.6%. The most frequent grade ≥3 toxicities were anemia, thrombocytopenia and neutropenia, with no significant differences between IV and SC group. There were no significant differences in the rate of peripheral neuropathy (PN). PN of any grade was present in 48% in the IV arm and in 41% in the SC arm. PN grade ≥2 was present in 20% vs 18% and PN grade ≥3 was present in 6% vs 4%.ConclusionsWe conclude that subcutaneous application of bortezomib has similar therapeutic outcomes and toxicity profile as intravenous route of application. In our cohort there was no difference in the incidence of PN, suggesting that PN is dose dependent and might be reduced by lower intensity schemes rather than by the route of administration.

Subcutaneous and Intravenous Bortezomib in Multiple Myeloma Patients Has Similar Response Rates and Toxicity Profile with No Difference in the Incidence of Peripheral Neuropathy: Report of the Czech Myeloma Group

Background:Subcutaneous (SC) application of bortezomib has been recently introduced as a new application route in multiple myeloma (MM) patients. The results of an international randomized phase III trial confirmed that SC application of bortezomib is not inferior to intravenous (IV) route, with similar response rates and improved toxicity profile.Our aim was to confirm the results on a larger cohort of patients treated with IV or SC bortezomib in 2-year period within the Czech Myeloma Group.Patients and methods: We performed a retrospective analysis of 262 patients with MM treated with bortezomib based regimens during 2012-2013 in the Czech Republic. In total, there were 177 patients in the IV arm and 85 patients in the SC arm. Patients undergoing high-dosed chemotherapy followed by autologous stem cell transplantation (ASCT) were assessed separately (N = 99). There were 164 patients treated in the first line setting and 98 patients in relapse/progression of MM. The patients received up to eight 28-day cycles of bortezomib-based regimen with bortezomib dose 1.3mg/m2. The regimens used were following: CVD (cyclophosphamide, bortezomib, dexamethasone) in 58.2%/60.0%, VD (bortezomib, dexamethasone) in 10.7%/9.4%, BDD (bortezomib, doxorubicin, dexamethasone) in 9.6%/14.2%, VMP (bortezomib, melphalan, prednisone) in 6.0%/9.0%, bortezomib monotherapy in 1.1%/1.2%, BBD (bortezomib, bendamustine, dexamethasone) in 1.1%/2.4%, BP (bortezomib, prednisone) in 0%/1.6%, and other in 13.6%/2.4%. In order to reduce neurological toxicities, most of the patients received bortezomib once weekly. In both IV and SC arms we assessed the demographics and baseline characteristics, response rates and toxicities.For statistical estimation we used Mann-Whitney U test and Chi-square test at p < 0.05.Results:There were mild differences in the age and gender between IV and SC arms (median age 71.3 vs 67.9 years, p = 0.024; M/F ratio 1.4:1 vs 0.6:1, p = 0.007), other variables were without significant difference, including laboratory parameters (M-protein, hemoglobin, thrombocyte count, serum calcium level, albumin, creatinine, beta-2-microglobulin, lactate dehydrogenase, CRP), line of chemotherapy (first line, second line, third line and fourth and higher line) and therapeutic regimen used. Patients received median of 6 cycles in the IV group and 5 cycles in the SC group. The rates of response were similar in both, IV and SC arms with overall response rate (ORR) 71.7% vs 70.7%, complete remissions (CR) including stringent complete remissions (sCR) in 13.9% vs 8.6%, very good partial remissions (VGPR) in 30.8% vs 34.5% and partial remissions (PR) in 27% vs 27.6%. Toxicities were present in most patients (up to 99%), prevailing grade 1-2 toxicities, the most frequent grade ≥3 toxicities were anemia, thrombocytopenia and neutropenia, with no significant differences between IV and SC group. There were no significant differences in the rate of peripheral neuropathy (PN). PN of any grade was present in 48% patients in the IV arm and in 41% in the SC arm. PN grade ≥2 was present in 20% vs 18% and PN grade ≥3 was present in 6% vs 4% (p = 0.782).Conclusions:Subcutaneous application of bortezomib has similar therapeutic outcomes and toxicity profile as intravenous route of application. In our cohort there was no difference in the incidence of PN, suggesting that PN is dose dependent and might be reduced by lower intensity schemes rather than by the route of administration.Supported by the grants IGA MZ CR NT 14393, NT 12215-4/2011, NT 14400, NT12451-5, NT 12215-4, and the grant MSM0021622434. DisclosuresNo relevant conflicts of interest to declare.

B and H-NMR Evaluation of Chemical Interactions between Two Polyphenols; Epigallocatechingallate and Quercetin with Bortezomib

Bortezomib (Velcade) is a boronic acid dipeptide, proteasome inhibitor drug that its antimyeloma activity in treatment of patients with multiple myeloma (MM) has been approved by FDA. Studies show that consumption of daily diet rich in polyphenols affect Bortezomib’s bioavailability and reduce its antitumor activity. In the present study we made an attempt to investigate the interactions between Bortezomib and some common polyphenols to examine whether these polyphenols interact with the drug. For this purpose, interactions between four dietary polyphenols including: Emodin, Rhein, Epigallocatechingallate (EGCG) and Quercetin with methyl boronic acid, Bortezomib’s substitute, were studied using 1H and 11B- NMR spectroscopy. The results suggest that the vicinal diols in the structure of the two polyphenols (EGCG and Quercetin) interact with the boronic acid moiety of Bortezomib and convert the active triangular boronic acid to an inactive tetrahedral boronate through direct chemical interaction, and this conversion abolishes the antimyeloma activity of Bortezomib. In conclusion, our study suggests that the consumption of dietary sources enriched in EGCG and Quecetin during treatment with Bortezomib in MM patients should be considered.

