GEP70 High Risk Research Articles

Concomitant deletion of the short arm (del(1p13.3)) and amplification or gain (1q21) of chromosome 1 by fluorescence in situ hybridization are associated with a poor clinical outcome in multiple myeloma.

Chromosome 1 abnormalities in multiple myeloma (MM) are increasingly recognized as high risk-defining features. The authors report the prognostic value of del(1p13.3) by fluorescence in situ hybridization (FISH) at enrollment in subjects treated on total therapy clinical trials 2-6. FISH probes were generated from specific BAC DNA clones for the AHCYL1 gene locus (1p13.3) and the CKS1B locus (1q21). A total of 1133 patients were included in this analysis. Although del(1p13.3) was detected in 220 (19.4%) patients, 1q21gain or 1q21amp were observed in 300 (26.5%) and 150 (13.2%) patients, respectively. Concomitant del(1p13.3) with 1q21 gain or amp was observed in 65 (5.7%) and 29 (2.5%) patients, respectively. There was enrichment of high-risk features such as International Staging System (ISS) stage 3 disease and gene expression profiling (GEP)70 high risk (HR) in the group with del(1p13.3). Presence of del(1p13.3) confers inferior progression-free survival (PFS) and overall survival (OS). On multivariate analysis, the presence of ISS stage 3 disease, GEP70 HR, 1q21gain, and 1q21amp were independent predictors of PFS or OS. The PFS and OS of patients with combined abnormalities of del (1p13.3)/1q21gain or amp was significantly worse compared to del(1p13.3) alone and 1q21gain or 1q21 amp alone, which identifies a subset of patients with poor clinical outcomes.

Deconvolution of the Immune Microenvironment Can Predict the Outcome of Myeloma Patients and Inform Potential Intervention Strategies

IntroductionThe microenvironment of cells around multiple myeloma (MM) tumors strongly influences patient outcomes, as evidenced by the success of immunomodulatory therapies. To develop precision immunotherapeutic approaches, it is essential to identify and enumerate pro- and anti-myelomatous cell types within the bone marrow.MethodsThe population of immune and other non-tumor cell types was estimated from RNA microarray data derived from paired whole bone marrow (WBM) core biopsies and CD138-enriched (CD138+) bone marrow aspirates at presentation from 405 newly diagnosed MM patients who underwent similar treatments. Expression profiles from CD138+ cells were used to infer the residual transcriptome contribution of immune and stromal cells in the WBM array data. We performed unsupervised clustering of the estimated microenvironment gene expression profiles and calculated the statistical significance of cluster splitting using the R packages ConsensusClusterPlus and sigclust, respectively. Individual cell type composition of these microenvironments was estimated using the DCQ algorithm and a gene expression signature matrix based on the published LM22 leukocyte matrix (Newman et al., 2015) that we augmented with phenotypic profiles of 5 bone marrow-specific cell types (myelomatous plasma cells, plasma memory cells, osteoclasts, osteoblasts, and adipocytes).ResultsThis deconvolution approach accurately estimated the percent of tumor cells in WBM core biopsy as estimated by both microscopy and flow cytometry (PCC = 0.57, RMSE = 10.9%). Unsupervised consensus clustering of whole bone marrow microenvironment gene expression data revealed 5 significantly different subtypes. The two largest subtypes, Cluster 1 (N=136) and Cluster 2 (N=128), had the most divergent outcomes with median PFS values of 78 months and 53 months, respectively. Cluster 1 was significantly enriched for ISS-I patients (FDR < 0.02) while Cluster 2 was enriched for ISS-III patients (FDR < 7x10^-5). Cluster 2 showed a significant increase in estimated M1 macrophages, CD8+ T cells, adipocytes, and dendritic cells with a decrease in estimated osteoclasts versus all other clusters combined (FDRs < 0.05). Cluster 5 (N=63) had the second worst PFS at 55 months, however, it had 44% fewer than expected ISS-III patients (FDR = 0.04). Cluster 5 had fewer estimated T cells and adipocytes, and it was the only cluster with a significant (3-fold) increase in estimated NK cells compared to the other clusters combined (FDRs < 0.05). No clusters were significantly enriched for older individuals, hyperdiploidy or common chromosomal translocations (t(4;14), t(11;14), t(14;16)). No clusters were significantly enriched for CD138+ gene expression-defined high risk patients (UAMS GEP-70) or CD138+ gene expression-based molecular subtypes (Zhan et al., 2006).ConclusionsWe demonstrated the technical feasibility to accurately delineate CD138+ expression profiles from a bulk transcriptome admixture and to use the residual microenvironment transcriptome to cluster patients into distinct microenvironment subtypes. Within these subtypes, the clinical outcomes are not explained by CD138+ molecular features nor ISS stage. For example, Cluster 5 has patients with poor prognosis compared to the rest of the cohort, yet it is not significantly enriched for high risk translocations, ISS-III patients, nor GEP-70 high risk patients. Cluster 5 patients show significant decrease in both CD8+ T cell infiltrate and activated dendritic cells, perhaps reflective of a high risk immune state that would not be responsive to checkpoint inhibition. Moreover, Cluster 5 patients are the only ones to have an increase in NK cells, suggesting one could try to stimulate these NK cells to reinvigorate their anti-tumor immunity. Cluster 2, with the poorest prognosis patients and highest tumor burden (by ISS stage), shows increased CD8+ T cells and dendritic cells (where all other clusters are neutral or decreased in these cell types). Cluster 2 patients may thus benefit from checkpoint blockade, and we plan to further explore relevant checkpoint-related pathways in this cohort. Adding this layer of immune-microenvironment to the analysis of myeloma patient samples enables us to formulate biological hypotheses independent of CD138+ biology and may eventually guide more tailored therapeutic interventions and improve outcomes for patients. [Display omitted] DisclosuresDanziger:Celgene Corporation: Employment. Dervan:Twinstrand Biosciences: Equity Ownership; Celgene Corporation: Employment, Equity Ownership. Schmitz:Celgene Corporation: Employment. Copeland:Celgene Corporation: Employment. Fitch:Celgene Corporation: Employment. Newhall:Celgene Corporation: Employment, Equity Ownership. Barlogie:Celgene Corporation: Consultancy, Research Funding; Millenium Pharmaceuticals: Consultancy, Research Funding. Foy:Celgene Corporation: Employment, Equity Ownership. Trotter:Celgene Corporation: Equity Ownership; Celgene Institute for Translational Research Europe: Employment. Hershberg:Adaptive Biotechnologies: Membership on an entity's Board of Directors or advisory committees; Fraizer Healthcare Partners: Consultancy; NanoString Technologies: Membership on an entity's Board of Directors or advisory committees; Celgene Corporation: Employment, Equity Ownership. Ratushny:Celgene Corporation: Employment. Morgan:Takeda: Consultancy, Honoraria; Bristol Myers: Consultancy, Honoraria; Celgene: Consultancy, Honoraria, Research Funding.

