Minimal Residual Disease Negativity Research Articles

Clinical outcomes of hypomethylating agents and venetoclax in newly diagnosed unfit and relapsed/refractory paediatric, adolescent and young adult acute myeloid leukaemia patients.

Venetoclax (VEN) combined with hypomethylating agents (HMA) decitabine or azacitidine is used for adult acute myeloid leukaemia (AML), but its application in paediatric, adolescent and young adult (AYA) AML lacks prospective studies. We performed a retrospective chart review of paediatric and AYA AML patients treated with HMA + VEN at Cincinnati Children's Hospital Medical Centre. Twenty-seven patients received 30 HMA + VEN treatment courses for relapsed/refractory (R/R, n = 21) or newly diagnosed (n = 9) AML due to ineligibility for intensive chemotherapy. The R/R cohort had high-risk cytomolecular genetic alterations and prior extensive treatments, with 50% (n = 9) of relapse patients (n = 18) having undergone haematopoietic stem cell transplantation (HSCT). Venetoclax treatment using the 400 mg adult exposure-equivelant dosing (AED) had a median duration of 21 days (range 7-30 days). Grade 3-4 toxicities included neutropenia (90%), anaemia (64%), thrombocytopenia (64%) and febrile neutropenia (44%). The overall complete remission (CR)/CR with incomplete blood count recovery (CRi) rate was 73% (77% minimal residual disease [MRD] negativity <0.1%), with 60% undergoing HSCT. Among newly diagnosed patients (n = 9), 89% achieved CR/CRi (78% MRD negativity) and 78% proceeded to HSCT. The R/R cohort (n = 21) showed a 67% CR/CRi rate (71% MRD negativity), with 52% undergoing HSCT. These findings support the safety and efficacy of HMA + VEN in paediatric/AYA AML, indicating it as a viable option for patients unfit for intensive chemotherapy. Further studies are necessary to determine optimal venetoclax dosing, chemotherapy combinations and pharmacokinetics in this population.

Single-point and kinetics of peripheral residual disease by mass spectrometry to predict outcome in patients with high risk smoldering multiple myeloma included in the GEM-CESAR trial.

The value of quantitative immunoprecipitation mass spectrometry (QIP-MS) to identify the M-protein is being investigated in patients with monoclonal gammopathies but no data are yet available in high-risk smoldering myeloma (HRsMM). We have therefore investigated QIP-MS to monitor peripheral residual disease (PRD) in 62 HRsMM patients enrolled in the GEM-CESAR trial. After 24 cycles of maintenance, detecting the M-protein by MS or clonal plasma cells by NGF identified cases with a significantly shorter median PFS (mPFS; MS: not reached vs 1,4 years, p=0.001; NGF: not reached vs 2 years, p=0.0002) but reaching CR+sCR did not discriminate patients with different outcome. With NGF as a reference, the combined results of NGF and MS showed a high negative predictive value (NPV) of MS: 81% overall and 73% at treatment completion. When sequential results were considered, sustained negativity by MS or NGF was associated with a very favorable outcome with a mPFS not yet reached vs 1.66 years and 2.18 years in cases never attaining PRD or minimal residual disease (MRD) negativity, respectively. We can thus conclude that 1) the standard response categories of the IMWG do not seem to be useful for treatment monitoring in HRsMM patients, 2) MS could be used as a non-invasive, clinical valuable tool with the capacity of guiding timely bone marrow evaluations (based on its high NPV with NGF as a reference) and 3) similarly to NGF, sequential results of MS are able identify a subgroup of HRsMM patients with long-term disease control. This study was registered at www.clinicaltrials.gov (ClinicalTrials.gov identifier: NCT02415413).

Daratumumab in transplant-eligible patients with newly diagnosed multiple myeloma: final analysis of clinically relevant subgroups in GRIFFIN

The randomized, phase 2 GRIFFIN study (NCT02874742) evaluated daratumumab plus lenalidomide/bortezomib/dexamethasone (D-RVd) in transplant-eligible newly diagnosed multiple myeloma (NDMM). We present final post hoc analyses (median follow-up, 49.6 months) of clinically relevant subgroups, including patients with high-risk cytogenetic abnormalities (HRCAs) per revised definition (del[17p], t[4;14], t[14;16], t[14;20], and/or gain/amp[1q21]). Patients received 4 induction cycles (D-RVd/RVd), high-dose therapy/transplant, 2 consolidation cycles (D-RVd/RVd), and lenalidomide±daratumumab maintenance (≤ 2 years). Minimal residual disease–negativity (10−5) rates were higher for D-RVd versus RVd in patients ≥ 65 years (67.9% vs 17.9%), with HRCAs (54.8% vs 32.4%), and with gain/amp(1q21) (61.8% vs 28.6%). D-RVd showed a trend toward improved progression-free survival versus RVd (hazard ratio [95% confidence interval]) in patients ≥ 65 years (0.29 [0.06–1.48]), with HRCAs (0.38 [0.14–1.01]), and with gain/amp(1q21) (0.42 [0.14–1.27]). In the functional high-risk subgroup (not MRD negative at the end of consolidation), the hazard ratio was 0.82 (0.35–1.89). Among patients ≥ 65 years, grade 3/4 treatment-emergent adverse event (TEAE) rates were higher for D-RVd versus RVd (88.9% vs 77.8%), as were TEAEs leading to discontinuation of ≥ 1 treatment component (37.0% vs 25.9%). One D-RVd patient died due to an unrelated TEAE. These results support the addition of daratumumab to RVd in transplant-eligible patients with high-risk NDMM.Video -YjyZJrsb3fs1sAVfK2kfK

Outcomes of acute myeloid leukemia patients who responded to venetoclax and azacitidine and stopped treatment.