Blood distribution of bortezomib and its kinetics in multiple myeloma patients

ObjectivesPharmacokinetic disposition of bortezomib in the blood has not been fully characterized in humans. This study aimed to evaluate the blood distribution of bortezomib and its kinetics in multiple myeloma patients. Design and methodEighteen multiple myeloma patients receiving bortezomib–dexamethasone combination therapy were enrolled. Blood specimens were drawn just before bortezomib administration on days 1 and 8 in the second and third cycles and after discontinuation. The relationships between bortezomib concentration and blood components were evaluated. ResultsBortezomib concentration in the blood on day 1 was higher than that on day 8 in the second cycle. No difference was observed in bortezomib blood concentrations between day 8 in the second and third cycles. The bortezomib concentration in the blood and blood cells was 3- and 7-fold higher than that in plasma. Bortezomib concentration in the blood was correlated with the red blood cell count. The half-life of bortezomib in the blood was 23days. ConclusionBortezomib was taken up into red blood cells to only a limited extent and eliminated in parallel to the red blood cells' lifespan. The turnover of red blood cells can affect the pharmacokinetic disposition of bortezomib in multiple myeloma patients.

Lenalidomide Versus Bortezomib: An Indirect Comparison

SUMMARY Aim: The objective of this study was to perform an indirect comparison between lenalidomide (LEN) and bortezomib (BORT). Methods: LEN and BORT are both effective for the treatment of patients with refractory multiple myeloma, but there are no head-to-head clinical trial data available. Therefore, an indirect statistical comparison between LEN and BORT was performed using the method of Bucher et al. Results: Three published randomized trials with LEN (n = 2) and BORT (n = 1) in the refractory setting were identified. Patients treated with LEN were significantly more likely to achieve a disease response (odds ratio: 1.92; 95% CI: 1.15–3.20) and to have a prolongation in time to progression (hazard ratio: 0.64; 95% CI: 0.44–0.91). Conclusion: Keeping in mind the caveats associated with cross-trial comparisons, the indirect statistical evaluation suggested the potential for increased activity of LEN over BORT in multiple myeloma patients with refractory disease.

Abstract 4607: Expression of Bcl-2 pro-survival family proteins predicts pharmacological responses to ABT-199, a novel and selective Bcl-2 antagonist, in multiple myeloma models.

Abstract A hallmark feature of cancer is the ability to evade cell death signals induced by stress response cues mediated, in part, by the the Bcl-2 family of pro-apoptotic and pro-survival proteins. ABT-199 is a potent BH3-only mimetic that selectively antagonizes the pro-survival function of Bcl-2. The work presented describes the efficacy of ABT-199 as a single agent and in combination with bortezomib in preclinical models of Multiple Myeloma (MM). Expression of Bcl-2 protein was detected in 95% of MM cell lines (n=21) evaluated and ABT-199 reduced cell viability in a sub-set of these lines (7/21) with EC50 values less than 0.5 μM. Expression of Bcl-xL and Mcl-1 at the mRNA and protein levels were also evaluated to determine predictors of drug sensitivity and resistance to ABT-199. MM lines that expressed higher levels of Bcl-2 relative to Bcl-xL and Mcl-1 were the most sensitive to ABT-199 treatment while those that were less sensitive expressed higher levels of Mcl-1 or Bcl-xL. Other predictors of sensitivity to ABT-199 included higher levels of Bcl-2/Bim complexes and t(11;14) status. Ex vivo, 75% of the MM bone marrow biopsies and aspirates (n=27) had high Bcl-2 levels whereas 50% had high Bcl-xL expression, demonstrating that a subset of patient samples (33%) have a favorable biomarker profile (Bcl-2-high/Bcl-xL-low) that may be predictive of ABT-199 activity. Efficacy of ABT-199 as a single agent and in combination with bortezomib was evaluated in vivo in MM xenograft models that expressed Bcl-2 (OPM-2, KMS-11, RPMI-8226, H929 and MM.1s). Bortezomib treatment alone at maximum tolerated doses resulted in tumor regressions or stasis in all xenograft models tested. ABT-199 at maximum tolerated doses was efficacious as a single agent in xenograft models that expressed higher protein levels of Bcl-2 but relatively lower levels of Bcl-xL. The combination of ABT-199 with bortezomib increased overall response rates, durability of anti-tumor activity and levels of apoptotic markers such as cleaved caspase 3 and PARP when compared to bortezomib alone even in MM xenograft models that also express relatively high levels of Mcl-1. Treatment with bortezomib in vivo increased levels of Noxa; a pro-apoptotic BH3-only protein that selectively antagonizes Mcl-1. Therefore, greater efficacy may be achieved when ABT-199 is combined with bortezomib due to inhibition of Bcl-2 by ABT-199 and neutralization of Mcl-1 by Noxa in tumors that express both pro-survival proteins. Our preclinical data supports the evaluation of ABT-199 as a single agent and in combination with bortezomib in MM patients in which relative expression of the Bcl-2 pro-survival proteins may serve as predictive biomarkers of drug activity. Citation Format: Deepak Sampath, Elizabeth Punnoose, Erwin Boghaert, Lisa Belmont, Franklin Peale, Nguyen Tan, Jun Chen, Walter Darbonne, Peng Yue, Jason Oeh, Leslie Lee, Wayne J. Fairbrother, Andrew J. Souers, Steven W. Elmore, Joel D. Leverson. Expression of Bcl-2 pro-survival family proteins predicts pharmacological responses to ABT-199, a novel and selective Bcl-2 antagonist, in multiple myeloma models. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4607. doi:10.1158/1538-7445.AM2013-4607

A Pilot Study of Acupuncture in Treating Bortezomib-Induced Peripheral Neuropathy (BIPN) in Multiple Myeloma (MM) Patients.

