Newly Diagnosed Multiple Myeloma Research Articles

Selinexor, Daratumumab and Dexamethasone for Patients with Multiple Myeloma Previously Treated with Lenalidomide at First Relapse: A Real-World Study

CONCLUSIONS As lenalidomide becomes increasingly established standard of care for patients with newly diagnosed multiple myeloma (NDMM), a significant number of patients may develop resistance to lenalidomide in their treatment, representing a clinically important population in need of effective therapies. Lenalidomide-refractory patients, who relapse quickly and have very poor outcomes, constitute a population with unmet medical needs. Selinexor is a selective inhibitor of exportin-1, leading to the accumulation of tumor suppressor proteins and growth regulator proteins in the nucleus. This results in reduced expression of several oncoproteins, leading to cell cycle arrest and apoptosis of cancer cells. Previous data indicate that the biology associated with resistance to the monoclonal antibody daratumumab is linked to sensitivity to selinexor (ASH 2021), and selinexor conbombined with daratumumab and dexamethasone (SDd) is a well-tolerated and effective option for patients with relapsed/refractory multiple myeloma (RRMM) (Gasparetto C, 2020). Here, we present the safety and preliminary efficacy findings from the first study of SDd combination therapy in Chinese patients with multiple myeloma who refractory to lenalidomide at first relapse (NCT05559788). This study is a single-arm, prospective, non-interventional, real-world study that enrolled pts who had previously received one-line anti-myeloma treatment. Subjects were treated with selinexor (60 mg QW) in combination with daratumumab (16 mg/kg per label) and dexamethasone (40 mg QW) in 28-day cycles until PD, death or patients' withdrawal. Data collected included treatment response, patient characteristics such as age, sex, multiple myeloma features (cytogenetics by fluorescence in situ hybridization, type, stage, anti-myeloma treatment, and stem cell transplantation [SCT] status), and patients' survival. Between Feb 1, 2023, and May 30, 2023, a total of 8 RRMM pts were enrolled and received treatment at The First Affiliated Hospital of Soochow University. The median age was 63 years (range 44-78), with all pts (100%) had R-ISS stage II/III disease. Among them, 6 (75%) pts were classified as high risk or above by mSMART risk stratification, and 4 (50%) pts had extramedullary disease (EMD). All 8 (100%) pts were refractory to lenalidomide, and 7（87.5%）have received autologous stem cell transplantation (ASCT) (Table 1). At the end of one course, 6 patients (75%) achieved remission (3 very good partial responses [VGPR] and 3 partial responses [PR]). Among the 4 pts with EMD, 1 pt showed progressive disease (PD) after two courses, 1 pt showed stable disease (SD), and 2 pt achieved PR and VGPR but progressed after four and two courses, respectively. The data suggests that SDd combination therapy brings about rapid remission in EMD patients, while the duration of response may be shorter. Therefore, for these patients, it is crucial to closely monitor and plan for the next steps of treatment after achieving rapid remission. All four remaining non-EMD pts achieved remission, three of whom are continuing treatment (one died of COVID-19). Four patients were infected with COVID-19 during the treatment process. One pt was asymptomatic and detected positive with virus infection by antigen test screening. Among the three pts with symptoms, one had fever, cough, and pneumonia, and one had multiple organ failure (MOF). Three pts received antiviral medication (two with Paxlovid and one with Molnupiravir), and three recovered, but the one with MOF died. The SDd treatment was interrupted in all four pts, with a median time of 18 days (range: 12 to 21 days), until COVID-19 turned negative. The most common grade 3 adverse events (AEs) were thrombocytopenia (25%), anemia (13%), and neutropenia (13%). Non-hematological AEs were mainly grade 1-2. Three patients had dose reductions due to myelosuppression. This real-world study demonstrates that SDd combination therapy led to early, deep responses in lenalidomide-refractory multiple myeloma patients at their first relapse. Considering that patients with extramedullary disease had limited benefit from SDd treatment, future study designs may restrict the recruitment of such patients.

Static and Dynamic Assessment to Identify Ultra-High Risk Multiple Myeloma：Analysis for Patients with Overall Survival No More Than Three Years

Background: The median overall survival (OS) in multiple myeloma (MM) is rapidly approaching 10 years. However, the prognosis of ultra-high risk MM (UHR-MM) remains very poor, the median overall survival (OS) is no more than 3 years. There is no consensus to define this population till now. Several prognostic factors with significant impact on survival have been discovered over time, with cytogenetic factors as the most potent. Nevertheless, there is little study to investigate the features of these UHR-MM, especially in Asian UHR-MM patients. Patients and Methods: To understand the characteristic of UHR-MM and help identify these patients as early as possible, we retrospectively analyzed the data of patients whose OS is <3 years from a single Chinese center with static and dynamic assessment. Baseline characteristic and response dynamic were collected. Results: From 2013.1 to 2019.12, 1270 patients with newly diagnosed MM (NDMM) were enrolled in a single Chinese center. In which, 265 (20.79%) patients deceased in 36 months. 271 survival patients with no more than 3 years follow-up were excluded. Compared with 734 patients survived more than 36 months, median OS were 18.48±10.05 months and 92.70±3.99 months, median progression survival (PFS) were 12.14±4.00 months and 53.66±2.43 months, respectively. These patients are older (median age: 56 vs. 61 years, p<0.0001), with higher percentage of genetic ultra-high risk (including del(17p)≥60%; or ≥2 high-risk cytogenetic abnormalities including TP53 mutation, del(17p)/P53 deletion, t(4;14), t(14;16), t(14;20), 1q21 gain/ amplification), more patients with ISS-III, R-ISS-III, R2-ISS-IV, more patients with primary refractory (including <MR after 2 cycles or <PR after 4 cycles standard first-line therapy) or early relapse (including lost best response within 6 months from the standard first-line therapy), and more patients with primary PCL history. With multivariate analysis, genetic ultra-high risk, primary refractory, early relapse and primary PCL history are independent factors for poorer PFS and OS. Conclusion: With static and dynamic assessment, we can identify a group of UHR-MM with survival no more than 3 years as early as possible. For these patients, we need more potent therapy model to improve their survival.