Venetoclax-azacitidine is the standard of treatment for unfit acute myeloid leukemia patients. In the VIALE-A study, treatment was given until progression but there are no data on its optimal duration for responding patients who do not tolerate indefinite therapy. We retrospectively analyzed the outcome of patients who discontinued venetoclax or venetoclax-azacitidine due to poor tolerance. Sixty-two newly diagnosed (ND) AML patients and 22 patients with morphological relapse or refractory AML were included. In the ND cohort (n = 62), 28 patients stopped venetoclax and azacitidine and 34 patients continued azacitidine monotherapy. With a median follow-up of 23 months (IQR, 20-32), median overall survival and treatment-free survival were 44 (IQR, 16-NR) and 16 (IQR, 8-27) months, respectively. Patients who stopped both treatments and those who continued azacitidine monotherapy had the same outcomes. Negative minimal residual disease was associated with a 2-year treatment-free survival of 80%. In the RR cohort (n = 22), median overall survival and treatment-free survival were 19 (IQR, 17-31) and 10 (IQR, 5-NR) months, respectively. Prior number of venetoclax-azacitidine cycles and IDH mutations were associated with increased overall survival. The only factor significantly impacting treatment-free survival was the number of prior cycles. This study suggests that patients who discontinued treatment in remission have favorable outcomes supporting the rationale for prospective controlled trials.

A 5-Year Follow-up Clinical Study of the B-cell Maturation Antigen Chimeric Antigen Receptor T-cell Therapy HDS269B in Patients with Relapsed or Refractory Multiple Myeloma.

This study aimed to report the 5-year clinical outcomes of anti-B-cell maturation antigen chimeric antigen receptor (CAR) T-cell (HDS269B) therapy in patients with relapsed/refractory multiple myeloma (RRMM), including those with poor performance status [Eastern Cooperative Oncology Group (ECOG) scores 3 to 4], and to identify factors influencing long-term outcomes. Forty-nine patients with RRMM enrolled from 2016 to 2020 received HDS269B (9 × 106 cells/kg) after receiving a conditioning chemotherapy consisting of cyclophosphamide and fludarabine. The overall response, long-term outcomes, and safety were assessed, as were their associations with clinical and disease characteristics. With a median follow-up of 59.0 months, the overall response rate was 77.55%. The median progression-free survival (PFS) and overall survival (OS) were 9.5 months [95% confidence interval (CI), 5.01-13.99] and 20.0 months (95% CI, 11.26-28.74), respectively. The 5-year PFS and OS rates were 21.3% (95% CI, 12.3%-36.7%) and 34.1% (95% CI, 22.7%-51.3%), respectively. Patients with ECOG 0 to 2 had marked longer survival, with a median PFS of 11.0 months and a median OS of 41.8 months. Early minimal residual disease negativity, higher and persistent CAR T-cell expansion, and the absence of extramedullary disease were associated with better survival outcomes. No new CAR T-cell therapy-associated toxicities were observed. Importantly, ECOG scores 0 to 2, prior therapy lines <4, and CAR T-cell persistence at ≥6 months were independently associated with longer OS. HDS269B is effective and safe, especially for patients with ECOG scores 0 to 2. Early CAR T-cell intervention may improve prognosis in patients with RRMM.

Low circulating tumor cell levels correlate with favorable outcomes and distinct biological features in multiple myeloma.

There is growing interest in multiple myeloma (MM) circulating tumor cells (CTCs), but their rareness in peripheral blood (PB) and inconsistency in cutoffs question their clinical utility. Herein, we applied next-generation flow cytometry in 550 bone marrow (BM) and matched PB samples to define an optimal CTC cutoff for both transplant-eligible and transplant-ineligible newly diagnosed MM (NDMM) patients. Deep phenotyping was performed to investigate unique microenvironmental features associated with CTC dissemination. CTCs were detected in 90% of patients (median 0.01%; range: 0.0002%-12.6%) and increased levels associated with adverse features. Correlations were observed between high CTC percentages and a diffused MRI pattern, a distinct BM composition characterized by altered B-cell differentiation together with an expansion of effector cells and tumor-associated macrophages, as well as a greater phenotypic dissimilarity between BM and PB clonal cells. Progression-free survival (PFS) and overall survival (OS) gradually worsened with each logarithmic increment of CTCs. Conversely, NDMM patients without CTCs showed unprecedented outcomes, with 5-year PFS and OS rates of 83% and 97%, respectively. A cutoff of 0.02% CTCs was independent of the ISS, LDH, and cytogenetics in a multivariate analysis of risk factors for PFS. The 0.02% CTC cutoff synergized with the MGUS-like phenotype and the R-ISS for improving the risk stratification systems. MRD negativity was less frequent if CTCs were ≥0.02% at diagnosis, but whenever achieved, the poor prognosis of these patients was abrogated. This study shows the clinical utility of CTC assessment in MM and provides evidence toward a consensus cutoff for risk stratification.

Response adaptive salvage treatment with daratumumab-lenalidomide-dexamethasone for newly diagnosed transplant-eligible multiple myeloma patients failing front-line bortezomib-based induction therapy-ALLG MM21.

In Australia, bortezomib-based induction (V-IND) is used in >90% of newly diagnosed transplant-eligible multiple myeloma (MM) patients. Four cycles of V-IND with bortezomib-cyclophosphamide-dexamethasone or bortezomib-lenalidomide-dexamethasone are available via the Pharmaceutical Benefits Scheme prior to autologous stem cell transplantation (ASCT). Patients who demonstrate suboptimal response or who are refractory to V-IND demonstrate inferior survival, representing a subgroup of MM where an unmet need persists. We evaluated an early, response-adapted approach in these patients by switching to an intensive sequential therapeutic strategy incorporating daratumumab-lenalidomide-dexamethasone-based (DRd) salvage, high-dose melphalan ASCT followed by DRd consolidation and R maintenance. The overall response rate following four cycles of DRd salvage was 72% (95% credible interval: 57.9-82.4); prespecified, dual, Bayesian proof-of-concept criteria were met. Euro-flow minimal residual disease (MRD) negativity was 46% in the intention-to-treat population and 79% in the evaluable population following 12 cycles of DRd consolidation. At the 24-month follow-up, median progression-free survival and overall survival were not reached. DRd salvage was well tolerated with grade 3 and 4 events reported in 24% and 8% respectively. Response-adapted DRd combined with ASCT achieves high rates of MRD negativity and durable disease control in this functional high-risk group.

