Diagnosed Myeloma Patients Research Articles

Serum Heavy-Light Chains (HLC) and Free Light Chains (FLC) As Predictors For Early CR In Newly Diagnosed Myeloma Patients Treated With Carfilzomib, Lenalidomide, and Dexamethasone (CRd)

BackgroundEffective anti-myeloma combination therapies including carfilzomib and lenaldiomide (Ln) induce deep clinical responses and durable remissions. Attainment of stringent (s)- complete response (CR), as well as negative minimal residual disease (MRD) by sensitive molecular techniques and multiparameter flowcytometry (MFC) in bone marrow is predictive of improved outcome. Here we report the association of HLC, FLC, and other prognostic factors to predict early CR and MRD in our ongoing prospective clinical CRd trials for multiple myeloma (MM) and high risk smoldering MM (SMM) patients. MethodsTreatment consisted of 8 cycles of CRd combination, followed by 24 cycles of Ln maintenance; the treatment schedule for SMM and MM was the same. Serum FLC, and immunoglobulin HLC pairs were determined using the Freelite and Hevylite assay (Binding Site, Birmingham, UK). The clonal FLC and HLC burden was measured as the difference between involved and uninvolved FLC (FLC-diff) and involved and uninvolved HLC pair (HLC-diff), as well as FLC κ to λ ratio (FLC ratio; normal range 0.26 to 1.65), and HLC ratios IgGκ/IgGλ and IgAκ/IgAλ; normal ranges, 1.12 to 3.21 and 0.78 to 1.94, respectively. Patients were evaluated for clinical responses by standard criteria and for MRD by sensitive MFC. Patients with any type of CR (CR, near(n)CR or sCR) were divided into groups according to whether their best response occurred in cycles 1-4, 5-8 or 9+, or 1-4 vs. 5+. Dichotomous parameters were compared using Fisher's exact test. The associations between cycle categories and dichotomous parameters were determined using a Cochran-Armitage test. Continuous parameters were compared between two groups using an exact Wilcoxon rank sum test, while continuous categories were compared across cycle categories using a Jonckheere-Terpstra test for trend. Logistic regression analysis was used to predict if any type of CR would occur within 1-4 cycles. All p-values are two-tailed and reported without formal adjustment for multiple comparisons. ResultsWe included 38 MM and 12 SMM patients (27 male, 23 female; median age 59.5; range 40–88). Among these patients, median M-spike was 2.5g/dL, median FLC-diff was 28.94mg/dL (range -0.06–1619.87); isotypes included 37–IgG, 7–IgA, 5–κ, and 1–λ; immunoparesis was present in 46 (92%); and abnormal FLC ratio in 47 (94%). Six patients with light chain only disease were excluded from HLC analyses; among 43 analyzed, all had abnormal HLC ratio, and median HLC-diff was 22.14 g/L (range 1.85–109.13). Of 8 patients, in whom M spike could not be precisely evaluated due to migration in beta region, accurate HLC pair analysis was possible in 7. A total of 33 patients achieved CR: 22–sCR, 3–CR, and 8–nCR (66%). The number of CRd cycles administered to first CR of any type was 1-4 in 15 patients, 5-8 in 12, and 9-17 in 6; median number of cycles was 6. Among patients who achieved CR, 23 CR/sCR + 4 nCR patients underwent MRD assessment, and all were negative. There was a strong trend of an association between a normalized FLC ratio after 1 cycle of CRd and all types of CR (p= 0.003) obtained in first 4 cycles. Similarly normalization of the HLC ratio after 2 cycles of CRd was significantly associated with obtaining a nCR/CR/sCR (p=0.0098) or sCR (p=0.001) in 1-4 cycles; CR was reached in 1-4 cycles in 7/9 (78%) patients who normalized their HLC ratios after 2 cycles, as compared with 4/15 (27%) among those who did not. In a univariate analysis, FLC-diff after 1 cycle of CRd (p=0.0035), and HLC-diff after 2 cycles of CRd (p=0.0092) was associated with a significant trend to achieving nCR/CR/sCR in 1-4 vs.5-8 vs.9+ cycles. In a multivariate model that initially included M spike, FLC-diff, normalized FLC ratio, HLC-diff, as well as normalized HLC ratio, only HLC-diff after 2 cycles of CRd (<2.6 g/L vs. ≥ 2.6 g/L) remained as an independent factor predictive of response. In this model, 90.9% (10/11) of those whose best response occurred in cycles 1-4, as well as 76.9% (10/13) of those whose best response occurred in cycles 5+ could be predicted by HLC-diff after 2 cycles of CRd. ConclusionsEarly monitoring (after 2 cycles) of HLC patterns is an independent predictor of rapid response among high risk SMM and newly diagnosed MM patients treated with CRd therapy. Biomarkers predictive of rapid responses to therapy have a major clinical potential as they will allow better tailoring of treatment with the goal to maximize survival and minimize toxicities. Disclosures:Off Label Use: Treatment of smoldering multiple myeloma- carfilzomib and lenalidomide.

Lenalidomide Combined With Cyclophosphamide and Dexamethasone Is Effective and Well Tolerated Induction Treatment For Newly Diagnosed Myeloma Patients Of All Ages

Lenalidomide Combined With Cyclophosphamide and Dexamethasone Is Effective and Well Tolerated Induction Treatment For Newly Diagnosed Myeloma Patients Of All Ages

Role Of Double Stem Cell Transplantation For Newly Diagnosed Multiple Myeloma In The Era Of Novel Agents