Daratumumab in high-risk relapsed/refractory multiple myeloma patients: adverse effect of chromosome 1q21 gain/amplification and GEP70 status on outcome.

Gain of chromosome 1q21 and the gene expression-based GEP70 risk score are established prognostic markers for newly diagnosed Multiple Myeloma (MM) patients. Here we addressed the prognostic impact of these two markers in 81 relapsed/refractory (RR) MM patients treated with the CD38-antibody daratumumab. Fluorescence in situ hybridization for 1q21 was performed at initial presentation, while the GEP70 score was determined at initial presentation and prior to daratumumab treatment. While the GEP70 at initial presentation showed a trend for inferior survival, the GEP70 collected prior to daratumumab treatment was significantly associated with poor outcome (P<0·05). The worst outcome was seen for patients who were positive for gain(1q) and classified as GEP70 high risk prior to daratumumab [progression-free (PFS) and overall survival (OS) of 0·3years (95% CI: 0·15-1·4years) and 0·8years (95% CI: 0·5-1·9years) respectively], while the median PFS and OS were not reached by patients without gain(1q) and GEP70 low-risk status. In conclusion, gain(1q) and the GEP70 are powerful prognostic markers for RR MM patients treated with daratumumab, and patients classified as high risk according to these markers experience shorter treatment response.