Improvement of daratumumab- or elotuzumab-mediated NK cell activity by the bi-specific 4-1BB agonist, DARPin α-FAPx4–1BB: A preclinical study in multiple myeloma

Multiple myeloma (MM) progression is closely dependent on cells in the bone marrow (BM) microenvironment, including fibroblasts (FBs) and immune cells. In their BM niche, MM cells adhere to FBs sustaining immune evasion, drug resistance and the undetectable endurance of tumor cells known as minimal residual disease (MRD). Here, we describe the novel bi-specific designed ankyrin repeat protein (DARPin) α-FAPx4–1BB (MP0310) with FAP-dependent 4–1BB agonistic activity. The α-FAPx4–1BB DARPin simultaneously binds to FAP and 4–1BB overexpressed by activated FBs and immune cells, respectively. Although flow cytometry analysis showed that T and NK cells from MM patients were not activated and did not express 4–1BB, stimulation with daratumumab or elotuzumab, monoclonal antibodies (mAbs) currently used for the treatment of MM, significantly upregulated 4–1BB both in vitro and in MM patients following mAb-based therapy. The mAb-induced 4–1BB overexpression allowed the engagement of α-FAPx4–1BB that acted as a bridge between FAP+FBs and 4–1BB+NK cells. Therefore, α-FAPx4–1BB enhanced both the adhesion of daratumumab-treated NK cells on FBs as well as their activation by improving release of CD107a and perforin, hence MM cell killing via antibody-mediated cell cytotoxicity (ADCC). Interestingly, α-FAPx4–1BB significantly potentiated daratumumab-mediated ADCC in the presence of FBs, suggesting that it may overcome the BM FBs’ immunosuppressive effect. Overall, we speculate that treatment with α-FAPx4–1BB may represent a valuable strategy to improve mAb-induced NK cell activity fostering MRD negativity in MM patients through the eradication of latent MRD cells.

Additional copies of 1q negatively impact the outcome of multiple myeloma patients and induce transcriptomic deregulation in malignant plasma cells

Additional copies of chromosome 1 long arm (1q) are frequently found in multiple myeloma (MM) and predict high-risk disease. Available data suggest a different outcome and biology of patients with amplification (Amp1q, ≥4 copies of 1q) vs. gain (Gain1q, 3 copies of 1q) of 1q. We evaluated the impact of Amp1q/Gain1q on the outcome of newly diagnosed MM patients enrolled in the FORTE trial (NCT02203643). Among 400 patients with available 1q data, 52 (13%) had Amp1q and 129 (32%) Gain1q. After a median follow-up of 62 months, median progression-free survival (PFS) was 21.2 months in the Amp1q group, 54.9 months in Gain1q, and not reached (NR) in Normal 1q. PFS was significantly hampered by the presence of Amp1q (HR 3.34 vs. Normal 1q, P < 0.0001; HR 1.99 vs. Gain1q, P = 0.0008). Patients with Gain1q had also a significantly shorter PFS compared with Normal 1q (HR 1.68, P = 0.0031). Concomitant poor prognostic factors or the failure to achieve MRD negativity predicted a median PFS < 12 months in Amp1q patients. Carfilzomib–lenalidomide–dexamethasone plus autologous stem cell transplantation treatment improved the adverse effect of Gain1q but not Amp1q. Transcriptomic data showed that additional 1q copies were associated with deregulation in apoptosis signaling, p38 MAPK signaling, and Myc-related genes.

Isatuximab, lenalidomide, dexamethasone and bortezomib in transplant-ineligible multiple myeloma: the randomized phase 3 BENEFIT trial

CD38-targeting immunotherapy is approved in combination with lenalidomide and dexamethasone in patients with newly diagnosed multiple myeloma (NDMM) that are transplant ineligible (TI) and is considered the best standard of care (SOC). To improve current SOC, we evaluated the added value of weekly bortezomib (V) to isatuximab plus lenalidomide and dexamethasone (IsaRd versus Isa-VRd). This Intergroupe Francophone of Myeloma phase 3 study randomized 270 patients with NDMM that were TI, aged 65–79 years, to IsaRd versus Isa-VRd arms. The primary endpoint was a minimal residual disease (MRD) negativity rate at 10−5 by next-generation sequencing at 18 months from randomization. Key secondary endpoints included response rates, MRD assessment rates, survival and safety. The 18-month MRD negativity rates at 10−5 were reported in 35 patients (26%, 95% confidence interval (CI) 19–34) in IsaRd versus 71 (53%, 95% CI 44–61) in Isa-VRd (odds ratio for MRD negativity 3.16, 95% CI 1.89–5.28, P < 0.0001). The MRD benefit was consistent across subgroups at 10−5 and 10−6, and was already observed at month 12. The proportion of patients with complete response or better at 18 months was higher with Isa-VRd (58% versus 33%; P < 0.0001), as was the proportion of MRD negativity and complete response or better (37% versus 17%; P = 0.0003). At a median follow-up of 23.5 months, no difference was observed for survival times (immature data). The addition of weekly bortezomib did not significantly affect the relative dose intensity of IsaRd. Isa-VRd significantly increased MRD endpoints, including the 18-month negativity rate at 10−5, the primary endpoint, compared with IsaRd. This study proposes Isa-VRd as a new SOC for patients with NDMM that are TI. ClinicalTrials.gov identifier: NCT04751877.