BackgroundAutologous stem cell transplantation (ASCT) has been a part of the standard therapy for newly diagnosed multiple myeloma and several studies showed double ASCT improved the outcome in comparison with single ASCT, especially the patients who failed to achieve very good partial remission (VGPR). Recently, the introduction of novel agents significantly improved the response rate of the treatment for the multiple myeloma. Although ASCT is still crucial for newly diagnosed myeloma patients, the role of the double ASCT is unclear in the era of novel agents. We performed a single institution-based retrospective study. MethodsWe reviewed the medical records of patients who treated with ASCT for multiple myeloma between January 2001 and April 2013 in National Center for Global Health and Medicine, Tokyo, Japan. The regimen of the remission induction therapy, number of stem cell transplantations, survival after the first ASCT, progression free survival, the response after the induction therapy and the first ASCT were analyzed. ResultsSince 2001, we performed ASCT for 167 patients. Ninety-three patients were treated with double ASCT, and 2 patients were treated with tandem ASCT–allogeneic SCT. In 127 patients were treated with vincristine, adriamycin, and dexamethasone (VAD) as an induction therapy, and 40 patients were treated with bortezomib and dexamethasone (BD). Very-good-partial-remission (VGPR) or complete remission (CR) was obtained in 25.2%, 34.6% of the patients treated with VAD, and in 45.7%, 54.3% with BD regimen before and after the transplantation respectively. Overall survival (OS) and progression free survival (PFS) did not differ significantly between VAD and BD induction, the estimated 2 year-OS was 89.8% vs. 79.5%, and the 2 year-PFS was 43.2% vs. 63.5% respectively. Double transplantation improved PFS and OS in VAD induction than single transplantation (p=0.000, p=0.002). In BD induction, patients who failed to achieve VGPR or better after the first ASCT, double transplantation improved OS (p=0.010) but not PFS. In both VAD induction and BD, there was no significant survival benefit in double transplantation in patients who achieved VGPR or better. ConclusionThe achievement of VGPR or better after the ASCT resulted in significantly better PFS. The role of double transplantation is still crucial for patients with inadequate response after the first ASCT even in the era of novel agents. Disclosures:No relevant conflicts of interest to declare.

The Value Of Serum Free Light Chain Monitoring Compared To Urinary Bence-Jones Measurement In Light Chain Only Myeloma

IntroductionThe significant subset of myeloma patients (MM) who only secrete light chains are referred to as light chain only myelomas (LCO). These patients represent 16% of all cases. Although, Bence-Jones proteinuria (BJ) is classically used to monitor these patients, cases with negative Bence-Jones proteinuria (BJ) but positive serum free light chains (sFLC) have been reported.The aim of this study was to quantify these patients and determine whether sFLC could be used instead of BJ to monitor disease response in LCO patients. Methods1960 newly diagnosed myeloma patients were enrolled in the myeloma IX trial (ISRCTN68454111) to receive depending on their age and performance status either an intensive or non-intensive treatment. Response was assessed depending on the trial arm at 3 months post end of induction or 6 weeks and 100 days post transplant. Response was assessed based on the IMWG criteria. Data was analysed using the SPSS version 19.0 (SPSS Inc., Chicago, USA) software and survival estimated using the Kaplan-Meier method. Results259 patients were identified as being LCO among which 86% (n=223) were BJ positive. 166 were evaluated for sFLC (68%) among which 16% had a negative BJ (n=26). As expected, median values of sFLC were higher in the presence of a BJ proteinuria [median kappa: 3313 (1151-8381), median lambda: 2687 (1274-6099)] than in the negative group [median kappa: 438 (51-791), median lambda: 313 (69-609)] (p<0.05). Data on best response achieved were available for 122/166 of these patients (73.5%). 26% patients (n=32) had both a normal ratio and a normal value of their involved sFLC and 41% of patients (n=50) had a normal ratio but still had an abnormal involved sFLC. The remaining 40 patients were considered to have a sub-optimal response. Patients who normalized both the ratio and sFLC values had a significantly longer Progression Free Survival (PFS) and Overall survival (OS) compared to patients that normalized their ratio only. Both these groups had a better survival than those who failed to achieve an optimal response [median PFS were respectively 43.3, 33.0 and 18.8 months (p<0.001) and median OS were respectively 85.3, 69.9 and 45.5 months, (p=0.012)]. Furthermore, this survival benefit was seen in patients with an involved sFLC within the normal range irrespective of their sFLC ratio. With a median follow up of 5.9 years 138 patients (83%) have relapsed. Complete data at relapse are available in 46% of them. sFLC at relapse were abnormal in 100% of patients. In 23/55 (42%) of the BJ positive patients at diagnosis, relapse was identified only by an increase in the sFLC, whilst 4/8 BJ negative patients relapsed with a measurable paraprotein. DiscussionBJ proteinuria cannot be detected until the production of sFLC is greatly raised, leading to a misclassification of 16% of LCO MM patients as being non-secretory. This could be of clinical relevance as it may help prevent end organ damage to the kidney. We were able to show, in a large cohort of newly diagnosed MM patients, that sFLC are imbalanced in virtually all evaluated LCO MM patients. This data also suggests that both the ratio and the absolute value of sFLC are important in predicting outcome after treatment. Furthermore, the sFLC ratio, although essential for the diagnosis, may be less reliable to assess response due to a low non-involved chain and delayed immune reconstitution. ConclusionThe correct identification of a myeloma clone secreting only light chains has important clinical relevance. The sFLC assay enables us to efficiently diagnose and monitor patients and should therefore be standard practice when there is not a measurable paraprotein on serum protein electrophoresis. Disclosures:Leleu:CELGENE: Honoraria; JANSSEN: Honoraria. Morgan:Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Millenium: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Merck: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Johnson and Johnson: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees.