Long-Term Outcome of Total Therapy Regimens: Impact of Molecular Subgroups

Introduction. Our TT regimens for newly diagnosed multiple myeloma (MM) incorporate novel agents into a sequential treatment program comprising induction, tandem autologous stem cell transplantation and consolidation followed by 3 years of maintenance. Herein, we report the very long-term results in a large cohort of 1986 patients treated on successive TT protocols, the most mature of which (TT1, 2, and 3a) have a median follow-up ranging from 12.8 to 23.1 yrs. Methods. TT1 (1990) was followed by TT2 (1998), which introduced Thalidomide (T) in a randomized fashion. TT3 used bortezomib (V) throughout, with TT3a (2003) and 3b (2006) having different maintenance. TT3a used in year 1 of maintenance V, T and dexamethasone (D) and in years 2 and 3 TD. TT3b introduced lenalidomide (R) during maintenance for 3 years together with V and D. TT4 (2009) only enrolled patients with GEP-defined low risk disease and randomized patients to a standard arm or light arm using a similar regimen as TT3b. TT5 (2009) was specifically designed for patients who have a high 70-gene score and employed a dose dense treatment approach. Finally, TT6 (2009) accrued previously treated, patients irrespective of GEP-defined risk using a treatment schema similar to that used in TT5. Gene expression profiling was used to assign molecular classifications. These include HY (hyperdiploidy), LB (gene expression patterns frequently seen in patients with fewer focal bone lesions), MF (spikes in MAF and MAFB expression), MS (hyperactivation of MMSET +/- FGFR3), PR (over-expression of proliferation-related genes), and CD-1 or CD-2 (different forms of aberrant CCND1 and CCND3 expression). A mixed parametric cure model was used to estimate the proportion of patients with long-term, event-free survival, or the "cure fraction." When using progression free survival (PFS) in the model, the cure fraction is the percent of patients who are likely to never experience relapse based on trends in the survival times that have been observed. When using complete remission duration (CRD) in the model, the model estimates the cure fraction among patients who achieved complete response. Results. The median follow-up on the entire cohort patients was 11.6 years (range: 0.0-27.6) The median overall survival was 9.2 years, with 79.3% and 48.0% having an event-free survival greater than 3 and 10 years, respectively. Overall, patients with GEP70 low risk MM had estimated PFS and CRD cure fractions of 20.1% and 32.7%, respectively. GEP70 high risk MM patients fared much worse with estimated cure fractions of only 8.2 and 11.0%. The estimated PFS- and-CRD based cure fractions increased over time with successive protocols (PFS-cure: 6.0% in TT1 to 27.7% in TT4; CRD-cure: 9.3 to 49.8%). These cure fractions were consistent with the early plateau in the PFS and CRD curves seen at 9 years in TT4 patients. The highest cure fractions were seen in the CD-1 molecular group (34.9 and 40.3%) with intermediate outcomes in the HY (20.1 and 30.0%) and MS (22.8 and 33.5%) groups (Table 1). Surprisingly, low cure fractions were observed in the LB (1.1 and 13.5%) and CD-2 groups (13.5 and 26.4%). CD-1, LB and CD-2 groups had similar 5-yr PFS rates of 60, 60 and 63% respectively, but a steady low rate of relapse was observed in the CD-2 and especially the LB group. These findings were confirmed in a 5-yr landmark analysis showing high PFS and CRD cure fractions in the CD-1 group of 62.7 and 72.3% respectively contrasting to much lower cure fractions in the CD-2 (47.2 and 49.2%) and LB (30.8 and 45.0%) groups. Conclusions. We report excellent long-term outcomes in patients with GEP70 low risk MM and cure fractions in the range of 20-30%. Patients with LB and CD-2 subgroups have lower overall cure rates, despites similar initial 5-yr PFS rates compared to the superior performing CD-1 group, which can be explained by the occurrence of late relapses. Table 1 Disclosures van Rhee: EUSA: Consultancy; Adicet Bio: Consultancy; Takeda: Consultancy; Sanofi Genzyme: Consultancy; Kite Pharma: Consultancy; Karyopharm Therapeutics: Consultancy; Castleman Disease Collaborative Network: Consultancy. Walker:Celgene: Research Funding. Davies:Janssen, Celgene: Other: Research Grant, Research Funding; Amgen, Celgene, Janssen, Oncopeptides, Roche, Takeda: Membership on an entity's Board of Directors or advisory committees, Other: Consultant/Advisor. Morgan:Amgen, Roche, Abbvie, Takeda, Celgene, Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Other: research grant, Research Funding. OffLabel Disclosure: anti-CD38 monoclonal antibody targeting myeloma

Poor Overall Survival in Hyperhaploid Multiple Myeloma Is Defined By Double-Hit Bi-Allelic Inactivation of TP53