Effect of dose-adjusted melphalan on MRD-negativity to full dose melphalan in patients with multiple myeloma post-autologous stem cell transplant.

7557 Background: Despite significant therapeutic advancements, Multiple Myeloma (MM) remains an incurable disease. Autologous stem cell transplantation (ASCT) is a standard treatment for eligible patients, with high-dose melphalan (MEL200) as the preferred conditioning regimen. Reduced-dose melphalan (MEL140) is used for older or less fit patients. However, this was not prospectively studied and there has been ongoing debate about the efficacy of reduced dosing. This study aimed to investigate the impact of melphalan dose on minimal residual disease (MRD) negativity rates in MM patients undergoing upfront ASCT. Methods: We conducted a retrospective, single-center study involving 74 MM patients who underwent ASCT between 2018 and 2022 at UHCMC, Cleveland, OH and had MRD testing done after transplant. MRD testing was performed using the ClonoSEQ next generation sequencing platform. Results: Median age was higher in the MEL140 group compared to MEL200 (70.3 vs 59.8 years), both groups were similar in terms of sex and race distribution, BMI and KPS scores. Both groups have comparable ISS staging and high-risk cytogenetics. Similar numbers of lines of treatment prior to transplant were seen, with approximately 64% having only one line. First-line induction therapy included triplet therapy (Lenalidomide, Bortezomib, and Dexamethasone) in 73% of patients. Depth of remission at transplant was comparable between groups. MRD negativity rates at 10-5 and 10-6 were comparable between MEL140 and MEL200 groups (64% and 39% in MEL140; 61% and 41% in MEL200; p=0.8 and 0.7 respectively). Sustained MRD negativity at 10-5 over at least 12 months was also comparable (43% in MEL140; 50% in MEL200, p=0.8). After a median follow-up of 37 months, PFS was not reached for either group (p=0.69). Patients achieving MRD negativity at levels of 10-5 had a not reached median PFS, while those not achieving MRD negativity had a median PFS of 41 months (95%CI 23-NR; p=0.024). There was no significant difference in hospital stay duration, time to neutrophil engraftment, readmission rate, or infections within 100 days post-transplant between the MEL140 and MEL200 groups. Conclusions: Our real-world analysis demonstrates that MEL140 yields similar deep post-transplant remissions as MEL200, translating to improved PFS for patients achieving MRD negativity, regardless of the dose used. This is the first report to our knowledge of MRD negativity rate in patients receiving MEL140. [Table: see text]

Daratumumab (DARA) + bortezomib/lenalidomide/dexamethasone (VRd) in transplant-eligible (TE) patients (pts) with newly diagnosed multiple myeloma (NDMM): Analysis of minimal residual disease (MRD) in the PERSEUS trial.

7502 Background: In the primary analysis of the phase 3 PERSEUS study, subcutaneous DARA (DARA SC) + VRd (D-VRd) induction/consolidation (ind/consol) and D-R maintenance improved progression-free survival (PFS) and increased depth of response (complete response or better [≥CR] and MRD negativity [neg]) compared to VRd ind/consol and R maintenance for TE NDMM. Here, we report further results on deepening of response and MRD neg during maintenance. Methods: TE pts with NDMM were randomized 1:1 to D-VRd or VRd. Pts in both arms received up to six 28-day cycles (4 pre-ASCT ind, 2 post-ASCT consol) of VRd (V 1.3 mg/m2 SC on Days [D] 1, 4, 8, 11; R 25 mg PO on D 1-21; d 40 mg PO/IV on D 1-4, 9-12) followed by R maintenance (10 mg PO on D 1-28 until progressive disease [PD]). Pts in the D-VRd arm also received DARA SC (DARA 1,800 mg + recombinant human hyaluronidase PH20 [rHuPH20; 2,000 U/mL; Halozyme]) QW in Cycles 1-2, Q2W in Cycles 3-6, and Q4W during maintenance until PD. MRD-neg rate (clonoSEQ) was defined as the proportion of ITT pts who achieved both ≥CR and MRD neg. Results: In the 709 pts randomized (D-VRd, n=355; VRd, n=354), responses deepened over time with D-VRd vs VRd, including rates of ≥CR (end of consol: 44.5% vs 34.7%; P= 0.0078 and overall: 87.9% vs 70.1%; P&lt;0.0001). MRD-neg rates increased over time and were higher with D-VRd vs VRd at 12, 24, and 36 mo after Cycle 1 Day 1 (all P&lt;0.0001; Table). Rates of sustained MRD neg for ≥12 mo were higher for D-VRd vs VRd (10–5: 64.8% vs 29.7%; P&lt;0.0001; 10–6: 47.3% vs 18.6%; P&lt;0.0001); results were consistent across prespecified clinically relevant subgroups. Among pts who were MRD positive (pos) at end of consol, significantly higher proportions of pts in the D-VRd group vs the VRd group achieved MRDneg during maintenance at 10−5 (60.2% vs 40.5%; P= 0.0049) and 10−6 (56.7% vs 25.2%; P&lt;0.0001) and sustained MRD neg for ≥12 mo at 10−5 (38.6% vs 17.4%; P= 0.0006) and 10−6 (31.3% vs 10.3%; P&lt;0.0001). End of consol and overall MRD neg at both 10–5 and 10–6 were associated with improved PFS. Additional data on response rates in different study phases and sustained MRD neg will be presented. Conclusions: During maintenance, a greater proportion of pts with MRD-pos status achieved MRD neg with D-R vs R. The higher rates of deep (10–6) and sustained MRD neg achieved with D-VRd ind/consol and D-R maintenance vs VRd ind/consol and R maintenance translated to a clinically meaningful benefit of improved PFS. These data further support D-VRd and D-R maintenance as a new standard of care for TE pts with NDMM and highlight the benefit of DARA SC in maintenance. Clinical trial information: NCT03710603 . [Table: see text]

Ciltacabtagene autoleucel in patients with lenalidomide-refractory multiple myeloma: CARTITUDE-2 cohort A expansion subgroup.