A Phase I/II Trial Of Cyclophosphamide, Carfilzomib, Thalidomide and Dexamethasone (CYCLONE) In Patients With Newly Diagnosed Multiple Myeloma: Final Results Of MTD Expansion Cohort

BackgroundCarfilzomib is a proteasome inhibitor that irreversibly binds its target and has been validated as both relapse and upfront therapies for multiple myeloma. To optimize pre transplant response, we combined carfilzomib with the widely accessible backbone of cyclophosphamide-thalidomide-dexamethasone (CTD). We previously reported results of the Phase I component of the trial (in which no MTD was reached); we now report results for the MTD and fully accrued expansion cohorts at the MTD of the CYCLONE trial NCT01057225. MethodsNewly diagnosed myeloma patients intended for stem cell transplant were eligible. All patients were treated on a 28 day cycle with carfilzomib IV Days 1,2,8,9,15,16 (see Table below for dosing per cohort) along with cyclophosphamide 300 mg/m2 PO Days 1,8,15, thalidomide 100 mg PO Days 1-28 and dexamethasone 40 mg PO Days 1,8,15,22. The initial phase I/ II regimen is shown below – as no DLTs were observed, we increased dosing of carfilzomib to 36 and then 45mg/m2 and have now nearly fully accrued to the Phase II dose level +1 (27mg/m2) and expansion MTD (36mg/m2). Treatment was for 4 cycles with planned SCT post induction. The primary endpoint of the trial is the proportion of patients who have ≥very good partial response (VGPR) to treatment. All patients received herpes zoster prophylaxis and ASA daily. ResultsA total of 54 patients have been accrued to the trial, 6 in the initial Phase 1, 21 in the initial Phase II (CFZ 27mg/m2), and 27 at CFZ 36-45mg/m2. Median age was 63 (range 27-77) and 52% were male. ISS Stage was advanced (II-III) in 57% The overall partial response rate or better following 4 cycles of CYCLONE at dose level 0 or greater is 91%: CR 18%, VGPR 58%, PR 16%, MR 2%, SD 4%. One patient withdrew from the trial after cycle 1.At dose level 2, 3/7 patients experienced dose-limiting toxicity in cycle 1 including: grade 3 alanine aminotransferase increase (possibly related); grade 3 infusion reaction (probably related); and grade 4 heart failure with grade 3 dyspnea, atrial fibrillation, and fatigue (all possibly related). No dose-limiting toxicity was observed in 6 patients at dose level 1 and thus DL1 was deemed the MTD.Across dose levels, adverse events are fully evaluable in 48 patients. AEs of grade 3 or higher at least possibly related to CYCLONE occurred in 26 (54%) – 35% non hematological and 33% hematological. Most commonly reported non hematological toxicities (all grades) included fatigue (63%), constipation (46%), elevated creatinine (27%), hyperglycemia (27%), lethargy (25%) peripheral sensory neuropathy (25% - all grade 1), and somnolence (21%); however, grade 3/4 toxicities occurring in >5% were uncommon: hypertension (8%), thromboembolic event (6%) and hyperglycemia (6%). Three cases of pneumonia required hospitalization. There were no cardiac events seen in greater than 5% of patients. Grade 3/4 hematological toxicities included lymphopenia (23%) and neutropenia (17%). All patients advancing to SCT successfully collected stem cells. One patient died on study from pneumonia. 90% completed at least 4 cycles.With median follow-up of 16 months (range 0-64), 1-year PFS was 90% and 1-year OS was 98%. ConclusionThe 4 drug CYCLONE regimen is highly efficacious with an overall response rate after only 4 cycles of 91% (76% ≥VGPR) at the dosing level of carfilzomib IV 20/27-36 mg/m2 in newly diagnosed myeloma. Toxicities are manageable, with only grade 1 neuropathy and minimal cardiac or pulmonary toxicity. CYCLONE is a combination that results in rapid and deep responses with minimal neuropathy prior to stem cell transplant. Comparative studies of this regimen with longer duration of therapy (as induction or consolidation) at the defined MTD should be considered. Disclosures:Mikhael:Celgene: Research Funding; Onyx: Research Funding; Sanofi: Research Funding. Reeder:Millenium: Research Funding; Celgene: Research Funding; Novartis: Research Funding. Costa:Otsuka: Research Funding. Stewart:Celgene: Honoraria; Millenium: Honoraria, Research Funding; Onyx: Research Funding.

Observational Study Of VMP (Bortezomib, melphalan, prednisolone) Regimen For Newly Diagnosed Korean Myeloma Patients Who Are Not Eligible For Transplantation

BackgroundVMP regimen for newly diagnosed myeloma patients is well-documented treatment. However patients in real practice generally have worse performance status and less attention than those in clinical trials. Thus we conducted observational study to evaluate the efficacy and toxicity of VMP treatment in newly diagnosed Korean myeloma patients. Patients and MethodsData were prospectively collected from 39 hospitals. One hundred seventy three patients who started VMP as first line from 2011 May to 2012 April were included for analysis. ResultsMedian age was 71 and 22.5% were more than 75 years old. Fifty-seven per cent were male sex. IgG type was most common (61.9%) and IgA 24.9%. ISS stage I was 13.8% and III was 51.5%. Patients with high risk FISH (Del17p, t(4;14), and t(4;16)) were 4.1%, 4.1%, and 2.3% respectively. Dose and schedule was followed original VISTA trial except for use of prednisolone instead of prednisone. Median 5cycles (range 1-9) were given and 105 patients stopped in the course of treatment. Most common cause were adverse event (28.8%) followed by disease progression or no response (19.6%). Twenty-five mortality cases were reported and 22 were in the course of treatment. The most common cause of mortality was infection (61%) followed by disease progression (13%). Overall response rate was 72.3% and response more than VGPR was 37.6%. Median progression free survival is 455 days and median OS was 504 days. One year PFS was 80.9 % and one year OS was 83.4%. Most common toxicity was cytopenia, peripheral neuropathy, and gastrointestinal toxicities such as nausea and diarrhea. Peripheral neuropathy of all grade and grade 3 or more was 58.6% and 6.36%, respectively DiscussionsEven though patients with higher proportion of ISS stage, efficacy of VMP regimen was considerable in Korean patients. With relatively high mortality due to infection in the course of treatment prophylactic measures for infection need to be developed. To reduce the incidence of peripheral neuropathy, close observation and intervention are needed to prevent aggravation of neuropathy. Disclosures:Off Label Use: lenalidomide in newly diagnosed myeloma. Kwak:celgene: Research Funding.