AbstractAbstract 3168 Background:Peripheral neuropathy (PN) is the dose-limiting toxicity of bortezomib in MM patients, affecting >30% patients, including painful PN. Treatment is mostly supportive with narcotics, antidepressants, and anticonvulsants. Acupuncture has been reported to be effective in treating neuropathic pain in diabetic and cancer patients. Methods:We initiated a pilot study to assess the feasibility, safety and efficacy of acupuncture in reducing the severity of BIPN in MM patients. Patients had acupuncture twice weekly for 2 weeks, weekly for 4 weeks, and then biweekly for 4 weeks. All patients continued their prescribed PN medications. Clinical Total Neuropathy Score (TNSc), Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity (FACT/GOG-Ntx) questionnaire and Neuropathy Pain Scale (NPS) were used to assess patients at study entry and week 1, 2, 3, 4, 5, 6, 8, 10 during and after 4 weeks of completion of therapy. Serum was obtained from the patients at baseline, right after first acupuncture and before acupuncture session on week 2, 4, 8, and at follow up visit on week 14. Serum samples were used to measure cytokines concentrations. Before and after acupuncture treatments, a complete neurological examination was performed. Nerve conduction studies at baseline and end of study were conducted. Treatment included insertion of disposable sterile acupuncture needles, which retained for 25 minutes, at the following points: bilateral ear points: shen men, point zero, two auricular points where electro-dermal signal was detected, and bilateral body acupuncture points: LI4, SJ5, LI11, ST40, and Ba Feng in upper and lower extremities. Results:From May 17, 2011 to February 28, 2012, 27 MM patients were enrolled in the study. Thirteen patients were women; median age was 63 years (range: 49–77); nine were black, one Asian, 17 Caucasian, and eight had diabetes. All patients had grade 2–4 sensorimotor PN: grade 2 (n=12), grade 3 (n=14), and grade 4 (n=1); 8 had painful PN. All patients had persistant PN despite discontinuation of bortezomib for a median of 19 months (range: 1–83). Eight patients were enrolled within 6 months of stopping bortezomib, all of them had grade 3–4 painful PN. Median time from diagnosis of MM to study entry was 30 months (range: 5–178). Nineteen patients were in remission and eight had progressive disease. MM therapy at study entry and through the follow up period included: revlimid (n=12), carflizomib (n=2). Therapy of PN included narcotics (n=13), gabapentin (12), amitriptyline (n=3), pregabalin (n=2), and duloxetine (n=2). Two patients withdrew after first acupuncture treatment. Twenty-five patients were evaluable for response after completion of 3 weeks (n=2), 6 weeks (n=2), 9 weeks (n=1) and 10 weeks of acupuncture (n=20). There were no adverse events associated with the acupuncture treatment. All but five patients maintained the same dose of pain medications throughout the study. Fourteen patients (56%) reported improved daily functions (e.g. walking and coordination). Ten patients (40%) reported > 50% decrease in average NPS during treatment (week 1–10). Seven patients reported 50% reduction in FACT/GOG-Ntx total scores. The decrease in NPS and FACT/GOG-Ntx, was statistically significant between baseline assessments through week 14; p-values are 0.001 and <0.0001, respectively. On the other hand, TNSc scores, an objective clinical assessment, did not significantly change. Of fifteen patients who had nerve conduction studies, five showed >10% increase in motor nerve amplitude but there was no correlation observed between symptoms/function improvements and nerve conduction studies. At week 8, one of the measured cytokines: Brain-Derived Neurotrophic Factor (BDNF) significantly increased from baseline (p=0.043). This increase was no longer significant at week 14 follow up. Conclusions:Acupuncture is safe and effective in treating persistent moderate to severe BIPN, with improvements of patient reported outcomes, pain and function. The increased BDNF during acupuncture treatment suggests that acupuncture may work through promoting survival and growth of neurons, a lengthy process that may explain the lag of significant objective clinical improvement in the short follow up of our patients. The mechanism of acupuncture working through BDNF to treat PN warrants further evaluation. Disclosures:No relevant conflicts of interest to declare.

Efficacy and safety of once-weekly bortezomib in multiple myeloma patients

AbstractIn a recent phase 3 trial, bortezomib-melphalan-prednisone-thalidomide followed by maintenance treatment with bortezomib-thalidomide demonstrated superior efficacy compared with bortezomib-melphalan-prednisone. To decrease neurologic toxicities, the protocol was amended and patients in both arms received once-weekly instead of the initial twice-weekly bortezomib infusions: 372 patients received once-weekly and 139 twice-weekly bortezomib. In this post-hoc analysis we assessed the impact of the schedule change on clinical outcomes and safety. Long-term outcomes appeared similar: 3-year progression-free survival rate was 50% in the once-weekly and 47% in the twice-weekly group (P > .999), and 3-year overall survival rate was 88% and 89%, respectively (P = .54). The complete response rate was 30% in the once-weekly and 35% in the twice-weekly group (P = .27). Nonhematologic grade 3/4 adverse events were reported in 35% of once-weekly patients and 51% of twice-weekly patients (P = .003). The incidence of grade 3/4 peripheral neuropathy was 8% in the once-weekly and 28% in the twice-weekly group (P < .001); 5% of patients in the once-weekly and 15% in the twice-weekly group discontinued therapy because of peripheral neuropathy (P < .001). This improvement in safety did not appear to affect efficacy. This study is registered at http://www.clinicaltrials.gov as NCT01063179.