7535 Background: The phase 2 multicohort CARTITUDE-2 study is evaluating ciltacabtagene autoleucel (cilta-cel) in patients (pts) with MM across multiple settings. Cohort A is examining cilta-cel in earlier lines of treatment (tx; LOT) in pts with lenalidomide (len)-refractory multiple myeloma (MM). Initial results for cohort A (N=20; median follow-up, 30 mo) showed cilta-cel led to minimal residual disease negativity (MRD neg) at 10–5 in 100% of pts with evaluable samples (n=17). ORR was 95% (19/20), median DOR was not reached (NR), and the 24-mo PFS rate was 75%. We report protocol-specified results for the expansion subgroup. Methods: Pts with len-refractory MM after 1–3 LOT, including a PI and IMiD, and no anti-BCMA tx were enrolled. A single cilta-cel infusion (target dose, 0.75×106 [range, 0.5–1.0×106] CAR+ viable T cells/kg) was given 5–7 d after the start of lymphodepletion. Cohort A initially evaluated cilta-cel manufactured by clinical trial processes and later expanded to evaluate cilta-cel manufactured by commercial processes. Primary endpoint was MRD neg at 10–5. Efficacy is reported for pts who received cilta-cel at target dose; demographics, baseline disease characteristics, and safety are reported for all treated pts in the expansion subgroup. Results: As of Sept 5, 2023, median follow-up was 16 mo. Of 24 pts enrolled, 23 received cilta-cel infusion (22 at target dose). Median age was 63 y, 52% were male, and 61% were triple-class exposed. Of 16 MRD-evaluable pts, 100% achieved MRD neg at 10–5; median time to MRD neg was 2 mo (range, 1–12). ORR was 91% (20/22). Median DOR was NR; 79% of responders remained in response at 12 mo. Median (range) time to first and best responses were 1 mo (1–10) and 6 mo (1–19), respectively. 12-mo PFS and OS rates were 77% and 91%, respectively. All pts had TEAEs (grade [gr] 3/4, n=22; gr 5, n=1). Hematologic TEAEs included neutropenia (96%), leukopenia (65%), lymphopenia (65%), anemia (57%), and thrombocytopenia (57%). Infections occurred in 8 (35%) pts (gr 3/4, n=1; gr 5, n=1 due to sepsis). CRS occurred in 23 (100%) pts (gr 1/2, n=23); median time to onset was 8 d and recovery was 4 d. ICANS occurred in 4 (17%) pts (gr 1, n=3; gr 4, n=1); median time to onset was 10 d and recovery was 2 d. No other neurotoxicities or MNTs/parkinsonism occurred. 2 pts had secondary malignancies (SM); 1 pt had separate SM of gr 2 basal cell carcinoma and gr 2 squamous cell carcinoma and 1 pt had MDS diagnosed on d 846 that later transformed to AML. Per investigator assessment, SM were not tx-related. Conclusions: In the expansion subgroup of cohort A, cilta-cel led to deep and durable responses in pts with len-refractory MM as early as after first relapse; safety was consistent with the known mechanism of action of CAR-T tx. Results in the expansion and initial subgroups are comparable. Data for CARTITUDE-2 cohort A underscore observations in CARTITUDE-4 which enrolled a similar pt population. Clinical trial information: NCT04133636 .

Efficacy and safety of ciltacabtagene autoleucel ± lenalidomide maintenance in newly diagnosed multiple myeloma with suboptimal response to frontline autologous stem cell transplant: CARTITUDE-2 cohort D.

7505 Background: CARTITUDE-2 is a phase 2 multicohort study evaluating ciltacabtagene autoleucel (cilta-cel) across various clinical settings. Cohort D is evaluating cilta-cel ± lenalidomide (len) maintenance in patients (pts) with newly diagnosed multiple myeloma (NDMM) who achieved less than complete response (CR) after autologous stem cell transplant (ASCT) frontline therapy (tx). We report efficacy and safety for this cohort. Methods: Adults with NDMM per IMWG criteria, best response of &lt;CR and ≥stable disease after 4–8 cycles of initial tx, including induction, high-dose chemotherapy and ASCT ± consolidation, and without exposure to CAR-T or anti-BCMA tx received a single cilta-cel infusion (target dose, 0.75×106 CAR+ viable T cells/kg) 5–7 d after the start of lymphodepletion. Per protocol, safety was assessed in the first 5 pts with cilta-cel only; subsequently, 12 pts initiated continuous len maintenance ≥21 d post cilta-cel for ≤2 yrs. Primary endpoint was minimal residual disease negativity (MRD neg) at 10–5 based on next-generation sequencing or flow. Results: As of Sept 5, 2023 (median follow-up, 22 mo [range, 5–39]), 17 pts received cilta-cel (with len, n=12; without len, n=5). Median age was 54 yrs; 6% had high-risk cytogenetics; and 100% were International Staging System stage I at baseline. Of 15 MRD-evaluable pts, 12 (80%) achieved MRD neg at 10–5; median time to MRD neg was 1 mo (range, 1–6). Overall response rate was 94% (n=16/17; ≥CR, 94%). Median duration of response was not reached, and median time to first response was 1 mo. Progression-free survival (investigator-assessed) and overall survival rates at 18 mo were 94% each. CAR+ T cells peaked in blood at a median of 12 d post infusion (mean, 2187 cells/µL; SD, 2102 cells/µL) and remained detectable for a median of 43 d (range, 26–209). All pts had grade (gr) 3/4 TEAEs. Hematologic TEAEs included neutropenia (94%), lymphopenia (65%), thrombocytopenia (47%), and leukopenia (41%). Infections occurred in 12 (71%) pts (gr 3/4, 29%). CRS occurred in 14 (82%) pts, and median time to onset was 8 d. All CRS events were gr 1/2 and recovered in a median of 3 d. ICANS occurred in 1 pt (gr 1); median time to onset was 7 d and recovery was 1 d. Other neurotoxicities occurred in 6 pts (gr 1, n=1; gr 2, n=4; gr 3, n=1); median time to onset was 21 d and recovery was 70 d (n=4). No MNTs/parkinsonism occurred. 1 pt had a secondary malignancy of gr 3 MDS with an onset on d 353 that was not treatment related per investigator assessment. Conclusions: In pts with NDMM and &lt;CR after frontline ASCT, a single cilta-cel infusion ± len maintenance demonstrated deep responses that were durable. TEAEs were consistent with the known safety profile of cilta-cel. These data show promising efficacy and safety with cilta-cel ± len maintenance in pts with NDMM who achieved &lt;CR after ASCT frontline tx. Clinical trial information: NCT04133636 .