Impact Of Dialysis-Dependent Renal Failure At Time Of Myeloma Diagnosis On Overall Survival - a 15-Year Single Centre Analysis

In myeloma, the use of autologous stem cell transplantation in younger patients as well as the introduction of thalidomide, lenalidomide and bortezomib has resulted in improvement in long-term survival of both younger and older patients. Bortezomid and high dose dexamethasone is currently recommended to treat newly diagnosed myeloma patients presenting with renal impairment and may lead to varying degrees of improvement in renal function. We have assessed not only survival trends for all patients diagnosed at our centre over the past 18 years but also the survival of the subset of patients with severe renal impairment who required dialysis at diagnosis.All patients diagnosed with myeloma at our centre between January 1995 and December 2012 were included. We constructed Kaplan-Meier curves and used the Breslow generalised Wilcoxon test to evaluate overall survival (OS) patterns (diagnosed in three calendar periods: 1995-2000; 2001-2006; 2007-2012) for our total patient population as well as the subset of patients who required dialysis within 4 weeks of diagnostic bone marrow test.262 patients (60.3% males) were diagnosed between 1995 and 2012. For all patients, median OS significantly increased from 13.2 months in period 1995-2000 to 27 months in period 2001-2006 with median OS not yet reached in period 2007-2012 (p=0.0001). In patients 70 years old or less, median OS significantly increased from 25.4 months in period 1995-2000 to 46.7 months in period 2001-2006 with median OS not yet reached in period 2007-2012 (p=0.0482). Improved median OS was also seen in patients > 70 years old: 4.4 months in period 1995-2000, 17.4 months in period 2001-2006 and 25.1 months in period 2007-2012 (p<0.0001). In contrast, patients requiring dialysis at diagnosis (n = 44) had much worse outcomes: median OS in the period 1995-2000 was 2.8 months and although there was a slight improvement in median OS in the period 2001-2006 (p=0.0318), there has been no further improvement in median OS in the period 2007-2012.In our overall myeloma patient population, median OS has continued to increase over the time periods 1995-2000, 2001-2006 and 2007-2012, both for younger patients 70 years old or less and older patients >70 years old. Patients requiring dialysis at diagnosis, however, continue to have much poorer median OS, despite the use of bortezomib and dexamethasone containing regimens in recent years. The possible benefit of improved supportive measures and the early use of other emerging novel agents in this poor prognostic subgroup should be explored in the clinical trial setting. Disclosures:No relevant conflicts of interest to declare.

Role Of Folate Receptor Targeted Therapy In Multiple Myeloma

In multiple myeloma (MM) the interaction of plasma cells, bone marrow stromal cells and tumor associated macrophages (TAMs) plays a significant role in conferring resistance to therapy and in the maintenance of residual disease. Folate receptors (FR) are specifically expressed on metabolically active malignant cells and TAMs and their expression in normal tissues and resting macrophages is limited. FR mediates folate uptake by receptor-mediated endocytosis. This qualifies the receptor to be exploited for drug delivery of folate conjugated cancer therapeutics. Our primary goal in this study is to evaluate the expression of functional FR in MM cells and TAMs with a view to exploit this for folate conjugated targeted therapy for MM. First we evaluated the presence of TAMs in paraffin embedded bone marrow slides of newly diagnosed MM patients with CD68 (pan-Macrophage marker) and CD163 antibodies (specific marker of TAMs) and found extensive infiltration of macrophages in bone marrow from MM patients. Next to evaluate expression of FR in MM cells, we employed an FR antibody and evaluated MM cell lines with immunoblot, flow cytometry and confocal microscopy. In a panel of ten MM cell lines, we found that out of the three FR isoforms (α, β and γ), FR beta (FR-β) is expressed by all of them. Next to test whether this expressed receptor is indeed functional, we incubated the cells with folate deficient media, added different concentrations of EC17 (folate conjugated to FITC, Endocyte Inc.) to the medium and looked for the uptake by flow cytometry after washing off the drug at different time points (after 10, 20, 40 and 60 min).We observed that the uptake begins in 10 min and is saturated at 1 hour with 100nM Folate-FITC. With confocal imaging, Folate-FITC was found in the cytoplasm of MM cells suggesting internalization of Folate-FITC and localization in the cytoplasm. In addition to myeloma cell lines, we also confirmed the uptake of Folate-FITC in CD138+ plasma cells of a newly diagnosed myeloma patient by flow cytometry. This strongly suggests that MM cells express functional FR-β. To test the specificity of this FR mediated uptake, we pre-incubated cells with 0.1mM folic acid in medium for 30 min and then added EC17. This maneuver blocked the activity mediated by FR and no uptake was observed , which proves that the Folate-FITC is internalized only through the FR. To evaluate the expression of FR in-vivo samples, we stained paraffin embedded bone marrow slides of newly diagnosed MM patients with FR-β antibody and TAM specific markers. We observe that FR is expressed on both MM cells as well as TAMs. To assess the endurance of cytotoxic effect of folate conjugated chemotherapeutic agents, we treated MM cell lines with folate conjugated vinka alkaloids and compared them to unconjugated drug and found no significant difference in their action suggesting conjugation with folate does not alter its efficacy. To assess potential toxicity of folate conjugated therapeutics, we obtained CD34+ cells and looked for the uptake of Folate-FITC with flow cytometry. We found no uptake and this is in line with previous reports suggesting that CD34 positive cells express nonfunctional FR. So we propose that FR qualify as potential targets for cancer treatment. Folate targeted therapy using folate-conjugated drugs which can selectively act against both MM cells and supporting TAMs has the potential of specific anti-MM tumoricidal activity. This therapeutic approach would broaden the use of drugs that could be conjugated with folate for MM therapy. Additionally assessment of TAMs in bone marrow sections of MM patients would add another feature for grading, classifying and prognosticating MM. Disclosures: Fonseca: Cylene: Research Funding; AMGEN: Consultancy; Millennium: Consultancy; Binding Site: Consultancy; Onyx: Consultancy, Research Funding; Lilly: Consultancy; BMS: Consultancy; Genzyme: Consultancy; Celgene: Consultancy; Medtronic: Consultancy; Otsuka: Consultancy; Prognostication of MM based on genetic categorization of the disease: Prognostication of MM based on genetic categorization of the disease, Prognostication of MM based on genetic categorization of the disease Patents &amp; Royalties.