Efficacy and Safety of Once Weekly Bortezomib In Multiple Myeloma Patients

Efficacy and Safety of Once Weekly Bortezomib In Multiple Myeloma Patients

Efficacy and Safety of Retreatment with Bortezomib in Patients with Multiple Myeloma: Interim Results From RETRIEVE, a Prospective International Phase 2 Study.

Abstract 3866Poster Board III-802Bortezomib (Velcade®) retreatment has been shown to be active and well tolerated in patients with relapsed multiple myeloma (MM) in a number of retrospective studies and a small prospective phase 4 study (EVEREST). This large, prospective, international, multi-center, open-label phase 2 study was conducted to confirm the efficacy and safety of retreatment with bortezomib in MM patients who had previously responded (at least partial response [PR]) to bortezomib-based therapy as their most recent prior treatment. Patients had to have previously tolerated bortezomib 1.0 or 1.3 mg/m2 alone or in combination and have had a treatment-free interval (TFI; time from last dose of initial bortezomib treatment to first dose of bortezomib retreatment) of ≥6 months. Additional eligibility criteria included progressive disease or relapse from complete response (CR) by EBMT criteria, no MM therapy (except maintenance with dexamethasone, thalidomide, or interferon) since the last dose of initial bortezomib treatment, KPS ≥60, and adequate renal, hepatic, and hematologic function; patients with grade ≥2 peripheral neuropathy or neuropathic pain (as defined by NCI CTCAE v3.0) were excluded. Patients received bortezomib at the last tolerated dose (1.0 or 1.3 mg/m2) during initial treatment on days 1, 4, 8, and 11 for up to eight 21-day cycles, either alone or in combination with dexamethasone at the investigator's discretion. Response was assessed by EBMT criteria every 6 weeks during treatment and then every 2 months until disease progression. Adverse events (AEs) were graded according to NCI CTCAE v3.0. A total of 130 patients received at least 1 dose of bortezomib retreatment and were included in the safety population. Patients had a median age of 67 years, 57% were male, and 16% had KPS '70%. Median time from diagnosis of MM was 4.5 years (range 0–14 years); median number of prior therapies was 2; 15, 80, 23, and 12 patients had received 1, 2, 3, and ≥4 prior lines of therapy (excluding initial bortezomib therapy). Best response by EBMT criteria to initial bortezomib treatment was CR in 26% and PR in 74% of patients; median time to progression and TFI after initial bortezomib treatment were 17.9 months and 14.3 months, respectively. Last tolerated dose of previous bortezomib therapy was 1.3 mg/m2 and 1.0 mg/m2 for 62% and 29% of patients, respectively; 9% received another dose. Patients received a median 7.0 (range 1–8) cycles of bortezomib retreatment (23% of patients completed all 8 cycles); 72% of patients received concomitant dexamethasone. A total of 126 patients were evaluable for response. In the 126 response-evaluable patients, the overall response rate (ORR; CR+PR) by best confirmed response (EBMT criteria) was 40%; in addition, 18% of patients achieved minimal response (MR), to give a CR+PR+MR rate of 58%. After a planned secondary efficacy analysis, the ORR (CR+PR) by single best response was 55% (75% ≥MR). Median time to best confirmed response (≥MR) was 2.9 months; time to first response was 1.5 months. Analysis of ORR by patient subgroups showed comparable results in patients who did versus did not receive concomitant dexamethasone (42% vs 32%), in those who received ≤1.0 mg/m2 vs 1.3 mg/m2 bortezomib (35% vs 41%), and in those aged ≤65 years vs >65 years (45% vs 36%). ORR was 67%, 39%, 33%, and 25% in patients who had received 1, 2, 3, and ≥4 prior lines of therapy (excluding initial bortezomib), respectively. Analysis of best confirmed responses according to response to initial bortezomib showed that 63% and 52% of patients who achieved a CR or PR, respectively, to initial bortezomib treatment responded to retreatment. Most (98%) patients experienced a treatment-emergent AE; 60% experienced a grade 3/4 AE, and 32% experienced a serious AE; there were 8 deaths, 2 of which (due to sepsis and stroke) were possibly treatment-related. The most common grade 3/4 AEs were thrombocytopenia (35%), neutropenia (7%), diarrhea (7%), and pneumonia (5%). AEs leading to dose reductions or discontinuations were reported for 22% and 12% of patients, respectively. The incidence of neuropathy was 39%, including 9% grade 3; 4% of patients discontinued treatment due to PN; 61% of neuropathy events resolved or improved within a median 1.3 months. These results confirm that bortezomib retreatment is a well-tolerated, feasible, and active therapeutic option for heavily pretreated MM patients without evidence of cumulative toxicity. Disclosures:Petrucci:Janssen-Cilag: Honoraria; Celgene: Honoraria. Dimopoulos:Ortho-Biotech: Consultancy, Honoraria; Millennium Pharmaceuticals, Inc.: Honoraria. Drach:Janssen-Cilag: Consultancy, Honoraria; Amgen: Honoraria; Celgene: Honoraria. Blade:Janssen-Cilag: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Honoraria; Johnson and Johnson: Honoraria; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

Developing a SNP Classifier for Predicting Peripheral Neuropathy by Bortezomib in Multiple Myeloma Patients.