Introduction Hyperhaploid multiple myeloma is a rare numerical aberration group defined by a range of 24-34 chromosomes. We have previously shown that hyperhaploid myeloma is associated with a poor prognosis with a 5-year survival rate of 23.1%, compared to 64% for hyperdiploid myeloma, and 80.4% for those with a normal karyotype. It is known that hyperhaploid myeloma frequently has monosomy of chromosome 17, making it a high risk group, but no data are currently available on the mutational status of this interesting sub-group, or how the copy number difference arises.Methods We analyzed data from whole genome, whole exome, and targeted panel sequencing from 1141 newly diagnosed myeloma patients. Internal samples were selected for whole exome or targeted sequencing based on previous karyotype information, or were identified in the process of other sequencing studies. The CoMMpass dataset was screened for the presence of hyperhaploidy. Hyperhaploid samples without prior karyotype information were identified by conflicting copy number profile and B allele frequency information, where the samples had incorrectly been normalized to a diploid copy number. These samples were re-normalized to a haploid copy number. Copy number, B allele frequency, and mutations of key genes were examined.Results In the entire dataset 9 hyperhaploid samples were identified, of which 2 came from the CoMMpass dataset. From those with gene expression array data, 5/7 were GEP70 high risk and all belonged to the D1 hyperdiploid gene expression subgroup. Samples had a median of 13 monosomies (range 9-14), which in general were those not associated with trisomies in hyperdiploid samples. The chromosomes traditionally trisomic in hyperdiploid myeloma were disomic in hyperhaploid myeloma. We examined the B allele frequency of these disomic chromosomes and saw that they all retained heterodisomy. Retention of heterodisomy indicates that the method of generating hyperhaploidy is through deletion of the monosomic chromosomes, rather than reverting to a haploid genome followed by duplication of some chromosomes. Retention of heterodisomy was also seen on chromosome 18, which is not normally trisomic in hyperdiploid samples, indicating that heterodisomy of chromosome 18 may be essential for a viable plasma cell clone.We examined the hyperhaploid samples for frequently mutated genes and found that 8/9 (88.8%) of hyperhaploid samples had a mutation in TP53. This rate of mutation far exceeds the overall rate of mutation in newly diagnosed patients (5.5%), indicating an oncogenic dependency in this group. The sample without mutation of TP53 had only 9 monosomies, fewer than the other samples (12-14 monosomies), indicating there may be a prognostic difference that is dependent on the total chromosome count. All samples with TP53 mutation also had monosomy of chromosome 17, indicating bi-allelic inactivation of TP53. The variant allele frequency of the TP53 mutations was high (median=0.94), indicating that bi-allelic inactivation was a clonal event. No other significant mutations were found, including those that encode chromosome segregation or kinetochore proteins.Conclusions We have previously described bi-allelic inactivation of TP53 as Double Hit myeloma, and here we identify that hyperhaploid myeloma belongs to this poor prognosis group. The method of generating the hyperhaploid clone is through deletion of chromosomes, which may happen in a way that is similar to gain of chromosomes in hyperdiploid myeloma. These Double Hit patients may be good candidates for new therapies, but using next generation sequencing techniques researchers must be careful when normalizing data to correctly identify them as hyperhaploid rather than hyperdiploid, using copy number and B allele frequency data. DisclosuresDavies:MMRF: Honoraria; TRM Oncology: Honoraria; Janssen: Consultancy, Honoraria; Takeda: Consultancy, Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Abbvie: Consultancy; ASH: Honoraria. Morgan:Takeda: Consultancy, Honoraria; Bristol-Myers Squibb: Consultancy, Honoraria; Janssen: Research Funding; Celgene: Consultancy, Honoraria, Research Funding.

Baseline and on-Treatment Bone Marrow Microenvironments Predict Myeloma Patient Outcomes and Inform Potential Intervention Strategies

Baseline and on-Treatment Bone Marrow Microenvironments Predict Myeloma Patient Outcomes and Inform Potential Intervention Strategies

Clonal selection and double-hit events involving tumor suppressor genes underlie relapse in myeloma

AbstractTo elucidate the mechanisms underlying relapse from chemotherapy in multiple myeloma, we performed a longitudinal study of 33 patients entered into Total Therapy protocols investigating them using gene expression profiling, high-resolution copy number arrays, and whole-exome sequencing. The study illustrates the mechanistic importance of acquired mutations in known myeloma driver genes and the critical nature of biallelic inactivation events affecting tumor suppressor genes, especially TP53, the end result being resistance to apoptosis and increased proliferation rates, which drive relapse by Darwinian-type clonal evolution. The number of copy number aberration changes and biallelic inactivation of tumor suppressor genes was increased in GEP70 high risk, consistent with genomic instability being a key feature of high risk. In conclusion, the study highlights the impact of acquired genetic events, which enhance the evolutionary fitness level of myeloma-propagating cells to survive multiagent chemotherapy and to result in relapse.

Molecular Subtyping and Risk Stratification for the Classification of Myeloma

Molecular Subtyping and Risk Stratification for the Classification of Myeloma

Further Evolution of Metronomic Therapy Extended to 28 Days (Metro28) for Relapsed Refractory Multiple Myeloma (RRMM)