The impact of response on bone-directed therapy in patients with multiple myeloma

AbstractSignificant benefits for zoledronic acid (ZOL) over clodronate acid (CLO) were seen in the Medical Research Council Myeloma IX randomized trial. ZOL significantly reduced skeletal-related events (SREs), and improved progression-free survival and overall survival (OS), making it the bisphosphonate of choice for newly diagnosed myeloma patients. In this analysis of Myeloma IX data, we have investigated the impact of response on bone disease in 1111 transplant-eligible patients. At posttransplant day 100, complete response (CR) was seen in 48% of patients, very good partial response (VGPR) in 20%, and partial response (PR) in 23%. For patients in VGPR or less, ZOL was superior to CLO in reducing SREs (P = .048), whereas for patients in CR, both agents were equivalent (P = .83). For OS, ZOL was associated with a significant benefit in patients in PR (P = .0091). No difference in OS was seen with patients in CR (P = .91) or VGPR (P = .74). These findings indicate that response category posttransplant may influence the impact of bisphosphonate therapy. This trial was registered as #ISRCTN68454111 at www.isrctn.org.

Bortezomib before and after autologous stem cell transplantation overcomes the negative prognostic impact of renal impairment in newly diagnosed multiple myeloma: a subgroup analysis from the HOVON-65/GMMG-HD4 trial

Renal impairment is frequent in patients with multiple myeloma and is correlated with an inferior prognosis. This analysis evaluates the prognostic role of renal impairment in patients with myeloma treated with bortezomib before and after autologous stem cell transplantation within a prospective randomized phase III trial. Eight hundred and twenty-seven newly diagnosed myeloma patients in the HOVON-65/GMMG-HD4 trial were randomized to receive three cycles of vincristine, adriamycin, dexamethasone (VAD) or bortezomib, adriamycin, dexamethasone (PAD) followed by autologous stem cell transplantation and maintenance with thalidomide 50 mg daily (VAD-arm) or bortezomib 1.3 mg/m(2) every 2 weeks (PAD-arm). Baseline serum creatinine was less than 2 mg/dL (Durie-Salmon-stage A) in 746 patients and 2 mg/dL or higher (stage B) in 81. In myeloma patients with a baseline creatinine ≥ 2 mg/dL the renal response rate was 63% in the VAD-arm and 81% in the PAD-arm (P=0.31). The overall myeloma response rate was 64% in the VAD-arm versus 89% in the PAD-arm with 13% complete responses in the VAD-arm versus 36% in the PAD-arm (P=0.01). Overall survival at 3 years for patients with a baseline creatinine ≥ 2 mg/dL was 34% in the VAD-arm versus 74% in the PAD-arm (P<0.001) with a progression-free survival rate at 3 years of 16% in the VAD-arm versus 48% in the PAD-arm (P=0.004). Overall and progression-free survival rates in the PAD-arm were similar in patients with a baseline creatinine ≥ 2 mg/dL or <2 mg/dL. We conclude that a bortezomib-containing treatment before and after autologous stem cell transplantation overcomes the negative prognostic impact of renal impairment in patients with newly diagnosed multiple myeloma. The trial was registered at www.trialregister.nl as NTR213 and at www.controlled-trials.com as ISRCTN 64455289.

Bortezomib induction, reduced-intensity transplantation, and lenalidomide consolidation-maintenance for myeloma: updated results

AbstractA sequential approach including bortezomib induction, intermediate-dose melphalan, and autologous stem cell transplantation (ASCT), followed by lenalidomide consolidation-maintenance, has been evaluated. Efficacy and safety data have been analyzed on intention-to-treat and results updated. Newly diagnosed myeloma patients 65 to 75 years of age (n = 102) received 4 cycles of bortezomib-pegylated liposomal doxorubicin-dexamethasone, tandem melphalan (100 mg/m2) followed by ASCT (MEL100-ASCT), 4 cycles of lenalidomide-prednisone consolidation (LP), and lenalidomide maintenance (L) until disease progression. The complete response (CR) rate was 33% after MEL100-ASCT, 48% after LP and 53% after L maintenance. After a median follow-up of 66 months, median time-to-progression (TTP) was 55 months and median progression-free survival 48 months. Median overall survival (OS) was not reached, 5-year OS was 63%. In CR patients, median TTP was 70 months and 5-year OS was 83%. Median survival from relapse was 28 months. Death related to adverse events (AEs) occurred in 8/102 patients during induction or transplantation. Rate of death related to AEs was higher in patients ≥70 years compared with younger (5/26 vs 3/76, P = .024). Bortezomib-induction followed by ASCT and lenalidomide consolidation-maintenance is a valuable option for elderly myeloma patients, with the greatest benefit in those younger than 70 years of age.

Early versus delayed autologous stem cell transplant (ASCT) in patients receiving induction therapy with lenalidomide, bortezomib, and dexamethasone (RVD) for newly diagnosed multiple myeloma (MM).

8540 Background: Lenalidomide, bortezomib and dexamethasone (RVD) is an active, tolerable induction regimen with superior response rates (≥VGPR rates of 80%) in newly diagnosed MM pts. However, the optimal timing of ASCT with this triplet combination is uncertain. We have evaluated our institutional experience to provide an insight for the best timing of ASCT, where specific patients were offered delayed ASCT based on risk, response and toxicity of therapy. Methods: 222 consecutive transplant-eligible pts with newly diagnosed MM that received at least 3 cycles of RVD and harvested stem cells were included in the analysis from May 2007 until October 2011. Patients underwent early ASCT (received planned ASCT immediately after stem cell harvest, n=136) or delayed transplant (received planned maintenance therapy after collection with intent to proceed with ASCT at first relapse, n=86). Results: Median age of the patients at the time of diagnosis is 60.5 yrs (32-77) vs. 60 yrs (22-73) for early vs. delayed groups. ISS stage 3 disease was seen in 31% patients and 10% patients; high risk cytogenetics were seen in 11% and 7% patients in early vs. delayed groups, respectively. Median time from initiation of induction therapy to ASCT in early group is 5.45 months (range, 3.19-12.68 months). In the delayed SCT group, 28 patients underwent ASCT at a median time of 26.21 months (range, 13.67-41.72 months) from initiation of therapy. At a median follow up of 32 months, 5-year overall survival from diagnosis was 68% and 88% in patients undergoing early and delayed ASCT, respectively (p = 0.106). Conclusions: Transplantation-eligible patients who receive RVD as initial therapy followed by early vs. delayed ASCT result in comparable overall survival. In carefully selected newly diagnosed myeloma patients with lower ISS stage receiving RVD as induction therapy, planned delayed ASCT results in 5-year survival rates close to 90%.