Deletion 1p at Time of Diagnosis of Multiple Myeloma Portends Inferior Outcomes

Background: Multiple myeloma (MM) is associated with several cytogenetic abnormalities (CA) that influence the disease course, response to treatment and survival. Trisomies and immunoglobulin H chain translocations are primary CA while del(17p), gain(1q), del(1p) and others are secondary CA. Gain (3 copies) and amplification (>3 copies) 1q have been recognized as adverse prognostic markers and incorporated into the second revision of the International Staging System (R2-ISS). However, the role of del(1p) is less well defined, especially in the era of modern myeloma therapeutics. We aimed to analyze the outcomes of newly diagnosed MM (NDMM) patients (pts) with chromosome 1 abnormalities, mainly del 1p, treated with autologous hematopoietic cell transplant (AHCT) consolidation at The Ohio State University. Methods: We identified and reviewed the medical records of all NDMM pts who were treated with AHCT from 1/1/2015-2/13/2019 (n=511). High-risk cytogenetics (HRC) was defined by the presence of del(17p), t(4;14), or t(14;16) similar to R-ISS; standard-risk cytogenetics (SRC) were defined as the absence of HRC. Modified HR cytogenetics (mHRC) included gain/amp 1q and/or t(14;20) in addition to HRC, while ultra high-risk (uHRC) included 2 or more mHRC risk factors. Results: The baseline pt characteristics are presented in Table 1. Of 511 pts transplanted, 453 had cytogenetic data from diagnosis. SRC were seen in 353 pts (77.9%), while 100 (22.1%) had HRC, 156 (34.4%) had mHRC, and 43 (9.5%) had uHRC. Thirty-two (7.1%) pts had del(1p) while 105 (23.2%) had gain 1q and 30 (6.6%) had amp 1q. As expected, compared to SRC pts, pts with HRC, mHRC and uHRC had higher risk of relapse or death. Patients with gain and amp 1q had inferior outcomes in terms of PFS (HR 1.35; 95% CI 1.06-1.73, p=0.016), TTNT (HR 1.84; 95% CI 1.40-2.42, p<0.001) and OS (HR 1.47; 95% CI 1.06-2.02, p=0.02), consistent with published literature. The median PFS, TTNT and OS from AHCT in pts with gain/amp 1q was 3.17 years (y), 3.95y and 7.13y, respectively, compared to 4.01y, 7.60y and 8.21y in pts without gain/amp 1q. Pts with del(1p) had inferior PFS (median 2.43y versus 3.98y; HR 1.75; 95% CI 1.16-2.64, p=0.008), TTNT (median 2.72y versus 6.17y; HR 1.96; 95% CI 1.22-3.14, p=0.005) and OS (median 4.11y versus 8.38y; HR 2.19; 95% CI 1.34-3.58, p=0.002) from AHCT compared to those without del(1p). (Figure 1). Conclusions: In this cohort of NDMM pts that underwent AHCT, del(1p) at diagnosis was an independent predictor of shorter PFS, TTNT and OS. Despite advances in induction regimens, AHCT consolidation and maintenance therapy, del(1p) continues to portend inferior outcomes. Larger analyses are needed to validate the prognostic value of del(1p) and investigate its role in predicting outcomes in MM.

Identification of Therapy-Induced Clonal Evolution and Resistance Pathways in MRD Clones in Multiple Myeloma through Single-Cell Sequencing

Introduction In multiple myeloma (MM), the leading cause of disease progression, exhibits intratumoral heterogeneity that enables adaptability, limits therapeutic success, and remains incompletely understood. Previous studies have confirmed that clonal evolution frequently occurs at disease follow-up, and the patterns of clonal evolution between diagnosis and relapse correlates with patient outcomes. However, it remains unclear whether clonal evolution occurs as early as after induction therapy. Additionally, the mechanisms of malignant plasma cells (PCs) resistance after induction therapy have only been partly resolved. Here, we use single-cell RNA sequencing (scRNA-seq) to identify the clonal architecture at diagnosis and after induction therapy, and elucidate the resistance pathways occurs early after upfront therapy. Methods In this study, we analyzed single-cell RNA sequencing from 19 patients with newly diagnosed MM (NDMM), paired bone marrow (BM) samples after 2-4 cycles of proteasome inhibitor (PI) plus immunomodulatory drugs (IMiDS)-based induction therapy were collected and underwent scRNA-seq. By tracing transcriptional and cytogenetic PCs clones over time and performing differential expression analysis, we defined different patterns of clonal evolution and identified potential resistant pathways. Results In our cohort, 12 patients were identified with more than 30 PCs in the BM samples sequenced after induction therapy. Among them, our analysis of the transcriptional and cytogenetic clonal dynamics in MM patients identified three main trajectories: patients with sensitive PC clones or clone that responds to treatment with >90% of the malignant PCs replaced with seemingly health PCs (3/12 patients, 25%); in patients with a resistant clone that did not respond or only very partly responded to treatment, > 50% of the malignant PCs were found in the BM post-treatment (5/12 patients, 42%); and patients with clonal selection, indicating that the significant clone has been replaced by a small or undetectable clone at baseline (4/12 patients, 33%). For these four patients identified with clonal selection, one was observed with branching evolution, and the other three were observed with differential evolution. Transcriptional differences among sensitive clones, resistant clones, and selective clones were detected based on a pairwise comparison of the gene expressions. A large number of differentially expressed genes with reported MM resistant-related functions were observed in the resistant clones, including previously reported 1q-related genes such as CKS1B, HNRNPU, and H3F3A; cell cycle- and cell proliferation-related genes such as TUBA1B, STMN1, and HMGB2. For selective clones, an evident activation of the NF-kB signaling pathway was observed. Conclusions Together, our study confirms that clonal dynamics of the evolving PC clones may occur early after upfront therapy, and reveals that the acquisition of therapeutic resistant pathways is associated with early adaptation to treatment.