Despite the increasing availability of novel agents for RRMM, many patients run out of treatment options due to disease refractoriness and/or progressive toxicities, both hematological (cytopenia) and non-hematological (cachexia, asthenia, renal and cardiopulmonary).Patients who are refractory to both proteasome inhibitors and immunomodulatory agents (IMIDs) carry an ominous prognosis with a median overall survival (OS) of 9 months (Leukemia, Kumar 2013). We previously reported on the efficacy and toxicity profiles of a metronomically scheduled chemotherapy regimen administered over the course of 16 days (Haematologica, Papanikolaou 2014). Encouraged by the results of that treatment, we have since modified metronomic chemotherapy to cover a 28-day period (metro28). The regimen consisted largely of bortezomib 1.0mg/m2 on days 1, 4, 7, 10, 13,16,19, 22,25,28; along with dexamethasone 12mg on days 1-4, 7-10, 13-16, 19-22, 25-28; thalidomide 100mg days 1-28, continuous 28 day infusion of doxorubicin 1.0mg/m2 (0.5mg/m2 for Ejection Fraction <40%) and cis-platinum 1.0mg/m2 (0.5mg/m2 for creatinine >2mg/dL), with the addition of arsenic trioxide (ATO) at 0.1mg/kg on each day after bortezomib; and lately vincristine (VCR) at 0.07mg daily dose by continuous infusion for 28 days. Patient characteristics included age >65yr, 46%; female, 33%; cytogenetic abnormalities at any time prior to therapy (CA), 86%; Gene Expression Profile (GEP) 70-defined high risk, 44%. The median number of prior therapies was 8 (1-64), prior transplants, 83% (1, 2, >=3), 20%, 32%, 31%; prior exposure to novel agents including Carfilzomib/Pomalidomide was 81%. Thrombocytopenia prior to treatment was present in 75% including thrombocytopenia <50,000/uL in 15%. Clinical outcomes are depicted in Figure 1. At a median follow up of 8.1 months, the median number of metro 28 cycles administered was 1 (1-5), with 37% achieving a partial response and median OS not yet reached. Interestingly, the 6 month - partial response duration estimate for the patients achieving PR was 53% (Figure 1A), while the one year OS estimate for all patients receiving metro 28 was 59% (Figure 1B). Prognostic factors that held statistical significance in univariate analysis for overall survival were albumin <3.5 g/dl (HR 2.56, P=0.009), beta-2-microglobulin (B2M) ≥3.5 mg/L (HR 3.03, P=0.003), LDH≥ 190 U/L (HR 2.81, P=0.003), GEP-70 High Risk (HR 2.32, P=0.048), GEP-5 High Risk (HR 5.75, P<0.001) (Figure 1C) and GEP PR subgroup designation (HR 3.71, P=0.003). In multivariate analysis, albumin < 3.5 g/dL (HR 2.81, P=0.035), B2M≥ 3.5 mg/L (HR 3.4, P=0.017), GEP PR subgroup (HR 3.8, P=0.012), and GEP-5 High Risk (HR 8.58, P<0.001) (Figure 1C) achieved statistical significance. The majority of cycles administered in the patient population were done in the outpatient setting (81%), while secondary admissions due to regimen toxicity occurred in 36% of the cycles administered. Grade 3 & 4 neutropenia and thrombocytopenia within 3 months from the start of the metronomic treatment were evident in 64% and 78% respectively of the cases. Treatment related mortality was 2%, due to one instance each of grade 5 infection and cerebrovascular event. In conclusion 28 day metronomic therapy is a feasible treatment with acceptable toxicity and encouraging preliminary results both in terms of ORR and OS for RRMM.Table 1:Patient characteristics at start of Metro28 therapyFactorn/N (%)Age >= 65 yr56/122 (46%)IgA Isotype28/110 (25%)Female40/122 (33%)White108/122 (89%)Albumin < 3.5 g/dL47/122 (39%)B2M >= 3.5 mg/L46/93 (49%)B2M > 5.5 mg/L26/93 (28%)CRP >= 8 mg/L54/122 (44%)Creatinine >= 2 mg/dL15/122 (12%)Hb < 10 g/dL57/122 (47%)LDH >= 190 U/L36/121 (30%)Platelet Count < 150 x 10^9/L92/122 (75%)Cytogenetic abnormalities105/122 (86%)CA within 1 year of therapy84/121 (69%)CA within 90 days of therapy65/119 (55%)New Kit GEP Sample91/91 (100%)GEP 70 High Risk40/91 (44%)GEP 5 High Risk39/91 (43%)GEP CD-1 subgroup5/91 (5%)GEP CD-2 subgroup17/91 (19%)GEP HY subgroup14/91 (15%)GEP LB subgroup6/91 (7%)GEP MF subgroup9/91 (10%)GEP MS subgroup9/91 (10%)GEP PR subgroup31/91 (34%)GEP proliferation index >= 1028/91 (31%)GEP centrosome index >= 326/91 (29%)n/N (%): n- Number with factor, N- Number with valid data for factor ND: No valid observations for factor [Display omitted] [Display omitted] [Display omitted] DisclosuresZangari:Norvartis: Membership on an entity’s Board of Directors or advisory committees; Onyx: Research Funding; Millennium: Research Funding. van Rhee:Janssen: Membership on an entity’s Board of Directors or advisory committees; Celgene: Membership on an entity’s Board of Directors or advisory committees; Millenium: Membership on an entity’s Board of Directors or advisory committees; Sanofi: Membership on an entity’s Board of Directors or advisory committees. Morgan:Celgene Corp: Membership on an entity’s Board of Directors or advisory committees; Novartis: Membership on an entity’s Board of Directors or advisory committees; Janssen: Membership on an entity’s Board of Directors or advisory committees; Myeloma UK: Membership on an entity’s Board of Directors or advisory committees; International Myeloma Foundation: Membership on an entity’s Board of Directors or advisory committees; The Binding Site: Membership on an entity’s Board of Directors or advisory committees; MMRF: Membership on an entity’s Board of Directors or advisory committees.