MiR-15a, Mir-16-1 and Mir-17-92 Cluster Expression Are Linked to Poor Prognosis in Multiple Myeloma

Abstract 5000Multiple myeloma (MM) is characterized by a profound genomic instability of potential prognostic relevance. Loss of chromosome 13, observed in almost half of patients, negatively affects prognosis. MiR-15a, miR16-1 and miR-17-92 cluster, located on 13q, play important roles in the regulation of cell proliferation, differentiation and apoptosis. Therefore, we investigated a possible correlation of miRNA expression with chromosome 13 deletions (del(13)) and prognosis. We measured the expression of miR-15a, miR16-1 in 70 newly diagnosed MM patients and miR-17-92 cluster in 85 newly diagnosed MM patients by quantitative real-time PCR analyses. MiR-15a, miR-16-1 and miR-17 -92 cluster expression levels are independent of the del(13). High levels of miR-15a, miR-16-1, miR-17, miR-20a and miR-92-1 are associated with shorter progression-free survival (PFS), suggesting poor prognosis. Our data suggest that the expression of specific miRNAs may be contributed to MM prognosis. Disclosures:No relevant conflicts of interest to declare.

Whole Genome Sequencing Reveals Novel Recurring Somatic Mutations Affecting HUWE1 and DIAPH2 Genes in Multiple Myeloma

Abstract 320Multiple myeloma (MM) is an incurable malignancy of antibody secreting plasma B-cells whose etiology is still poorly understood. We used whole genome sequencing (WGS) and deep-read capture validation to thoroughly characterize the mutation landscape in four newly diagnosed MM patients and further examined mutation recurrence in 89 additional MM patients. WGS cases were selected to be racially diverse and represent both hyperdiploid and non-hyperdiploid MM with otherwise “simple” karyotypes. All studies to date have used peripheral blood as controls, however, abnormal B cells and circulating tumor cells frequently contaminate the peripheral blood of MM patients and these studies may have missed the early genetic events potentially important in disease pathogenesis. We therefore chose to use matched skin samples as normal controls. The use of skin DNA controls and deep read count capture validation of single nucleotide variants (SNV) allowed us, for the first time, to demonstrate clear separation between normal and malignant cell populations. Our analysis pipeline detected both somatic SNVs and structural variants (SV, ie. translocations, deletions, insertions). In all four patients, we observed chromosomal translocations at the Ig heavy chain locus, VDJ recombination, and Ig locus somatic hypermuation. We found somatic mutations affecting the E3 ubiquitin ligase HUWE1 in 4% (4/94) of cases, as well as recurring deletions affecting the Rho pathway regulator DIAPH2 (recurrence data will be presented). RNA sequencing was preformed for 3 of the WGS patients to explore transcriptional effects of mutations observed. Statistical analysis identified significantly mutated genes, i.e. mutation hotspots, including ROBO2, BCL6 and cadherin/catenin genes. Genes involved in cell polarity, cell adhesion and axon guidance were affected in all four WGS patients. Chromosomal translocations present in all four WGS patients involved both known oncogenes (CCND1, MYC and MAFB) and putative oncogenes. A novel translocation implicated KCNT2, encoding a sodium-activated potassium channel, as a potential oncogene in MM. Recurrent point mutations were relatively rare in MM, suggesting that SVs are more common driver mutations and/or that SNVs in MM disrupt a diverse array of genes to affect key pathways. For genomic studies in MM moving forward, our results emphasize the importance of matched normal controls uncontaminated by tumor cells, and suggest that careful analysis of SVs be included to find novel oncogenes and important clinical correlations. Disclosures:No relevant conflicts of interest to declare.

Results From the Phase II Dose Expansion of Cyclophosphamide, Carfilzomib, Thalidomide and Dexamethasone (CYCLONE) in Patients with Newly Diagnosed Multiple Myeloma