Prevalence of Exclusion Criteria in Multiple Myeloma Randomized Controlled Trials: A Systematic Review

Introduction: Patients with the most aggressive, hardest-to-treat, and rarer forms of multiple myeloma (MM), such as patients with severe renal impairment, central nervous system (CNS) disease, extramedullary disease, and plasma cell leukemia, have the greatest need of novel therapeutic approaches. Strict eligibility criteria for randomized controlled trials (RCTs) both deny access to clinical trials to these patients in greatest need, and also limit generalizability of trial results. We thus systematically assessed newly diagnosed MM RCT's from 2006 to 2023 to ascertain the prevalence of restrictive eligibility criteria, and their trends over time. Methods: We searched MEDLINE/PubMed, Embase, and the Cochrane Registry of Controlled Trials to measure the prevalence of restrictive inclusion criteria MM RCTs. We included all published newly-diagnosed MM RCTs from 2006-2023. Restrictive eligibility criteria evaluated included 1) age exclusions, 2) projected life expectancy requirements, 3) performance status 4) requiring thresholds of “secretory disease”, 5) CNS disease, 6) plasma cell leukemia, 7) hepatic and/or 8) renal function requirements, 9) hematological thresholds, 10) prior malignancy, 11) history of neuropathy, and 12) exclusion of extramedullary disease. We searched manuscripts, clinicaltrials.gov listings, and individual protocols whenever publicly available to ascertain these criteria. We ascertained what proportion of trials had each of these twelve restrictive criteria and assessed trends over time. A logistical regression was used to compare these variables over time. Results: 85 RCTs were included (Table 1). Exclusion criteria included: age in 43 (51%); projected life expectancy in 20 (24%); performance status in 74 (87%); thresholds of “secretory or measurable” disease in 47 (55%), , hepatic function in 64 (79%), renal function in 63 (74%), hematological thresholds in 50 (59%), prior malignancy (various time windows) in 68 (80%), neuropathy in 50 (59%) (various grades), plasma cell leukemia in 16 (18.8%), extramedullary disease in 4 (4.7%) and CNS disease in 9 (10.6%). Trends in exclusion criteria were assessed over time (Figure 1) showing all criteria (other than performance status) have failed to improve from 2006 to 2023, and there has been an increase in exclusionary criteria pertaining to plasma cell leukemia, extramedullary disease, CNS involvement and pre-existing neuropathy. Specific definitions of secretory disease varied with trials that required secretory disease (n=47), with 24 (51%) of these trials requiring a serum monoclonal protein of 1 g/dL or 0.5 if IgA/IgD/IgE/IgM MM, 2 (4.3%) requiring serum monoclonal protein of 2 g/dL regardless of MM subtype, 3 (6.4%) requiring serum monoclonal protein of 0.5 regardless of MM subtype, 11 (23.4%) requiring a serum free light chain of 10 mg/dL, and one (2.1%) requiring a serum free light chain of 5 mg/dL. Conclusion: The majority of MM RCTs have restrictive eligibility criteria that limit enrollment of the sickest MM patients and subsequent external validity of these trials, which perpetuates the status quo where limited data are available to guide the treatment of these challenging MM subtypes. It is very likely our methodology under-estimates the true prevalence of exclusionary criteria, as protocols were not universally available, and a trial was considered as having an exclusionary criteria only if explicitly listed. The presence of these restrictive eligibility criteria has failed to decrease over time.

RRMM and Post-BCMA Treated Subjects from the CC-220-MM-001 Study Show Increased Genomic Aberrations Associated with High-Risk and Significant Dysfunction in CD4+ T-Cell Compartment Compared to NDMM Subjects

Introduction Outcomes for patients with multiple myeloma (MM) have improved significantly through development of novel therapeutics, including immunomodulatory agents (IMiDs ®), proteasome inhibitors, anti-CD38 monoclonal antibodies and new BMCA targeting T-cell redirecting therapies. While most MM patients respond well to initial therapy, over time their disease relapses, requiring several subsequent lines of treatment. However, how patient tumors and immune profiles evolve over lines of treatment and how this may impact the efficacy of subsequent treatment regimens remains poorly understood. CC-220-MM-001 is a multicohort, phase 1/2 trial (NCT02773030) studying the efficacy of iberdomide (CC-220; a cereblon [CRBN] E3 ligase modulator) as monotherapy, and in combination with other treatments in subjects with newly diagnosed MM (NDMM) or relapsed/refractory MM (RRMM), including patients who have received prior BCMA targeting agents. This study allows uniform comparison of immune and tumor biomarkers across these clinical patient segments. Methods Baseline samples collected in the CC-220-MM-001 study prior to iberdomide treatment included peripheral blood for immunophenotyping, bone marrow biopsies for immunohistochemistry and CD138+ enriched bone marrow aspirates for genomic analysis. Biomarkers were evaluated for differences between NDMM subjects and subjects refractory to IMiD agents, proteasome inhibitors, anti-CD38 antibodies, and BCMA targeting CAR-T and T-cell engager therapies. Results Analysis of immune profiles showed NDMM subjects had a less immunodeficient profile compared to RRMM subjects, particularly in the CD4+ compartment, with significantly more total and naïve CD4+ T-cells (p<0.001) and significantly lower proportion of PD-1+ CD4+ T-cells (p=0.002) and CD4+ Tregs (p=0.005). RRMM subjects had median levels of several immune cells well below the lower limit of normal (LLN) reference range for healthy individuals, including low B cells, NK-cells, and total CD3+ and CD4+ (but not CD8+) T-cells. Median number of CD4+ T-cells was approximately half of the LLN (500 cells/mL) and median ratio of CD4+ to CD8+ T-cells was ~0.75. Phenotypic assessment of immune cells in RRMM subjects showed evidence of immune stimulation with >30% T-cells expressing activation markers (HLA-DR+ and ICOS+) and exhibiting a memory phenotype (CD45RO+). In contrast, a low proportion of pre-treatment T-cells were observed to be in a proliferative state (Ki-67+; median 6.2% of CD3+) despite evidence of activation, and more than 1/3 of both CD4+ and CD8+ cells in RRMM subjects expressed PD-1, together suggesting T-cell dysfunction and/or exhaustion. These results were mostly consistent regardless of prior refractoriness to IMiDs and PIs. Conversely, subjects post anti-CD38 had lower levels of NK and CD38+ T-cells (p<0.001) and subjects post-BCMA T-cell redirecting therapies (n=22) trended to have lower absolute levels of both CD4+ and CD8+ T-cells and increased proportion of T-cells expressing activation markers than other RRMM patient segments. Analysis of the bone marrow compartment showed that while CRBN protein was quantifiably detectable in CD138+ cells in almost all samples, including in subjects coming off IMiD based regimens, 40% of RRMM subjects had evidence of molecular dysregulation of CRBN including, loss of COPS7b/COPS8, high CRBN-del-exon10 expression, CRBN LOH or CRBN mutation. A wide range of CRBN protein levels was observed, however, differences in protein levels did not correlate with refractory status to any therapy. Notably, median CRBN expression levels were 2× higher in NDMM subjects. Prevalence of translocations, hyperdiploidy, CNAs and other mutations in RRMM subjects showed 31% of subjects had KRAS mutations, 28% had Amp1q, 23% were hyperdiploid, 21% had del17p, 12% had t(11;14), 11% had NRAS mutations and 9% had t(4;14). Conclusions These data illustrate that late-line RRMM subjects have appreciable immunosuppression compared to NDMM subjects, with particular dysfunction in the CD4+ helper T-cell compartment, suggesting that the efficacy of immunotherapies in late line myeloma may benefit from combinations with agents that improve CD4+ T-cell function. These data also show enrichment of molecular high-risk segments and CRBN-related genomic aberrations in RRMM subjects in the CC-220-MM-001 study.