Efficacy of venetoclax-dexamethasone (VenDex) v pomalidomide-dexamethasone (PomDex) in patients (Pts) with t(11;14)-positive relapsed/refractory multiple myeloma [t(11;14)+ RRMM]: Phase 3 CANOVA study biomarker subgroup analysis.

7510 Background: The randomized Phase 3 CANOVA study’s (NCT03539744) primary analysis showed multiple numerically improved efficacy endpoints with VenDex v PomDex, but the primary endpoint of mPFS by IRC was not statistically significant. Here, we report correlative biomarker analyses from CANOVA. Methods: CANOVA is a randomized, global, open-label Phase 3 study of VenDex v PomDex in pts with t(11;14)+ RRMM and ≥2 prior lines of therapy (LOTs). The primary endpoint was mPFS by IRC. Key secondary endpoints included ORR, ≥VGPR, mOS, and MRD negativity (&lt;10-5). In post hoc mPFS sensitivity analysis, disease progression, death, and start of next LOT were defined as events. BCL2 gene expression by RNAseq (3.7 log2 FPKM prespecified median cutoff for BCL2high v BCL2low) and chr1q abnormalities by whole-exome sequencing (normal, gain, or amp) were assessed centrally from pretreatment, CD138-enriched BM aspirates. Results: mPFS, post hoc mPFS, and mOS in the VenDex arm were similar by BCL2 status, with numerically higher ORR, ≥VGPR, and MRD negativity rates in the BCL2highsubgroup. In contrast, mPFS and mOS within the PomDex arm were numerically longer in the BCL2lowsubgroup, despite equal ORR in both subgroups (Table). Presence of 1q abnormalities was evenly distributed across BCL2high v BCL2low subgroups in the VenDex arm (51% v 45%) but not in the PomDex arm (59% v 31%). Normal 1q and gain(1q) subgroups had numerically improved mPFS, mOS, ORR, ≥VGPR, and MRD negativity with VenDex; pts with amp(1q) had poor outcomes regardless of treatment, albeit the sample size was small. Conclusions: Pts with BCL2high or gain(1q) had numerically improved clinical efficacy with VenDex v PomDex. Clinical benefit was consistent across BCL2 subgroups ( BCL2high or BCL2low) with VenDex but not PomDex. Pts with amp(1q) fared poorly irrespective of treatment arm. Clinical trial information: NCT03539744 . [Table: see text]

A phase III, randomized study of daratumumab, cyclophosphamide, bortezomib and dexamethasone (DARA-VCD) induction followed by autologous stem cell transplant or DARA-VCD consolidation and daratumumab maintenance in patients with newly diagnosed AL amyloidosis.

TPS7575 Background: Light chain (AL) amyloidosis is a plasma cell malignancy characterized by the production of amyloidgenic clonal light chains that deposit in various tissues. The addition of daratumumab to bortezomib, cyclophosphamide and dexamethasone (Dara-VCD) has improved depth of hematologic and organ responses. However, this approach has not yet demonstrated an overall survival (OS) benefit with short follow-up. Autologous stem cell transplant (ASCT) consolidation remains safe and is associated with deep and durable hematologic responses with an 83% 2-year progression free survival (PFS) and up to 72% of patients achieving a VGPR or better, comparable to Dara-VCD (79%). In multiple myeloma, ASCT improved PFS even in patients who are MRD negative at the end of standard induction therapy. It is thus reasonable to consider that ASCT might provide similar benefits in AL patients. No randomized data exist to inform the optimal use of ASCT in the era of Dara-VCD. Methods: This randomized phase 3 SWOG led intergroup trial will accrue a total of 143 participants per arm and compare MOD-PFS (major organ deterioration progression free survival: defined as time from randomization to death, cardiac/renal progression, or hematologic progression) between participants receiving an ASCT with those receiving Dara-VCD consolidation following uniform Dara-VCD induction. A median MOD-PFS of 31 months is anticipated in the non-ASCT arm. This study has 90% power and a two-sided significance level of 0.05 to detect a hazard ratio of 0.62 corresponding to a MOD-PFS of 50 months in the ASCT arm. Important additional endpoints include OS, hematological PFS, cardiac and renal responses and progression, MRD negativity both by peripheral blood mass spectrometry and bone marrow next generation flow cytometry, delayed utilization of ASCT, and quality of life. This trial was activated on 12/1/2023. Funding: NIH/NCI/NCTN grants and in part by Janssen Pharmaceuticals. Clinical trial information: NCT06022939 . [Table: see text]

Association of patient (pt) factors and pharmacodynamic biomarkers with progression-free survival (PFS) after idecabtagene vicleucel (ide-cel) in pts from KarMMa-3.