Final Results Of Phase II Study Of Pomalidomide (Pom) In GEP-Defined High Risk Relapsed and Refractory Multiple Myeloma (RRMM)

BackgroundPom is an IMiD® immunomodulatory agent now FDA approved for treatment of patients who have received > 2 prior therapies, including lenalidomide (Len) and bortezomib (Bor), and have demonstrated disease progression on or within 60 days of completion of the last line of therapy. There is limited data evaluating efficacy of Pom in high risk RRMM. Herein, we are reporting the final report on a phase II clinical trial employing Pom in high risk RRMM with prior exposure and/or refractoriness to Len. MethodsHigh risk RRMM was defined by having high risk on gene expression profiling (GEP70 or GEP80 signatures), elevated LDH, or having abnormal metaphase cytogenetics. Cycle #1 Pom was given at 4mg orally Days 1-21 q 4 weeks; in the absence of > PR by IMWG criteria after 2 cycles, dexamethasone (Dex, 4-20 mg orally q week) and/or Bor (1.3 mg/m2 IV days 1,4,8,11) and/or Vorinostat (Vor, 100-200 mg po days 1-21 q 4 weeks) could be added; in the absence of > PR by IMWG criteria after 4 cycles, cyclophosphamide (Cy, 300 mg/m2 q week) could be added. Primary endpoint was progression free survival (PFS) at 1 year, secondary endpoints included overall survival (OS), response rates and duration of response (DoR). Cox regression modeling was employed for univariate and multivariate analyses, Kaplan-Meier curves were used for OS and PFS. Best response was defined as the best response achieved while enrolled (regardless of prior progression, or relapse). Pharmacogenomic analyses using GEP were performed on 18 patients with paired baseline and 48hr post-Pom, using CD138-purified bone marrow plasma cells. Results71 patients with HRMM were enrolled between May 2010 and August 2012. Baseline patient characteristics included age > 65 years in 45%, cytogenetic abnormalities (CA) in 86%, GEP70 high risk in 14/34 (41%), GEP80 high risk in 28/34 (82%), extramedullary disease in 3/71 (4%) and secondary plasma cell leukemia in 2/71 (3%). 68/71 patients (96%) had a prior autologous stem cell transplant (ASCT), 30/71 (42%) had > 2 ASCT. Patients had received a median of 5 prior lines of therapy (range 1-10). There were 58 (82%) patients with Len-refractory (Len-R) MM, 64 (90%) with Bor-refractory (Bor-R) MM and 53 (75%) with dual-refractory (dual-R) MM prior to enrollment. 34 (48%) patients received > 6 cycles of treatment, 9(13%) received > 12 cycles. Patients who received > 6 cycles, had addition of Dex(67%), Bor+Dex(18%), Bor+Dex+Cy(12%), Bor+Dex+Cy+Vor(3%). As of July 2013, 45 patients (63%) discontinued therapy primarily due to progression or death. 20 (28%) patients achieved > PR as best response (1 Len-R, 2 Bor-R, 6 in dual-R), with median DoR for patients > PR of 1 month (range 0.5-18 months). 58 patients (5 Len-R, 8 Bor-R, 43 dual-R) had > stable disease, giving an overall disease control rate of 82%. Slight PFS benefit was observed in younger patients (HR=0.64, 95% CI: (0.39, 1.06), p=0.098). An increased risk for OS was observed among patients with LDH >= 190 U/L (HR=4.62, 95% CI: (2.28, 9.38), p<0.001), C-reactive protein >= 8 mg/L (HR=2.13, 95% CI: (1.03, 4.40), p= 0.041), hemogloblin < 10 g/dL (HR=3.47, 95% CI: (1.66, 7.27), p<0.001), and albumin < 3.5 g/dL (HR=2.83, 95% CI: (1.38, 5.79), p=0.005). The most common toxicities > grade 3 were leukopenia (75%), thrombocytopenia (60%), anemia (44%), infections (26%), dyspnea (19%), hypophosphatemia (20%) and hypocalcemia (19%). OS and PFS at 12 months were 63% and 13%, respectively. Pre/48hr-post POM GEP analyses showed that expression levels of 55 probe-sets (48 genes) were significantly changed in response to POM treatment (false discovery rate 0.01). These genes were related to cell adhesion, inflammatory and hypersensitivity response, such as GAS6, ITGB1, ITGB7, LYN, RAC1, PYCARD, CORO1B, F11R, and DKK1, all with higher expression values observed post POM. IRF4, one of the targets of cereblon (CRBN) previously reported to be critical for myeloma cell survival, was down-regulated post POM treatment (p=0.001,FDR=0.09), suggesting a unique CRBN-dependent anti-myeloma activity for POM ConclusionPom demonstrates good anti-myeloma activity in a heavily pretreated, GEP-defined high risk RRMM in combination with other anti-myeloma drugs. Given the efficacy in patients with poor prognostic features, there is precedence to evaluate Pom as an IMiD of choice in combination with other novel agents in front line setting for GEP-defined high risk MM. Disclosures:Usmani:Celgene: Consultancy, Research Funding, Speakers Bureau; Onyx: Research Funding, Speakers Bureau. van Rhee:Janssen Research & Development: Research Funding. Barlogie:Millennium: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; MyelomaHealth: Patents & Royalties.