Mitoxantrone Hydrochloride Liposome, Bortezomib, and Dexamethasone- Based Regimen in Multiple Myeloma Patients with Extramedullary Plasmacytoma: A Pilot Study

Background Extramedullary plasmacytoma (EMP) is frequently presented in multiple myeloma (MM), especially in relapsed/refractory MM (RRMM), indicating a high-risk state of disease with inferior survival. Even in novel agent era, most anti-myeloma therapeutics demonstrated limited efficacy in EMP. Since there are no randomized controlled studies specifically addressing this complicated situation, standard treatment recommendations still lacked in this setting. Mitoxantrone hydrochloride liposome (Lipo-MIT) has shown higher concentration in tumor tissues and extended half-life, which exhibited clinical benefits in leukemia and solid tumors. Herein we designed a pilot study to explore the efficacy and safety of Lipo-MIT, bortezomib, and dexamethasone (MVD)- based regimen in MM with EMP. Methods MM patients with measurable EMP were enrolled in this study. Patients were planned to receive a maximum of 8 cycles of Lipo-MIT, bortezomib, and dexamethasone (MVD)- based regimen. Other combination agents were chosen based on previous treatments and the tolerance of patients, according to the clinician's decision. For patients who were refractory or intolerant to bortezomib, carfilzomib could be an alternative option. The dose of Lipo-MIT was 12mg/m 2 on the first day of every cycle. Both hematological response and EMP response were assessed by the International Myeloma Working Group (IMWG) criteria. Results Between Nov 4, 2022 and Jun 25, 2023, fifteen patients were enrolled from Beijing Chaoyang Hospital, with a median age of 65 years (range: 46-77). All patients had at least one kind of EMP, of which 12 (80.0%) patients had paraskeletal plasmacytoma, 7 (46.7%) had soft-tissue plasmacytoma, and 4 (26.7) had plasma cell leukemia. Four (26.7%) patients were newly diagnosed MM (NDMM), three (20.0%) were first relapse, and eight (53.3%) were previously heavily treated (2-12 lines). All of the 11 RRMM patients had been previously treated with proteasome inhibitors and immunomodulatory drugs (IMiDs), seven of them (46.7%) had been treated with CD38 antibodies, five (33.3%) had been treated with anthracyclines, and three (20.0%) had received CAR-T therapy (Table 1). By the data cut-off date of July 30, 2023, enrolled patients received a median of 2 cycles of Lipo-MIT treatment (range: 1-4). Specific regimens included: Lipo-MIT- bortezomib/carfilzomib- dexamethasone (MVD) triplet regimen (20.0%), MVD plus lenalidomide regimen (M-VRD) (20.0%), MVD plus IMiDs and etoposide regimen (M-VTED) (40.0%), and MVD plus other cytotoxic drugs (cyclophosphamide or cisplatin) (20.0%). The overall response rate (ORR) of EMP was 53.3%. Among the 9 patients who had measurable hematological disease at baseline, the hematological ORR was 77.8% (22.2% ≥VGPR, 33.3% PR, 22.2% MR) (Table 1). The most common adverse effects (AEs) at all grades (incidence >10%) were myelosuppression, including leukocytopenia (80.0%) and thrombocytopenia (53.3%), as well as respiratory infection (46.7%), diarrhea (13.3%), blue skin (13.3%), dizzy (13.3%), and fatigue (13.3%). Common grade ≥3 AEs including leukocytopenia (46.7%), thrombocytopenia (26.7%) and respiratory infection (26.7%) (Table 2). Median follow-up time was 4.5 months. Five patients had died, among which 3 died of disease progression, 1 died of severe respiratory infection, and 1 died of Covid-19 infection. Median PFS and OS have not been reached in this cohort. Conclusion This study revealed promising results of early response and efficacy of MVD-based regimen in MM with EMP, which could be further explored in prospective phase 2 studies.