7527 Background: Ide-cel, a B-cell maturation antigen (BCMA) CAR T cell therapy (tx), significantly improved PFS vs standard regimens in pts with triple-class–exposed relapsed or refractory MM (13.8 vs 4.4 mo, P&lt;0.001) in KarMMa-3. Median PFS in the ide-cel treated population (pop; n=225) was 15.7 (95% CI, 12.5–18.9) mo (Rodríguez-Otero ASH 2023). PFS benefit of ide-cel was consistent across high-risk pt subgroups. Previous analyses indicated that lower levels of baseline soluble BCMA (sBCMA; measure of tumor burden) and lower basal inflammatory markers were positively associated with response to ide-cel. This analysis identified pre- and post-tx pt factors and pharmacodynamic biomarkers associated with longer PFS with ide-cel in the treated pop. Methods: Median PFS (15.7 mo) of the treated KarMMa-3 pop was used to divide pts into 2 groups: longer PFS (&gt;15.7 mo; n=106) or shorter PFS (≤15.7 mo; n=110). Censored pts (n=9) who had a PFS &lt;15.7 mo were excluded. Pre- and post-tx values for laboratory parameters, MM assessments, sBCMA, inflammatory cytokines, ide-cel transgene persistence, and minimal residual disease (MRD; 10−5 sensitivity) were evaluated. Serum free light chains (sFLCs) were evaluated as biomarkers of plasma cell clearance; clearance was defined as level below limit of detection of both involved and heterotypic sFLC. Analyses were post hoc and exploratory; statistical tests were used to identify relationships of interest. Results: In total,94% of pts with longer PFS achieved a best overall response of ≥very good partial response and had lower levels of β-2 microglobulin ( P&lt;0.01), lactate dehydrogenase ( P&lt;0.01), and sBCMA ( P&lt;0.01) at baseline. Inflammatory markers (eg, tumor necrosis factor, ferritin, C-reactive protein) were significantly higher ( P&lt;0.05) in pts with shorter vs longer PFS at baseline. All pts with longer PFS (100%) achieved sFLC clearance after ide-cel infusion. Among pts who achieved initial clearance, pts with longer PFS had a longer duration of sFLC clearance than shorter PFS ( P&lt;0.001), suggesting more durable engraftment of ide-cel and tumor control. Within MRD-evaluable pts, those with longer PFS achieved higher MRD negativity vs shorter PFS (87% vs 41%) at 6 mo post infusion with sustained MRD negativity (53% vs 4%) lasting 8–12+ mo. No apparent relationship was observed between PFS and ide-cel persistence at 6-, 9- and 12-mo post-infusion. Conclusions: Pts with longer PFS after ide-cel infusion had relatively lower tumor burden and lower levels of peripheral inflammatory markers before tx, highlighting the importance of managing baseline tumor burden before CAR T cell infusion to achieve optimal response. Complete and sustained clearance of sFLCs within the first few mo post infusion was associated with longer PFS. MRD negativity at 6 mo and sustained MRD negativity were enriched in pts with longer PFS. Clinical trial information: NCT03651128 .

Efficacy of carfilzomib-based regimens as induction/consolidation therapy in newly diagnosed multiple myeloma: A meta-analysis.

e19535 Background: Carfilzomib (K) is a 2nd generation selective and irreversible proteosome inhibitor. It has shown encouraging results in newly diagnosed multiple myeloma (NDMM) patients. However, no direct comparisons were made among different regimens. This analysis aims to compare efficacy with different K-based regimens in NDMM. Methods: A literature search was done on PubMed and Embase with keywords for “Carfilzomib” and “multiple myeloma” till 1/1/2024. 25 articles (N = 3221) were included after screening 2800 articles. Data was collected for overall response rate (ORR), complete response (CR), minimal residual disease negativity (MRD-), 2-year progression free survival (PFS), and 2-year overall survival (OS). Survival data was extracted from visualization of Kaplan-Meier curve if not provided in text. R software was used for the meta-analysis. Results: In one trial (N = 72), ORR and CR were 90% and 7%, respectively in patients with K and dexamethasone (d). In one trial (N = 111), ORR, CR, PFS, and OS were 93%, 18%, 74%, and 96%, respectively with Kd and thalidomide (T). In six trials (N = 844), ORR, CR, MRD-, PFS, and OS were 92%, 43%, 38%, 78%, and 88%, respectively with Kd and lenalidomide (R). In one trial (N = 22), ORR, CR, and MRD-, were 100%, 64%, and 23%, respectively with Kd and Bendamustine (B). In three trials (N = 576), ORR, CR, MRD-, PFS, and OS were 82%, 23%, 16%, 48%, and 82%, respectively with Kd, and melphalan (M). In three trials (N = 189), ORR, CR, MRD-, PFS, and OS were 89%, 24%, 30%, 71%, and 89%, respectively with Kd and cyclophosphamide (Cy). In two trials (N = 63), ORR, CR, MRD-, PFS, and OS were 97%, 86%, 55%, 95%, and 100%, respectively with KRd and daratumumab (D). In one trial (N = 64), ORR, CR, PFS, and OS were 91%, 8%, 77%, and 95%, respectively with KCyTd. In one trial (N = 46), ORR, CR, MRD-, PFS, and OS were 96%, 70%, 65%, 80%, and 89%, respectively with KRd and elotuzumab (E). In one trial (N = 125), ORR, CR, MRD-, PFS, and OS were 94%, 70%, 79%, 70%, and 78%, respectively with KRd and isatuximab (I). In one trial (N = 526), ORR, CR, MRD-, and PFS were 90%, 18%, 17%, and 78%, respectively with KCyRd. In three trials (N = 280), ORR, CR, MRD-, PFS, and OS were 97%, 66%, 60%, 87%, and 94%, respectively with KRd and stem cell transplant (SCT). In two trials (N = 180), ORR, CR, MRD-, PFS, and OS were 91%, 55%, 43%, 70%, and 85%, respectively with KCyd-SCT. In one trial (N = 123), ORR, CR, MRD-, PFS, and OS were 98%, 86%, 80%, 87%, and 94%, respectively with KRDd-SCT. Conclusions: Among K based regimens, the highest response and 2-year-survival rates were achieved with KRDd, IKRd and were comparable to regimens with SCT. Highest MRD negativity was achieved with KRDd-SCT and IKRd. Hence, four drug regimens can be considered in NDMM to achieve high response and survival rates instead of SCT especially in patients who cannot tolerate or chose not to undergo SCT. Long-term results are needed to confirm these results.