Abstract 1800Poster Board I-826 BackgroundThe prevalence of peripheral neuropathy (PNP) during the treatment of MM with Bortezomib is high. About 20% of patients develop a grade 3-4 PNP due to this treatment, and as a result Bortezomib treatment is stopped or a reduced dose is given. Therefore, there is a strong need to find markers which predict the susceptibility of a patient to develop Bortezomib related PNP. Materials and methods: Bortezomib treated patients from the Dutch/German Hovon 65 GMMG-HD4 trial and the French IFM-2005/01 trial were used for this analysis. In both trials, the efficacy of Bortezomib as induction treatment prior to high-dose therapy is evaluated and PNP status was recorded. Samples were genotyped using a custom-built molecular inversion probe (MIP)-based single nucleotide polymorphism (SNP) chip containing 3404 SNPs (Bank on a Cure program; Van Ness et al., 2008). In total, 232 patients who did not develop PNP were compared to 210 PNP cases (grade 1, n=82; grade 2 n=86, grade 3, n=31, grade 4, n=11). ResultsThe data were processed on the basis of the following criteria. First, SNPs genotyped in less than 75% of the samples were removed (n=155). This resulted in elimination of 59% of the data with unknown genotype while only 1% of the genotyped data were lost. The remaining 41% of the missing data were imputed using BIMBAM (Guan et al., PLoS Genet. 4:e1000279, 2008). As reference panels, the data sets of the BOAC chips from this study, 500 random samples from the Rotterdam ERGO study (Köttgen et al., Nat. Genet. 41, 712–717, 2009) and 60 phased CEU HAPMAP samples were used. Secondly, SNPs were excluded which did not show any genotype variance and which were not in Hardy Weinberg equilibrium. As a last step the data was adjusted for stratification using Eigenstrat (Price et al., Nat. Genet. 38: 904–909, 2006). By removing 21 SNPs and 14 samples the variance between the IFM and Hovon was reduced to an acceptable level (p = 0.011). The resulting combined IFM/Hovon dataset now contained 2764 SNP and 428 samples. The data set was divided in 6/7 (n=367) part as a learning set and 1/7 (n=61) as a validation set. Possibly informative SNPs were selected using information gain as a feature selection method (Cover et al., Elements of information theory. New York, John Wiley, 1991). 66 SNPs with an information gain in allele and genotype frequency were selected (p value < 0.05 after permutation test (n=10000)). Classifiers generated by Partial C4.5 decision tree (PART), support vector machine (SVM) and Random forest learned on this set reached a better than random performance. Sensitivity, specificity, positive predictive value and negative predictive value were respectively 55%, 70%, 60%, and 66% for the PART classifier. ConclusionPreliminary classifiers generated by this dataset suggest that building a classifier with clinically relevant performance may be within reach. To this end, we will report on the outcome of different combinations of existing classifier methods and feature selection methods.Van Ness, B, Ramos, C, Haznadar, M, Hoering, A,Haessler, J, Crowley, J, Jacobus, S, Oken, M, Rajkumar, V, Greipp, P, Barlogie, B, Durie, B, Katz, M, Atluri, G, Ganf, G, Gupta, R, Steinbach, M, Kumar, V, Mushlin, R, Johnson, D, and Morgan, G. (2008). Genomic Variation in Myeloma: Design, content, and initial application of the Bank On A Cure SNP Panel to analysis of survival. BMC Medicine. 6:26. DisclosuresHanifi-Moghaddam:Skyline Diagnostics: Employment.

The Addition of Bortezomib to the Combination of Lenalidomide and Dexamethasone Increases Bone Formation in Relapsed/Refractory Myeloma: a Prospective Study in 91 Patients.