FABP4 Suppresses the Progress of Multiple Myeloma through Enhancing Alarming Function of Bone Marrow Resident Memory T Lymphocytes

Multiple myeloma (MM) is a hematological malignancy which characterized by malignant plasma cells resident in the bone marrow (BM). The BM microenvironment plays critical roles in the invasion, proliferation and migration of myeloma cells. Despite the therapies of MM improved in recent years, this disease is still incurable and requires precise treatment. Resident memory (TRM) cells are a distinct tissue-localized T cell lineage that is crucial for protective immunity in peripheral tissues. Recent studies reveal TRM cells as a vital component of the host immune response to cancer. TRM-like tumor-infiltrating lymphocytes (TILs) can be found in a wide range of human cancers, where they portend improved prognosis. However, the precise role and mechanism of bone marrow TRM cells in MM still remain elusive. In present study we first found that the accumulation of T RM cells (CD8 +CD44 +CD69 +CD62L -) in BM newly diagnosed MM (NDMM) patients was significantly higher than that of relapse recurrent MM (RRMM) ( Figure A), which was further confirmed by the immunohistochemistry (IHC) staining analysis ( Figure B). By using Seahorse XF e analyzer we found a decrease of oxygen consumption rate (OCR) of T RM cells in RRMM comparing to that of NDMM ( Figure C). Since fatty acid metabolism is important in β oxidation, we further investigated the expression of fatty acid binding proteins (FABP4/FABP5) in T RM cells and showed that FABP4 was dominant in T RM cells of NDMM patients ( Figure D). FABP4 +/+ mice and their relative controls FABP4 -/- mice were adopted to further explore the role and mechanism of T RM cells in MM progression. The abundance of genes related fatty acids β oxidation was significantly decreased in FABP4 -/- T RM cells ( Figure E). The tumor cell viability was decreased in myeloma cells co-cultured with FABP4 -/- T RM cells in the presence of bortezomib ( Figure F). Moreover, the expression of cytotoxic cytokines including IFN γ, TNFα and CXCL10 was significantly higher in FABP4 -/- T RM cells ( Figure G). The alarming function of T RM cells was further enhanced via recruiting more effector T (CD8 +CXCR3 +) cells ( Figure H), therefore the apoptosis of tumor cells was elevated in BM of MM patients. In summary, T RM cells are necessary and sufficient for long-lived protection against tumors. T RM cells derived FABP4 exerts anti-tumor immunity through prolonging the survival of T RM cells and enhancing the recruitment of more effector T cells to suppress the tumor progression ( Figure I). This study suggests that T RM cells might serve as a novel therapeutic target in MM and treatment specific targeting FABP4 might shed light on the development of potential therapeutic strategies for treating MM especially relapse patients. Acknowledgement This project is supported by the Sun Yat-sen University Hundred Talents Program (PT19200101), Natural Science Foundation of Guangdong Province (2022A1515010290).

A Novel Biosignature for Potential Stratification and Elucidation of Newly Diagnosed Multiple Myeloma Patients at-Risk

Multiple myeloma (MM) patients have highly variable overallsurvival (OS) ranging from few weeks to more than ten years. Discovering an early biosignature to stratify short-term from long-term survivors offers the prospect of treating at-risk patients. Machine learning (ML) algorithms are currently being tested to discover biosignatures, but they consist of several features that make their implementation in healthcare an arduous task. Here, we have developed an algorithm called AlgoOS to stratify newly diagnosed MM (NDMM) patients by integrating a NetRank algorithm, a variation of the Google PageRank algorithm, and ML algorithms-the first of its kind in MM. Also, a dataset of NDMM patients ( n=31) was built consisting of transcriptomic (features=28256), clinical (features=13), biochemical (features=12), and fluorescent in situ hybridization (FISH) (features=3) data. A cut-off OS of 46 months was used to group short and long-term survivors based on domain knowledge. Finally, AlgoOS was implemented on this dataset, and a biosignature predictive of NDMM patient stratification was extracted. The prediction model's performance was evaluated by accuracy, precision, and F1-score, and 5-fold cross-validations were performed. R was used to build a transcription-factor-gene-regulatory network, while all other analyses, including ML, were performed using Python. During 1 st step of AlgoOS, all transcriptomic features were ranked by NetRank score, and the top 20 were selected for further processing. This ranking was similar to web page ranking done by the Google PageRank algorithm, except that the NetRank algorithm also takes into account the correlation of features to OS. In detail, we calculated NetRank scores of transcriptomic features by building a transcription-factor-gene-regulatory network using the JASPAR-v2022 database. Each transcription factor motif in JASPAR was matched to the putative promoter region (upstream 1000 base pairs) of genes in the hg38 human reference genome. Furthermore, correlations of transcriptomic features to OS were computed, and the NetRank score was calculated by iteratively optimizing a damping factor parameter d, see Figure 1. We trained the support vector machine (SVM) on top NetRanked 10-20000 transcriptomic features, trained it separately on the same number of randomly selected features and calculated their performance scores. The models were chosen by the criteria 1) precision and accuracy ≥ 80%, 2) kernel = non-linear, and 3) C < 1, where C is a regularization parameter. It was found that the top 20 NetRanked features were the best predictive of patient stratification. The results were better than random feature selection (accuracy= 90 vs. 62, precision= 100 vs. 44, F1-score= 91 vs. 51). The results were also validated by another classifier randomforest (RF) (accuracy= 70 vs. 44, precision= 71 vs. 32, F1-score= 77 vs. 44). During the 2 nd AlgoOS step, the importance of the 20 features in the RF model was calculated to find that leaving out 2 of them did not affect the performance. Therefore, 18 transcriptomic features were integrated with clinical, biochemical, and FISH data, and a final RF was trained. It was found that data integration improved the performance of the final RF compared to the previous RF model that was trained only on transcriptomic data (accuracy= 90 vs. 70, precision= 100 vs. 71, F1-score= 91 vs. 77). Finally, we found a novel biosignature to stratify short-term from long-term survivors. The biosignature consisted of twenty nine features only, including eighteen transcriptomic ( TMEM62, BUB1, CXorf21, PLEKHM1, PRPF18, ULK2, VMP1, LONRF1, USP15, TBC1D5, NUP93, CASP4, NDFIP1, TPM1, NRXN2, ALG9, C1QC and SOX13), seven biochemical (LDH, albumin, creatinine, calcium, M-proteins, Hb light chains, Hb heavy chains), three clinical (age, gender, ISS stage) and one FISH (17P13) features. Moreover, LDH, TMEM62 and BUB1 were the three most important features, see Table1. Bioinformatics analysis of the 18 transcriptomic features in the biosignature showed an enrichment to autophagy (autophagic cell death, p-value=9.8×10 -3; autophagosome, p-value= 1.5×10 -2) that is a known mechanism of resistant to drugs and cell death in MM. Our findings indicate that creating a biosignature using transcriptomic features in addition to previously used prognostic factors may improve prediction of outcome in MM. The model has to be tested in larger clinical material.