AbstractAbstract 445 Background:Carfilzomib is a proteasome inhibitor that irreversibly binds its target and has a favorable toxicity profile that has shown significant activity in relapsed multiple myeloma (MM), leading to recent FDA accelerated approval. To achieve rapid and deep response in patients eligible for stem cell transplant, we combined carfilzomib with the regimen of cyclophosphamide-thalidomide-dexamethasone (CTD). We recently reported the results of the Phase I component of the trial (in which no MTD was reached) followed by the initial Phase II trial; however, with increasing evidence for the safe and effective use of higher doses of carfilzomib, we now report results from dose escalation extension of the Phase II trial. Methods:Newly diagnosed myeloma patients intended for stem cell transplant were eligible. All patients were treated on a 28 day cycle with Carfilzomib IV Days 1,2,8,9,15,16 (see Table 1 below for dosing per cohort) along with Cyclophosphamide 300 mg/m2 PO Days 1,8,15, Thalidomide 100 mg PO Days 1–28 and Dexamethasone 40 mg PO Days 1,8,15,22.We initially conducted a Phase I run in trial of 6 patients with no DLT observed before expanding to the Phase II portion of the study. The initial phase II regimen is shown below – as no DLTs were observed, we have now fully accrued to the Phase II dose level +1. Treatment was for 4 cycles with expected SCT post induction. The primary endpoint of the trial is the proportion of patients who have ≥very good partial response (VGPR) to treatment. All patients received herpes zoster prophylaxis and ASA daily.Table 1:Dose Levels and Accrual for CYCLONEDose LevelNumberCycle 1Cycle 2 and beyond*-1 (initial Phase I)315 mg/m220 mg/m20 (initial Phase II - completed)3+ 21 = 2420 mg/m227 mg/m21 (completed, no DLTs)420 mg/m236 mg/m22 (accruing)720 mg/m245 mg/m2*At dose level 1 and 2, pts can initiate this dose starting on Day 8 of Cycle 1. Results:A total of 38 patients have been accrued to the trial, 6 in the initial Phase 1, 21 in the initial Phase II, and the remaining at dose escalated cohorts. We are reporting the 27 patients who have completed therapy and will update with the dose escalated cohorts. Median age was 65 (range 27–74) and 52% were female. ISS Stage was advanced (II-III) in 56%. Best overall response rate during 4 cycles of CYCLONE at dose level 0 is 96%: CR 29%, VGPR 46%, PR 21% (1 pt achieved MR).Adverse events of grade 3 or higher at least possibly related to CYCLONE occurred in 12 (44%). Most commonly reported non hematological toxicities (all grades) included fatigue (67%), constipation (56%), lethargy (41%) somnolence (37%), malaise (30%) depressed level of consciousness (22%); however, grade 3/4 toxicities occurring in >5% were uncommon: thromboembolic event 11%) and muscle weakness (7%). Two cases of pneumonia required hospitalization. Eight patients (30%) developed grade 1 sensory neuropathy; no higher grade or painful neuropathy was evident. There were no cardiac events seen in greater than 5% of patients. Grade 3/4 hematological toxicities included neutropenia (15%) and lymphopenia (7%). All patients advancing to SCT successfully collected stem cells. One patient died on study from pneumonia. Conclusion:The 4 drug CYCLONE regimen is highly efficaceous with a response rate after only 4 cycles of 96% (75% ≥VGPR, 29% CR) at the current dosing level of carfilzomib IV 20/27 mg/m2 in newly diagnosed myeloma. Toxicities are manageable, with only grade 1 neuropathy and minimal cardiac or pulmonary toxicity. Increasing the dose of carfilzomib is feasible and updated results of dose escalated cohorts will be reported at 20/36 and 20/45 mg/m2. Disclosures:Bergsagel:onyx: Membership on an entity's Board of Directors or advisory committees. Stewart:Millennium Pharmaceuticals: Consultancy, Honoraria, Research Funding; Onyx: Consultancy; Celgene: Consultancy.

Comparison of MRI and 18F-FDG PET for Evaluation of the Response to Treatment of Patients Diagnosed with Multiple Myeloma: A Prospective Clinical Study

AbstractAbstract 4004 IntroductionAlthough conventional radiography is still the standard staging procedure for newly diagnosed and relapsed multiple myeloma (MM) patients in clinical practice, magnetic resonance imaging (MRI) using T2- and T1-weighted contrasted enhanced images has proved to have advantages over a conventional skeletal survey. Fluoro-desoxy-glucose positron emission tomography (18F-FDG PET) is not yet validated as an imaging method for MM evaluation. The purpose of this study was to prospectively compare MRI and 18F-FDG PET for short-term evaluation of the response in newly diagnosed MM patients and to correlate the imaging assessment with the biological response. Materials and methodsA group of 15 newly diagnosed myeloma patients were treated in a single center. After induction with bortezomib-lenalidomide-dexamethasone (VRD), they all received high dose cyclophosphamide and G-SCF prior to peripheral stem cell collection. The patients were then randomized to either autologous stem cell transplantation (ASCT) with 2 consolidation VRD cycles or 5 VRD cycles. All patients subsequently received maintenance treatment with low dose lenalidomide for 1 year. Imaging was performed at diagnosis, after the first three VRD cycles and immediately before initiating maintenance treatment. The spinal and pelvic MRI protocol consisted of sagittal T1-weighted (T1-w) spin echo and fat-suppressed T2-weighted (T2-w) STIR sequences of the spine, axial and coronal T1-w spin echo and fat-suppressed T2-w STIR sequences of the pelvis and upper parts of the lower limbs and finally a fat-suppressed T1-w sequence after intravenous gadolinium covering the spine, pelvis and upper parts of the lower limbs. The biological response was evaluated according to IMWG criteria. The presence or absence of diffuse bone marrow infiltration (DI), diffuse patchy bone marrow infiltration (DPI) and focal bone marrow lesions (FL) was recorded prospectively. A hypointense T1, hyperintense STIR and enhanced fat-suppressed T1 lesion were scored as FL on MRI scans. The presence of extra-medullary disease (EMD) and the SUVmax of FDG-avid focal lesions were assessed. Complete response (CR) and partial response (PR) were determined by MRI and 18F-FDG PET after induction and before maintenance. CR was defined as the absence of diffuse infiltration or focal lesions for MRI and as the absence of diffuse and/or focal uptake for 18F-FDG PET. The response was considered to be partial if the image differed from CR. We compared the results of the two techniques with the biological response for every patient. ResultsThe 15 patients (5 females, 10 males; age: 55 ± 6 years (mean, SD)) were classified according to the ISS (1, n=6; 2, n=8; 3, n=1) and DSS (IIIA, n=14; IIIB, n=1). At baseline, MRI showed DI, DPI and FL in 3, 7 and 189 cases respectively; the 18F-FDG PET uptake displayed a diffuse homogeneous pattern in 4 patients and a diffuse heterogeneous pattern in 11 patients with only 55 focal uptakes. Five cases of extra-medullary uptake were observed on baseline 18F-FDG PET scans and remained at the follow-up. On the basis of the biological response, the patients were classified as MR (n=1), PR (n=7), VGPR (n=5) and CR (n=2) after induction and as MR (n=1), PR (n=6), VGPR (n=3) and CR (n=5) before maintenance treatment. Differences in focal lesion detection were observed between MRI and 18F-FDG PET for small lesions (<10 mm). Two false positive focal uptakes were observed (pulmonary infection, sacrum abnormality).The status assessment showed concordant results between the two techniques in only 5/15 (CR, n=2; PR, n=3) and 8/15 (CR, n= 2; PR, n=6) cases at induction and before maintenance respectively. MRI showed residual disease in 7/15 patients before the initiation of maintenance treatment. ConclusionAt diagnosis and during treatment evaluation, both 18-FDG PET and MRI provide information about the extent of the disease, allowing for a more comprehensive assessment of persisting or recurrent myeloma. The morphologic MRI can often be falsely positive due to persistent non-viable lesions. Hence 18-FDG PET might be more suitable than morphologic MRI for determination of the remission status. Disclosures:No relevant conflicts of interest to declare.