Abstract 1815Poster Board I-841Bortezomib is the first-in-class proteasome inhibitor with established activity in multiple myeloma (MM), which also increases osteoblast function both in vitro and in vivo. The addition of bortezomib to the combination of lenalidomide and dexamethasone (RD) regimen seems to increase the RD efficacy. There are very limited data in the literature for the effect of RD on bone metabolism while there are no reports for the effect of BRD on myeloma bone disease. The aim of this study was to evaluate the effect of BRD and RD on bone remodeling of patients with relapsed/refractory MM. We studied 91 patients who participated in a prospective study in which patients with pre-existing peripheral neuropathy (PN) grade <2 received BRD, while patients with PN of grade 2 or more received RD, regardless of their performance status and renal function. In BRD arm, patients received bortezomib at a dose of 1 mg/m2 on days 1, 4, 8 and 11; lenalidomide 15 mg on days 1-14 (or at a lower dose if creatinine clearance (CrCl) was <30 ml/min) and dexamethasone 40 mg, PO, on days 1-4, in a 21-day cycle. In RD arm, patients received lenalidomide on days 1-21 at a dose based on their CrCl, according to guidelines, and dexamethasone 40 mg, PO, on days 1-4 and 15-18 for the first 4 cycles and only on days 1-4 thereafter, every 28 days. All patients also received 4 mg zoledronic acid, iv, monthly. Bone remodeling was studied by the measurement of a series of serum indices, on day 1 of cycles 1, 4 & 7, in patients and in 31 healthy controls of similar age and gender: i) osteoclast regulators [sRANKL and osteoprotegerin (OPG)], ii) osteoblast inhibitor dickkopf-1 (Dkk-1), iii) bone resorption markers [C-telopeptide of collagen type-I (CTX) and 5b-isoenzyme of tartrate resistant acid phosphatase (TRACP-5b)], and iv) bone formation markers [bone-specific alkaline phosphatase (bALP) and osteocalcin (OC)]. Radiological skeletal survey was performed at baseline, after 6 cycles of therapy and then as needed, while patients were assessed for skeletal-related events (SREs) throughout the period of the study. As of July 2009, 80 patients (43M/37F, median age 67 years) have received 6 cycles of therapy (40 in each treatment arm) and the bone markers measurements have been completed and analyzed. Myeloma patients at baseline had increased serum levels of Dkk-1 (p<0.001), sRANKL (p=0.006), and bone resorption markers (p<0.01) compared to control group. On the contrary, both markers of bone formation were significantly reduced compared to controls (p<0.001). Strong correlation was observed between Dkk-1 and sRANKL/OPG ratio (r=0.639, p<0.001). Objective response was 60% (24/40 patients) in RD and 62.5% (25/40 patients) in BRD. BRD administration resulted in a significant reduction of Dkk-1 (p=0.031) and increase of OC (p=0.002) after 3 cycles of therapy which was continued after 6 cycles of therapy. Furthermore, BRD led to a reduction of sRANKL (p=0.023) and sRANKL/OPG ratio (p=0.027) and a significant increase of bALP (p=0.01) after 6 cycles of treatment. These changes were irrespective of treatment response. In BRD patients, percentage reduction of Dkk-1 strongly correlated with percentage increase of bALP after 6 cycles of therapy (r=-0.682, p=0.004). In patients who received RD no significant alterations in markers of bone remodeling were observed. However, patients who responded to RD showed a reduction in CTX (p=0.039) compared with those who did not respond after 6 cycles of therapy. Patients who received 6 cycles of RD showed an increase of Dkk-1 levels: responders had a median increase of 9% while non-responders had a median increase of 91% compared to baseline values (p<0.01). The percentage change of sRANKL (p=0.007) and Dkk-1 (p=0.009) was significantly different between patients who received BRD and those who received RD: both molecules were reduced after 6 cycles of BRD while both were increased after six cycles of RD. No SREs were observed in the BRD arm while two patients treated with RD who had not responded to therapy developed a vertebral pathological fracture. Our study suggests that RD regimen does not seem to have any effect on bone formation even in responding patients with relapsed/refractory MM, possibly due to the presence of high dose dexamethasone and to the enhancement of Dkk-1 expression by lenalidomide. On the contrary, patients who received BRD had an increased bone formation, at least partially due to a significant reduction of Dkk-1, reflecting the strong anabolic effect of bortezomib in MM patients. DisclosuresTerpos:Janssen-Cilag: Consultancy, Honoraria.

Alpha Lipoic Acid (ALA) Inhibits the Anti-Myeloma Effects of Bortezomib.

Abstract 3832Poster Board III-768 IntroductionALA is an antioxidant often used in the management of peripheral neuropathy (PN) for patients with multiple myeloma (MM). A clinical trial evaluating ALA in diabetic neuropathy showed this drug to be effective for patients with both somatic and autonomic neuropathies. It also normalized the endoneural blood flow, reduced oxidative stress and improved vascular dysfunction. Bortezomib (Velcade®), the first-in-class proteasome inhibitor (PI), which is approved for the treatment of patients with MM, may cause PN. As a result, patients are often treated empirically with ALA. In this study, we investigated whether ALA has any impact on the anti-MM effects of bortezomib. MethodsFirst, cells from the MM cell lines RPMI8226 and MM1S (1×105 cells per 100μl) were treated with ALA alone to determine whether ALA had any effects on their growth as determined with an MTS assay. MM cells were plated in a 96-well plate using serum-free media. The cells were treated with either media alone or ALA at concentrations ranging from 1 to 1000 μM for 48 hours. The acidity of ALA at these doses was determined and if the pH was less than 7, we neutralized it using NaOH. Second, we measured the proliferation of cells exposed to bortezomib alone and combinations of a fixed concentration of bortezomib and escalating concentrations of ALA. ResultsThe exposure of cells to ALA alone had a stimulatory effect on the growth of both MM cell lines in vitro. ALA alone at 1000 μM resulted in an increase in cell viability of MM1S cells by approximately 10% when compared to the control group. ALA alone also stimulated the growth of RPMI8226 cells but at much lower concentrations than observed for MM1S. Compared to untreated cells, there was an increase in cell viability with ALA at concentrations as low as 1 μM and a concentration dependent increase at concentrations of 1, 10, 100, and 1000 μM in RPMI8226 cells. At the highest concentration (1000 μM) of ALA, cell viability increased 150% when compared to RPMI8226 cells incubated with media alone. Next, we evaluated the effect of ALA on bortezomib's anti-MM activity. As a single agent, bortezomib reduced MM1S (20 nM) and RPMI8226 (5 nM) cell viability by 93% and 70% respectively. When ALA was added at a clinically achievable concentration (100 μM) to bortezomib (RPMI8226, 5 nM; MM1S, 20 nM), a reduction in the anti-MM effects of bortezomib on these cell lines was observed when compared to bortezomib treatment alone. Compared to bortezomib alone, the combination of ALA plus bortezomib doubled cell viability (increased RPMI8226 and MM1S cell viability from 32.5% to 65% and 7.5% to 15%, respectively). These negative effects of ALA on bortezomib's anti-MM activity were consistently observed in multiple experiments involving both of these cell lines evaluating concentrations of ALA ranging from 100 to 1000 μM and bortezomib ranging from 5 to 20 nM. ConclusionsOur data suggest that ALA has the potential to antagonize the anti-MM effects of bortezomib based on our in vitro results using MM cell lines. Thus, it is possible that ALA could negatively impact the therapeutic benefit of bortezomib for MM patients and this requires further study especially if ALA is accepted as an intervention in bortezomib-related neuropathy. We are currently completing studies evaluating primary MM patients' tumor cells in vitro and our human MM xenograft models in vivo to further validate this impact of ALA on bortezomib's anti-MM activity and whether changes in treatment schedule of these drugs may prevent this inhibitory effect from occurring. In addition, because part of bortezomib's anti-tumor effects are related to reactive oxygen species (ROS) levels, we are evaluating whether the inhibitory effects of ALA on this PI may be overcome by increasing intracellular ROS levels. Disclosures:Hilger:Millennium Pharmaceutcals: Employment. Berenson:Millennium Pharmaceuticals, Inc.: Consultancy, Honoraria, Research Funding, Speakers Bureau.