Fluorescent in Situ Hybridization Analysis in Multiple Myeloma: Enhancing Risk Stratification, Autologous Transplant Utilization and Treatment Decisions in Limited-Resource Settings

Introduction: Multiple myeloma (MM) is a heterogeneous and incurable disease with a high risk of relapse. Recent advancements in MM treatment, such as proteasome inhibitors (PIs), immunomodulatory drugs (IMiDs), and monoclonal antibodies, have improved outcomes. Risk stratification plays a crucial role in prognosis, with cytogenetic abnormalities being an important predictor. However, conventional karyotyping is limited in its sensitivity, while interphase Fluorescent In Situ Hybridization (FISH) has emerged as a powerful prognostic marker. In lower- and middle-income countries (LMICs), where MM management faces challenges, identifying high-risk patients through FISH can guide treatment decisions and improve outcomes, even in the absence of novel drugs like Daratumumab. Methods: We conducted a retrospective study on newly diagnosed MM (NDMM) patients from January 2016 to December 2022 in two South Indian centres. Patients receiving at least 16 weeks of induction chemotherapy ± autologous stem cell transplant (ASCT) were included. The cohort was divided into two groups: those with FISH results evaluable (FRE group) and those with FISH results unavailable (FRU group). FISH analysis used 5 probes (Del13q14.3, TP53/ CEN 17, IgH (14q32.3)/ FGFR3 (4p16), IgH (14q32.3)/CCND1 (11q13), IgH (14q32.3)/MAF (16q23)) till March 2020 and 7 probes (XL CDKN2C/CKS1B, XL t(4;14) FGFR3/IGH DF, XL 5p15/9q22/15q22 Hyperdiploidy, XL t(11;14) MYEOV/IGH, XL IGH BA, XL t(14;16) IGH/MAF DF, XL TP53/17cen) from April 2020. Data collected included demographics, International Staging System (ISS), mSMART 3.0-based FISH risk stratification, induction regimen, ASCT, maintenance, relapse and response. Survival analyses employed Kaplan-Meier (KM) and log-rank tests. IBM SPSS Version 26 Software was used for analysis. Results: Of the 427 screened NDMM patients, 333 were included: 192 (57.7%) in FRE and 141(42.3%) in FRU group. Baseline characteristics were comparable, except for hypercalcemia being significantly higher in FRE (p-0.015). In FRE, 128(66.67%) had standard risk, and 64 (33.33%) had high-risk MM. VRd induction was more frequently used in FRE (p-<0.001) with no significant difference in induction response. A higher percentage of FRE patients underwent ASCT (22.9% vs. 9.93%, p<0.002), achieving more complete responses post-transplant (p<0.001). FRE group also showed an increased use of doublet maintenance (p-0.014). No significant difference observed in the mortality (p-0.069). ASCT correlated with better median PFS (64 Vs. 37 months, p-0.013). Conclusions: In this resource-limited setting, the availability of FISH results seemed to have an impact on MM patient management and outcomes. FRE patients received more aggressive induction therapy, resulting in better response rates and increased ASCT utilization. Additionally, dual-agent maintenance was preferred for high-risk patients in FRE. However, it is essential to acknowledge that this was a retrospective analysis, and other factors may have influenced the outcomes, even though both cohorts were mostly matched. Notably, none of the patients had received Daratumumab as induction therapy, suggesting that FISH availability in LMICs may positively impact patient outcomes even in the absence of access to novel drugs. Further validation through multicenter prospective investigations is warranted to strengthen these findings and explore the broader implications of incorporating FISH into risk stratification strategies. By utilizing FISH, LMICs can enhance MM management and form tailored treatment strategies, thereby improving care for NDMM patients.

Phenotype Molding of Monocytes in the Multiple Myeloma Microenvironment

Human monocytes are mononuclear phagocytes that comprise a major population of innate immune cells. Various monocyte-derived cells, including osteoclasts, dendritic cells, and macrophages, have been implicated in immunosuppression within the multiple myeloma (MM) tumor microenvironment (TME). Despite recent developments in understanding the link between monocyte-derived cells and immunosuppression in myeloma, there are still critical knowledge gaps in the association between monocytes themselves and immunosuppression within the context of MM. Specifically, the functional and developmental alterations of monocytes in the MM TME have not been explored based on the single-cell studies. In the present study, we generated a comprehensive single-cell map of peripheral blood (PB) and bone marrow (BM) monocytes from both healthy donors (HDs) and MM patients. Specifically, Heparin-anticoagulated PB samples or BM aspirates were collected from seven newly diagnosed MM (NDMM) patients and healthy donors (HDs). Paired BM aspirates were obtained from 10 MM patients at the time of diagnosis and after induction therapy. Differential expression analysis showed that type I interferon (IFN) response was upregulated in MM monocytes. And BM monocytes derived from MM patients exhibited impaired T cell attraction abilities and demonstrated an elevated capacity for suppressing T cell function. Moreover, immune checkpoint molecules, including CD274 (encoding PD-L1) and PDCD1LG2 (encoding PD-L2), were significantly upregulated in MM monocytes. Additionally, a positive correlation was observed between type I IFN response and T cell suppression capacity of MM monocytes. Trajectory analyses revealed an IFN-focused disruption of developmental pathways of both BM and PB monocytes in MM. Lastly, we included 10 MM patients at the time of diagnosis and after induction therapy to monitor transcriptional changes over time. Our results revealed that anti-tumor therapy successfully mitigated the excessive type-I interferon response of BM monocytes in MM. We document that MM monocytes exhibited an augmented type-I IFN response compared to monocytes from HDs, while their overall heterogeneity remained unchanged. Furthermore, we extended the knowledge on immunosuppression of the MM TME that the excessive type-I IFN response in MM had a significant impact on the differentiation of both BM and PB monocytes, leading to T-cell immunosuppression, specifically in BM monocytes. In the cohort that we longitudinally followed, we observed a decrease in the type-I IFN response across nearly all monocyte subsets in MM BM monocytes after induction therapy, accompanied by a reduction in the expression of the T-cell suppression gene set. In sum, our findings indicates that monocytes in the BM promotes the immunosuppression of the MM TME and represents potential therapeutic targets for modulating the MM TME.