EPCORE FL-2: Phase 3 trial of epcoritamab with rituximab and lenalidomide (R2) vs chemoimmunotherapy or R2 in previously untreated follicular lymphoma.

TPS7084 Background: Follicular lymphoma (FL) is the most common indolent non-Hodgkin lymphoma. Most patients with advanced-stage FL in need of systemic therapy are treated with an anti-CD20 monoclonal antibody (eg, rituximab [R] or obinutuzumab [G]) with cyclophosphamide, doxorubicin, vincristine, and prednisone [CHOP] or bendamustine [benda]). Recent studies have shown R plus lenalidomide (R2) is a potent FL treatment in the 1L and relapsed or refractory (R/R) settings and is a promising backbone for combination therapies. Epcoritamab, a subcutaneous CD3xCD20 bispecific antibody, received breakthrough therapy designation by the FDA for R/R FL after ≥2 lines of systemic therapy. In the phase 1/2 trial (NCT04663347), epcoritamab plus R2 demonstrated high complete response (CR) rates in the 1L and R/R settings. The objective of this trial is to evaluate the safety and efficacy of 1L epcoritamab plus R2 vs CIT in patients with FL. Methods: EPCORE FL-2 (NCT06191744) is a global, randomized, open-label phase 3 trial. Eligible adult patients must have CD20+ histologically confirmed classic FL (previously grade 1–3A), stage III or IV disease (or bulky stage II), and in need of systemic treatment by meeting GELF criteria. Approximately 1080 patients will be randomized to 3 treatment arms (Table). Patients achieving CR or PR upon 6 cycles will move to epcoritamab on day 1 of cycles 7–12 (28-day cycles) and 13–21 (56-day cycles). After 120 weeks of treatment, patients will be followed for progression and survival. Dual primary endpoints will be CR rate at 30 months and progression-free survival in arm A vs arm B. Key secondary efficacy endpoints include overall survival, minimal residual disease negativity, and changes in patient-reported outcomes on the physical functioning scale of the European Organization for Research and Treatment of Cancer Quality of Life-C30 Questionnaire from baseline to week 25. Safety endpoints include incidence and severity of adverse events (AEs), including AEs of special interest (cytokine release syndrome, immune effector cell–associated neurotoxicity syndrome, and clinical tumor lysis syndrome). The study is open for enrollment. Clinical trial information: NCT06191744 . [Table: see text]

Phase 3 study results of isatuximab, bortezomib, lenalidomide, and dexamethasone (Isa-VRd) versus VRd for transplant-ineligible patients with newly diagnosed multiple myeloma (IMROZ).

7500 Background: The first line of treatment (tx) is important for patients (pts) with newly diagnosed multiple myeloma (NDMM) as pts may not have a chance for subsequent therapy. VRd is currently a standard of care (SOC) in NDMM. Isa is an approved anti-CD38 monoclonal antibody (mAb) inducing myeloma cell death through multiple mechanisms. In the Phase 3 IMROZ study (NCT03319667), we investigate the efficacy and safety of Isa-VRd vs VRd in transplant-ineligible NDMM pts. Methods: IMROZ is a global, prospective, randomized, open-label study done at 102 study sites in 21 countries. Included pts had active, measurable NDMM not considered for transplant due to elderly age or comorbidities. Pts aged ≥80 were excluded. Pts were randomized 3:2 and stratified by age, R-ISS stage and China vs non-China, to receive Isa-VRd or VRd. Isa-VRd arm pts received Isa (10 mg/kg IV); both arms received V (1.3 mg/m2 SC), R (25 mg PO) and d (20 mg IV/PO). The primary endpoint was progression-free survival (PFS). Key secondary endpoints were complete response (CR), minimal residual disease negativity (MRD-) (10-5 by NGS) in pts with CR, very good partial response or better and overall survival. Adverse events (AEs) and laboratory parameters were graded with NCI CTCAE v4.03. Results: 446 pts (265 Isa-VRd, 181 VRd) were randomized; pt characteristics were well balanced. At data cutoff (26 Sep 2023), 125 (47.2%) and 44 (24.3%) pts in Isa-VRd and VRd arms were still on tx, respectively. Median (mdn) tx duration was 53.2 (Isa-VRd) vs 31.3 (VRd) mo; addition of Isa did not significantly affect relative dose intensity of VRd. At mdn follow-up of 59.7 mo, mdn PFS was not reached (Isa-VRd) vs 54.3 mo (VRd); HR 0.596 (98.5% CI 0.406–0.876), log-rank p=0.0005. From the current trend, projected Isa-VRd mdn PFS will reach ~90 mo. PFS benefit was consistent across subgroups and maintained through subsequent line of therapy (PFS2 HR 0.697; 95% CI: 0.51-0.952). Isa-VRd led to deep and sustained responses and was well-tolerated (Table). Exposure-adjusted Grade 5 TEAE rate was 0.03 (Isa-VRd) vs 0.02 (VRd). Conclusions: IMROZ is the first Phase 3 study of an anti-CD38 mAb with SOC VRd in this pt population to show a significantly reduced risk of progression or death by 40.4% vs VRd while providing deep and sustained responses. The safety profile was consistent with addition of Isa to VRd. Numerical differences in TEAEs are largely explained by longer exposure in the Isa-VRd arm. These results support Isa-VRd as a potential new SOC in pts not intended for transplant. Clinical trial information: NCT03319667 . [Table: see text]