Results from the Phase I Portion of a Phase I/II Study of ATN-224 and Bortezomib for Patients with Multiple Myeloma Relapsed from or Refractory to Bortezomib

ATN-224 (bis-choline tetrathiomolybdate) is an orally-available small molecule that is currently being studied in several phase II oncology clinical trials. ATN-224 inhibits copper-zinc superoxide dismutase (Cu/Zn-SOD; SOD1) in endothelial and tumor cells. SOD1 is an enzyme that mediates signaling by a number of mitogens including VEGF, FGF-2, EGF, IGF-1 and PDGF. The inhibition of SOD1 by ATN-224 leads to the inhibition of proliferation in endothelial cells and the induction of apoptosis in tumor cells. In a preclinical mouse model using multiple myeloma (MM) cells obtained from a patient that was refractory to bortezomib, the combination of ATN-224 and bortezomib was more effective than either agent alone and led to tumor regression. Based on this data, a phase I/II clinical study evaluating the combination of ATN-224 and bortezomib for MM patients that had previously failed bortezomib was initiated. The phase I portion of this study evaluated the safety of several doses of both ATN-224 and bortezomib and established a recommended dose and schedule of this combination for the phase II portion of the study. The phase I study has completed enrollment and results are presented here. Patients with recurrent or refractory MM that had previously failed bortezomib and currently showing evidence of disease progression were enrolled. Patients had adequate ECOG performance status (PS 0–2) and hematologic and organ function. Patients were monitored for safety and preliminary evidence of efficacy. Blood samples were collected at specific intervals for pharmacokinetic and pharmacodynamic analyses. Twenty-one patients (62% male), aged 46–80 (mean 66) with PS 0–1 were enrolled into 6 cohorts. Dose Limiting Toxicity (DLT) was defined as grade 3 or 4 neutropenia with neutropenic fever, grade 4 neutropenia, grade 3 or 4 thrombocytopenia, grade 2 peripheral neuropathy with pain, grade 3 or 4 neuropathic pain and/or peripheral sensory neuropathy, grade 4 anemia or a fall in hemoglobin by >3 g/dL when day 1 hemoglobin is ≥11 g/dL or >2 g/dL when day 1 hemoglobin is <11 g/dL over a 28-day interval, or any grade 3 or 4 non-hematologic treatment-related toxicity (excluding alopecia) that cannot be reduced to grade 2 or less with symptomatic therapy within 7 days. In the initial 3 cohorts of the trial (n=10), ATN-224 was administered at doses of either 240, 180, or 210 mg daily in combination with bortezomib at a dose of 0.7 mg/m2/dose on days 1, 4, 8 and 11 of a 21 day cycle. Several DLTs [hemoglobin decreased >2g/dL from baseline (n=3) and grade 3 fatigue (n=1)] were observed within the first three cohorts. After review of this data, it was determined that the more appropriate dosing schedule included a 7 day drug holiday. In cohorts 4 through 6 (n=11), ATN-224 was administered at doses of either 180 or 210 mg daily for 21 days in combination with bortezomib at a dose of either 1.0 or 1.3 mg/m2/dose on days 8,11, 15 and 18 of a 28 day cycle. One DLT (grade 4 thrombocytopenia) was observed and occurred in the 180 mg ATN-224 plus 1.3mg/m2/dose bortezomib cohort. By incrementally increasing each dose of ATN-224 and bortezomib individually and modifying the treatment schedule, treatment-related toxicities have been minimized while maximizing the treatment doses. One patient experienced a complete response that was durable for over 10 months. The other 20 patients experienced disease progression within 90 days. A daily dose of 210 mg of ATN-224 for 21 days and a dose of bortezomib at 1.0 mg/m2 on days 8, 11, 15, and 18 of a 28 day cycle was well tolerated and recommended for the phase II portion of this trial, which is now enrolling patients. The phase I portion of the study demonstrates that the combination of ATN-224 and bortezomib can be safely administered and may be an effective treatment for MM patients that are relapsed from or refractory to bortezomib.