CD16, CD57 and DNAM-1 Positive NK Cells Predict MRD Negativity in Newly Diagnosed Multiple Myeloma Patients Treated with Daratumumab, Bortezomib, Thalidomide and Dexamethasone

Introduction: Daratumumab-based quadruplets are the current standard of care for newly diagnosed transplant-eligible multiple myeloma (MM) patients, because of improved depth of response and survival, compared with triplet regimens without daratumumab. Since one of the primary mechanisms of action of daratumumab is the induction of antibody-dependent cellular cytotoxicity (ADCC) via the Fc-gamma receptor CD16 on natural killer (NK) cells, it is crucial to understand the role of NK cells in combination therapy. We therefore set out to comprehensively profile NK cells by flow cytometry in newly diagnosed MM (NDMM) patients treated with either daratumumab, bortezomib, thalidomide, and dexamethasone (D-VTD) or VTD. Methods: A subset of NDMM patients (n = 152) who were treated in the Cassiopeia trial (EudraCT: 2014-004781-15) was included in this immunomonitoring analysis. In this trial, patients were first randomized to receive either four induction cycles and two consolidation cycles of D-VTD or VTD in conjunction with autologous stem cell transplantation (ASCT). In the second part of this trial, patients who achieved partial response or better at day 100 post-ASCT were randomized to either receive daratumumab maintenance or observation for the duration of two years. Bone marrow (BM) and peripheral blood (PB) samples were collected at study entry (baseline), and for PB at additional time points: cycle 1 day 28, cycle 4 day 28, day 100 (post-ASCT) and week 52 (maintenance). All baseline BM and PB samples and a selection of longitudinal PB samples were profiled by flow cytometry, with a focus on NK cell phenotype (CD56, CD16, CD57, DNAM-1, TIGIT, KLRG1, PD1, TIM3, NKG2A, NKG2C, NKG2D). To identify NK cell profiles associated with minimal residual disease (MRD) negativity, baseline PB and BM data were compared between MM patients based on MRD status after consolidation. Additionally, longitudinal data of PB samples collected during treatment were assessed to understand the impact of D-VTD and VTD on NK cell profiles. Results: In this cohort, 49 patients out of 77 (64%) randomized to the D-VTD arm achieved MRD negativity post-consolidation, while this was the case in 28 out of 75 patients (37%) in the VTD arm (fisher exact-test, p = 0.008). Patients with a higher proportion of BM-residing NK cells expressing the ADCC receptor CD16 (median 86 vs 72%, p = 0.007), the activating receptor DNAM-1 (median 94 vs 89%, p = 0.029), or the maturation marker CD57 (median 58 vs 48 %, p = 0.049) at baseline were more likely to achieve MRD-negativity post-consolidation in the D-VTD arm (Figure 1). Notably, this association was not present in the VTD arm. Although not significant, we found a similar trend for CD16 in PB in the D-VTD arm. During D-VTD treatment, we observed an increase in the proportion of CD56 bright and NKG2A + in PB NK-cells, and a corresponding decline in cells expressing CD16, CD57 and DNAM-1 (linear mixed effect model (LME) p <0.001). During VTD treatment we also observed a decrease in CD16 + NK-cells and an increase in CD56 bright and NKG2A + NK-cells (LME p <0.05), although these changes were more pronounced in the D-VTD arm. In patients who were assigned D-VTD at the first randomization and were subsequently randomized to the observation arm, we observed a restoration of the proportion of CD16 +, CD57 +, and CD56 bright NK cells to baseline values at week 52 after ASCT (Figure 2). As expected, the daratumumab associated NK cell changes persisted in the group that was randomized to the daratumumab maintenance arm. Conclusion: This study highlights the importance of NK cell immunophenotypic profiles in bone marrow as predictive markers for MRD negativity in NDMM patients treated with D-VTD in in conjunction with ASCT. Additionally, our findings illustrate that NK cell changes associated with daratumumab return to baseline levels after treatment cessation, indicating the potential for sequential NK cell-based therapies. In conclusion, this study not only provides valuable insights into the role of NK cells in the treatment of NDMM patients with D-VTD and ASCT, but also indicates that further research to optimize NK cell function in the context of combination therapies is warranted.