Five Gene Probes Carry Most Of The Discriminatory Power Of The 70-Gene Risk Model In Multiple Myeloma

Five Gene Probes Carry Most Of The Discriminatory Power Of The 70-Gene Risk Model In Multiple Myeloma

Secondary Myelodysplasia-Associated Metaphase Cytogenetic Abnormalities in Newly Diagnosed Multiple Myeloma Treated On Total Therapies 2 & 3– Influence of Cumulative Dosing of Maintenance Drugs

AbstractAbstract 324▪▪This icon denotes a clinically relevant abstract Background:There has been recent evidence that lenalidomide, while used in the treatment of myelodysplastic syndromes (MDS), also has been associated with an enhanced risk of secondary malignancies including MDS. Here we are examining the impact of maintenance on the development of metaphase-based MDS-associated cytogenetic abnormalities (MDS-CA), and subsequent development of therapy related MDS (t-MDS) and acute leukemia (t-AL) in the two arms of Total Therapy 2 (TT2) and two successive Total Therapy 3 trials (TT3A, TT3B). Methods:The details of TT2/TT3A/TT3B trials and patient outcomes have been reported previously. TT2 (median follow-up 118 months) patients were then randomized to receive thalidomide maintenance (TT2+Thal) for 3 years versus no thalidomide (TT2-Thal). Maintenance in TT3A (median follow-up 78 moths) consisted of VTD in the first year and TD for years 2 and 3 in TT3A, while TT3B (median follow-up 48 months) employed VRD for all 3 years. The patient populations were as follows: TT2-Thal arm (n=283), TT2+Thal arm (n=270), TT3A (n=279) and TT3B (n=162). Bone marrow examination with conventional cytogenetics was performed at baseline, post-induction, post-transplant and then at least semi-annually from maintenance in all patients prospectively. Chi-square and Fisher's exact tests were used to compare baseline characteristics between protocols. Univariate and multivariate Cox proportional hazard regression were used to model associations between baseline covariates and onset of MDS-CA and t-MDS/t-AL. Kaplan and Meier method was used to model cumulative incidence of MDS-CA and t-MDS/t-AL. Results:Baseline characteristics were fairly comparable between the two arms of TT2 and the two TT3 studies, except a higher proportion of GEP70 high risk patients in TT3B. Cumulative incidence of MDS-CA was significantly higher in TT3B protocol from time of first transplant (Figure 1), with the most common cytogenetic abnormality being deletion of chromosome 20 (del20, 35%), followed by monosomy/deletion 7 (27%) and monosomy/deletion 5 (17%) across all protocols. Of the 71 patients with an MDS-CA, 29 were also diagnosed with clinical MDS or AML; for these 29 patients, the median time to this diagnosis from first transplant was 58 months. The cumulative incidence of MDS-CA was higher and achieved more statistical significance (Figure 2) in TT3B compared to TT3A when landmarked from the start of maintenance. In univariate analysis for all patients, TT3B emerged as a significant variable in the univariate Cox regression model for MDS-CA, and in both the univariate and multivariate models for del20. Univariate and multivariate modeling within TT3B patient population did not reveal significance with cumulative dosing of different maintenance drugs. Discussion:Three randomized phase III trials (IFM-2005-02, CALGB 101104 and MM-015) have demonstrated an increase incidence of second malignancies in patients receiving lenalidomide maintenance after having been exposed to alkylating agent melphalan. In our present study, we are reporting an increased incidence of MDS-CA in the TT3B trial that employed VRD maintenance when compared with predecessor TT3A and TT2 trials. The data suggests that the risk is associated with lenalidomide exposure rather than its cumulative dosing in patients with prior exposure to therapy with alkylating agents. [Display omitted] Pairwise log-rank comparisons:TT3B vs. TT3A:p-value = 0.0206TT3B vs. TT2-Thal:p-value = 0.0134TT3B vs. TT2+Thal:p-value = 0.0178TT3A vs. TT2-Thal:p-value = 0.1502TT3A vs. TT2+Thal:p-value = 0.3134TT2-Thal vs. TT2+Thal:p-value = 0.8863 [Display omitted] Disclosures:Sawyer:University of Arkansas for Medical Sciences: Employment, under panding process, under panding process Patents & Royalties.