Lenalidomide Consolidation Followed by Maintenance After Autologous Transplantation for Multiple Myeloma Decreases Thymic Output and Terminally Differentiated CD4 and CD8 T Cells but Increases Treg

AbstractAbstract 4046Treatment with lenalidomide, an immunomodulatory drug, increases the time to progression in relapsed/refractory multiple myeloma. However, due to its pleiotropic effect, it is not known whether the efficacy of this drug is due only to direct tumor toxicity or also to immunomodulatory effects. We assessed in vivo the changes in T-cell reconstitution induced by lenalidomide consolidation and maintenance treatment following autologous peripheral blood stem cell transplantation (ASCT) in a cohort of multiple myeloma patients.Twenty-nine newly diagnosed myeloma patients were treated with the induction combination bortezomib plus dex followed by high dose melphalan (140–200 mg/m2) and ASCT. A first group of 11 patients were treated with lenalidomide consolidation initiated 3 to 6 months post transplantation: 25 mg/day, days 1–21 of a 28 day cycle for 2 months, followed by maintenance (10 mg/day) until disease progression. This group was compared with the 18 patients who did not receive any treatment after ASCT. Blood samples were collected at diagnosis, before the transplant and 1, 3, 6, 9, 12 and 18 months after ASCT. Thymic function was assessed by real-time PCR quantification of T cell receptor excision circles (sjTREC) and percentages and absolute counts of T lymphocyte subpopulations were determined by multicolor flow cytometry. Statistics were performed using the Log-Rank or Mann-Whitney test.The two cohorts had similar baseline characteristics and all 29 patients were in remission after ASCT. With a median follow-up of 4 years, progression-free survival (PFS) was superior with lenalidomide treatment (69% vs 36%, p=0.05) while overall survival (OS) was similar (82% vs 75%, p=0.5). Lenalidomide treatment induced a progressive decrease in sjTREC (median at 18 months, 0.25/μL vs 1.61/μL, p<0.05) and a decrease in the percentages and absolute counts of CD4+ and CD8+ CD45RA+CCR7- effector terminal T cell subpopulations (median at 18 months, 3.2/μL vs 17.6/μL, p<0.05 for CD4+CD45RA+CCR7- and 109/μL vs 345/μL, p<0.05 for CD8+CD45RA+CCR7-). Conversely, lenalidomide treated patients displayed an increase in CD4+CD25+CD127-/low Treg populations, in both percentage and absolute count (median 13% vs 8 %, p<0.05 and 48.9/μL vs 29.3/μL, p<0.05, respectively). No correlation was found with documented infections, relapse or survival.We confirm an increase in PFS with lenalidomide consolidation/maintenance following ASCT. However, our data also suggest that in myeloma patients, the effect of lenalidomide on the myeloma tumor may not be T cell mediated and this treatment may have a negative impact on the T cell immune surveillance. Disclosures:No relevant conflicts of interest to declare.

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

Activin-A is a transforming growth factor -β superfamily member, which seems to be implicated in the biology of osteolytic disease in multiple myeloma. 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. 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. 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.

Lenalidomide−prednisone induction followed by lenalidomide−melphalan−prednisone consolidation and lenalidomide−prednisone maintenance in newly diagnosed elderly unfit myeloma patients

This multicenter phase II trial evaluated the safety and efficacy of lenalidomide-prednisone (RP) induction, followed by lenalidomide-melphalan-prednisone (MPR) consolidation and RP maintenance in elderly unfit newly diagnosed myeloma patients. Patients received four 28-day RP induction courses (lenalidomide 25 mg/day on days 1-21 and prednisone 50 mg three times/week), followed by six 28-day MPR consolidation cycles (melphalan 2 mg, prednisone 50 mg three times/week and lenalidomide 10-15 mg/day on days 1-21), and maintenance with lenalidomide (10 mg/day on days 1-21 every 28 days) plus prednisone (25 mg three times/week). Forty-six patients were enrolled. Median age was 75 years, 59% of patients had at least one comorbidity and 35% at least two. Partial response rate was 80%, including 29% very good partial response. Median time to progression was 19.6 months, median progression-free survival was 18.4 months and 2-year overall survival was 80%. At the tolerated consolidation dose (melphalan 25 mg/month and lenalidomide 10 mg/day), the most frequent grade 3 adverse events were neutropenia (36.4%), anemia (12.1%), cutaneous reactions (18.2%) and infections (12.1%). Grade 4 neutropenia occurred in 12.1% of patients. In conclusion, RP induction followed by MPR consolidation and RP maintenance showed a manageable safety profile, and reduced the risk of severe hematological toxicity in unfit elderly myeloma patients.

Carfilzomib: a novel treatment in relapsed and refractory multiple myeloma

Carfilzomib is a second-generation proteasome inhibitor with well-documented clinical activity as a single agent in patients with relapsed/refractory multiple myeloma. Carfilzomib can partially overcome resistance in bortezomib-refractory patients and has significant efficacy in bortezomib-naïve patients. Responses generally occur rapidly and are durable in the majority of cases. Carfilzomib can be safely administered in patients with renal failure and adverse cytogenetics do not seem to interfere with its activity. Moreover, carfilzomib has the advantage of a favorable safety profile, especially a low incidence of peripheral neuropathy, which is often the dose-limiting factor in thalidomide and bortezomib-based regimens. The most frequently observed high-grade adverse event is cytopenia. However, long-term tolerability is good with no cumulative toxicity. The place of carfilzomib in the treatment of the advanced and the newly diagnosed myeloma patient is currently under examination in several ongoing phase 3 clinical trials.