An Observational Post Authorization Study on the Use of Bortezomib in Multiple Myeloma Patients in the Netherlands: Results of An Interim Analysis

Introduction: Bortezomib (Velcade) is a first-in-class proteasome inhibitor for the treatment of patients (pts) with multiple myeloma (MM). Most data on efficacy and safety are from randomised controlled studies in selected groups of pts with MM.Aim of the study: To evaluate safety and efficacy of bortezomib in the real-life community oncology practice setting as a second-line therapy or in subsequent lines of therapy in pts with MM.Materials and methods: In an observational, multicentre study, the efficacy and safety of treatment with bortezomib was assessed in MM pts. An interim analysis was performed on data of pts enrolled from November 04 until November 06 (109 pts).Results: All results are given as median. The pts age was 67 yrs, Karnofsky Performance Score was 80%, time from initial diagnosis was 3.3 years, 62% of the pts had more than 2 previous lines of treatment, 85% of the pts had disease stage III. Pts were treated with median 4 cycles (95% CI: 4.1–5.0) of bortezomib. Median time to initial response was 50 days and median time to best response category was 84 days. Of all pts 43.2% achieved a partial response or better (2.8% CR, 6.4% nCR, 3.7% VGPR, 30.3% PR); 16 pts were not evaluable for response. The duration of response (DOR) was 6.3 months, PFS was 5.8 months and overall survival was 1.2 yrs. The treatment was generally well tolerated. Most common adverse events (all grades) in >15% of the pts were, in order of decreasing frequency, thrombocytopenia, nausea, diarrhoea, fatigue, (poly)neuropathy, constipation, malaise, anaemia, pyrexia, vomiting and anorexia. For responding pts treatment discontinuation due to an AE occurred in 46.8% of the pts. For the three most common AE's (polyneuropathy, fatigue/malaise, thrombocytopenia), resulting in discontinuation of the bortezomib treatment, the discontinuation was not preceded by a dose adjustment in almost half of the cases. In 9 pts (8.3%), Herpes zoster reactivation was reported. Twenty-two out of 109 pts were thalidomide naïve when starting bortezomib. 59.4% of these pts achieved a PR or better vs. 39% in thalidomide pre-treated pts, but thalidomide pre-treated pts had a longer time from initial diagnosis (3.5 vs 2.6 years) and had more previous treatment lines compared to thalidomide naïve pts (3 2 lines of previous therapy 97.7% vs 59.1% respectively).Conclusion: Response rates in this study were comparable to those in other community studies and higher than reported in previous clinical studies. Overall the treatment with bortezomib was well tolerated. However, it seems dose adjustment as a strategy to continue treatment and to increase the quality of response, is still underutilized in clinical practice. Overall survival was as expected in this patient population. The thalidomide naïve group was yet too small to draw any conclusions on safety and efficacy as compared to the thalidomide pre-treated pts.

An Observational Post Authorization Study on the Use of Bortezomib in Multiple Myeloma Patients in The Netherlands: Results of an Interim Analysis.

Introduction: Bortezomib (Velcade®) is a relatively new drug in the treatment of patients with Multiple Myeloma (MM). Most data on efficacy and safety are from randomised controlled studies in selected groups of patients with MM. Aim of the study: To evaluate safety and efficacy of bortezomib in daily practice after its registration for second and later line therapy in patients with MM. Materials and methods: In an observational, multicentre study, the efficacy and safety of treatment with bortezomib was assessed in MM patients. An interim analysis was performed on data of the first 50 patients enrolled from November 04 until March 06. Results: All results are given as median ± SD. The patients’ age was 65 yrs, Karnofsky Performance Score was 80%, time from initial diagnosis was 3.4 years, 62% of the patients had more than 2 previous treatment lines, 88% of the patients had disease stage III. Patients were treated with 4 cycles (95% CI: 4.0 – 5.4) of bortezomib. The patients had Response Rate (RR; based on serum M-protein values) of 64% (2.0% nCR, 2.0% VGPR, 22% PR, 38% MR). Best RR remained 64% with an increasing depth of response (2% CR, 8% nCR 6.0% VGPR, 32% PR, 16% MR); 6 patients were not evaluable for response. Time to initial response was 45 days; time to best response was 63 days. The duration of response (DOR) was 6.4 months. Also, a relation between treatment duration and DOR was found (correlation coefficient 0.4118, p-value 0.0192). Overall survival was 1.3 yrs and PFS 6.4 months. The treatment was generally well tolerated. Most common adverse events (AE’s) were in order of decreasing frequency thrombocytopenia, nausea, constipation, diarrhoea, fatigue, malaise, polyneuropathy, pyrexia, anaemia, dizziness and leukopenia. Only 6.1% of all AE’s resulted in a permanent discontinuation of bortezomib; 13% of all AE’s were reported as serious of which 54.7% were considered as grade 3 or higher (CTCAE) and at least possibly related to bortezomib in 45.3%. In one patient (2%), Herpes zoster was reported. Conclusion: Response Rates in this study were comparable to those in other community studies and higher than reported in previous clinical studies. The somewhat shorter DOR observed versus previously reported studies might have been caused by a shorter duration of bortezomib treatment, although more data is needed to derive a final conclusion. Overall the treatment with bortezomib was well tolerated and overall survival was as expected in this patient population. The clinical significance of the observed relation between treatment duration and response duration requires further exploration.