Second Malignancies in Total Therapy 3 Trials for Newly Diagnosed Multiple Myeloma: Influence of Lenalidomide Versus Thalidomide in Maintenance Phases

Abstract 823 Background:Recent data from IFM, CALGB and GEMIMA trials suggest that utilizing lenalidomide as maintenance therapy is associated with a higher incidence of second cancers, including both hematologic and solid malignancies. Two successive Total Therapy 3 (TT3) trials, one employing as maintenance thalidomide (TT3A, n=303) and the other lenalidomide (TT3B, n=177), after tandem transplants offered the opportunity of investigating whether lenalidomide therapy was associated with greater probability of inducing second malignancies. Patients & Methods: The details of TT3A and TT3B trials and patient outcomes have been reported previously. Briefly, both employed identical induction therapy with 2 cycles of VTD-PACE (bortezomib, thalidomide, dexamethasone plus 4-day continuous infusions of cisplatin, doxorubicin, cyclophosphamide, etoposide), followed by melphalan 200mg/m2-based tandem autologous transplantation and 2 cycles of dose-reduced VTD-PACE consolidation. Maintenance consisted of VTD in the first year and TD for years 2 and 3 in TT3A, while TT3B employed VRD for all 3 years. All patients had signed an informed consent in keeping with institutional and federal guidelines. For the purpose of this analysis, the MM data base was interrogated for the development of CA-2 arising after protocol initiation and after start of maintenance therapy in TT3 trials. This was based on frequently scheduled positron emission tomography (PET) scanning, performed at baseline and on average every 3 months in the first year and semi-annually thereafter. For the early detection of potential MDS or AML, all bone marrow examinations included metaphase karyotyping and, when indicated because of pathological or clinical suspicion, inter-phase fluorescence in situ hybridization (FISH) for the detection of MDS- and AML- associated abnormalities. Chi-square and Fisher’s exact tests were used to compare baseline characteristics between protocols. Univariate and multivariate Cox proportional hazard regression were used to model associations between baseline covariates and onset of second malignancy. Furthermore, the Kaplan and Meier method was used to model cumulative incidence of second malignancy from the initiation of maintenance therapy. Results: TT3B patients had notably higher proportions of patients with ISS III disease and GEP70-high risk as compared to TT3A patients. There was an incidence of 16 new second primary cancers on TT3A over the entire period of observation with 7 solid tumors and 9 hematologic malignancies. We only observed 2 new second primaries on protocol TT3B (1 solid, 1 hematologic malignancy). There were no differences in cumulative incidence of hematologic CA2 or solid CA2 between the protocols from the initiation of maintenance therapy on the two TT3 trials (Figure 1). Cox regression analysis identified old age (> 66yrs) and high Kappa FLC levels (>168 mg/dl) as the only factors negatively associated with timing of onset of a second malignancy, when modeled from initiation of maintenance therapy. MDS associated cytogenetic abnormalities (MDS-CA) can occur as either transient or persistent anomalies on serial bone marrow analyses in post-transplant MM patients in absence of cytopenias or morphologic evidence of MDS, as previously reported. The 4-year incidence of MDS-CA in TT3B was significantly higher than TT3A. It remains to be seen whether such MDS-CAs progress to overt clinical MDS and therefore need to be followed prospectively. Conclusion: Our study has the great advantage containing large cohorts of patients who underwent treatment that only differed in the maintenance regimen. Furthermore we did not have to rely on multiple different methods of detecting incidental CA2 but rather obtained PET scans in regular intervals thus avoiding underreporting of CA2s. In terms of treatment our aproach can be best compared to the IFM 2005-02 and CALGB 100104 who both included HDT and HSCT. Overall we had a significant lower incidence of CA2 in the treatment arms than these comparable trials. Taken together, the data suggest that there are no discernable differences in CA-2 when combining different IMiDs with BZ/D as maintenance strategy. There is, however, a higher incidence of MDS karyotypic abnormalities, both transient and persistent, in patients who remain on the Bz/D/Len maintenance after having undergone autologous stem cell transplantation on TT3B. Disclosures:Barlogie:Celgene, Genzyme, Novartis, Millennium: Consultancy, Honoraria, Patents & Royalties.