Gain or Amplification of Chromosome 1q Mediate Multiple Myeloma Resistant to Xpo-1 Inhibitor Selinexor Via Transcription Factor ETV3

Background: Gain or amplification of chromosome 1q, which characterized as a poor prognosis indicater, is one of the most frequent cytogenetic abnormalities in multiple myeloma (MM), occurring in nearly 40% of newly diagnosed patients. Though several genes, such as IL6R and CKS1B, have been reported to related to its severity, there still remains a mist for us to explore. So, we further explore the potential mechanism that may illustrate the malignant phenotype of gain or amplification of chromosome 1q in multiple myeloma, and the ETS transcription factors ETV3 may make sense. Objective：Explore the functions ETV3 played in the malignant phenotype of gain or amplification of chromosome 1q in multiple myeloma. Methods：Dataset GSE2658 from GEO database was used to analyze the correlation of ETV3 expression and survival of newly diagnosed multiple myeloma (NDMM). Dataset GSE4581 from GEO database was used to investigate the relationship between the number of 1q copies and expression of ETV3. Next, ETV3 expression on different myeloma cell lines was detected by RT-PCR,WB and high ETV3 expression cell lines were selected for further study. Knocking down of ETV3 on these cell lines were performed and CCK-8 was used to detected the proliferation ability. XPO-1 inhibitor selinexor was used with different concentrations (0-300nM) to treat these cells for 24h and 48h, and apoptosis was detected by flow cytometry. Further, RNAseq was performed to explore the related changed genes that might be regulated by ETV3. Result s : Survival analysis showed MM patients with higher ETV3 expression exhibit worse prognosis according to Dataset GSE2658 (P mini=0.046). As for Dataset GSE4581, 414 patients were included, among which 186 patients carried more than 2 copies of 1q21. We found that along with the increasing of 1q21+ copies, expression of ETV3 increased (p<0.01). The results of RT-PCR and West-blots showed that all the MM cell lines expressed different level of ETV3, among which H929 and AMO1 were extremely high. Hence, we knocked down ETV3 on these two cell lines (H929 Sh-ETV3 and AMO1 Sh-ETV3) in subsequent experiments. Results showed that after knocking down of ETV3, the proliferation rate of myeloma cells was reduced (p<0.05). Besides, myeloma cells knocked down of ETV3 were more sensitive to selinexor (p<0.01). Based on the above results, we analyzed the genes changed after knocking down of ETV3 by RNAseq, results indicated several genes such as PKN1 might play a part in this process. Conclusion s : MM patients carrying with higher 1q21+ copies expressed higher level of ETV3 genes, which indicated a worse prognosis. Knocking down ETV3 on myeloma cells reduced their proliferation ability and enhanced their sensitivity to selinexor. PKN1 might involved in this process. Key words: ETV3, multiple myeloma, Gain or amplification of chromosome 1q, selinexor

Free from Drug Therapy in Multiple Myeloma (FREEDMM): MRD-Based Cessation of Maintenance

Background. Treatment of newly diagnosed multiple myeloma (NDMM) consists of induction therapy followed by autologous stem cell transplant (ASCT) and indefinite maintenance. Continuous lenalidomide carries both significant clinical and financial toxicity. Minimal residual disease (MRD) has proven to be a powerful surrogate for PFS and OS but is not yet used to guide treatment. We hypothesize that MRD could be used to predict a subset of patients who can safely stop maintenance therapy and enter into a disease surveillance phase. Study Design and Methods. This prospective phase 2 study (NCT 05192122) is designed to stop post-ASCT maintenance therapy once sustained MRD negativity is achieved. MM patients are eligible if they have completed ≥2 years of maintenance therapy post-ASCT, and meet IMWG criteria for ≥ PR. Bone marrow (BM) MRD testing is performed twice, one year apart, using NGS. Sustained MRD-negativity is defined at a threshold of 10 -6, with negative MRD sustained between the Year 1 and Year 2 interval. Patients with sustained MRD negativity and absence of new bony lesions on PET then undergo maintenance therapy cessation. MRD-positive patients are removed from study. In patients who discontinue maintenance, BM testing to re-assess for MRD is repeated yearly for 3 years. At the time of MRD testing, peripheral blood (PB) samples are collected for MALDI-TOF mass spectrometry testing and circulating multiple myeloma cell (CMMC) enumeration. These are done in parallel with MRD assessment. Health-related quality of life (HRQoL) using the EORTC QLQ-MY20 questionnaire is measured before and after maintenance cessation. This study plans to enroll 50 patients to meet the primary objective of assessing sustained MRD-negativity 1 year after maintenance cessation. For all patients, 5-mL PB and BM samples are collected, processed, and kept frozen until analysis. Cellular indexing of transcriptomes and epitopes (CITE-seq) to simultaneously quantify cell surface protein and transcriptome data is used to characterize differences in the immune microenvironment between MRD-negative, MRD-positive, as well as between patients with biochemical and/or clinical progression and patients with MRD-resurgence but biochemically and clinically stable. Preliminary Results. FREEDMM enrollment began December 2021, and 31 patients have been enrolled, 29 of whom have undergone Year 1 BM for MRD assessment. Median follow up of our cohort is 414 (0-577) days. The median age is 69.5 (40-78) years, and the majority are either Black (n=9; 29%) or Hispanic (n=11; 35%). 18 (58%) patients had R-ISS 1 or 2, while 2 patients had high risk disease with presence of 17p deletion. The median number of years of maintenance therapy completed prior to Year 1 BM is 3.4 (2-7.9) years. 28 (96.6%) were in CR at time of Year 1 BM. Year 1 MRD results are pending in 13 patients. At Year 1, 11 (68.8 %) of 16 patients were found to be MRD-negative, while 5 (31.3%) patients were found to be MRD-positive with a median of 206 (1-9,748) cells per 10 6 nucleated cells detected. 24 (85%) of 28 patients had a negative MALDI-TOF result at the time of the Year 1 BM. MALDI-TOF results were false negative in 3 MRD-positive patients. PB CMMC samples were concordant with MRD results in all 5 (100%) patients who were tested. There was concordance between MALDI-TOF and CMMC results in 9 (75%) of 12 patients. At year 2, 4 patients continued to be MRD negative, while 1 patient who was previously MRD-negative became MRD positive. At most recent follow-up, 3 (42.9%) of 7 MRD positive patients at Year 1 experienced clinical progression and were removed from the study. 2 (50%) of 4 patients with sustained MRD-negativity have undergone maintenance cessation, with the remaining 2 awaiting confirmation of MRD-negative results. 59 paired PB (n=29) and BM (n=30) samples have been collected for CITE-seq analysis. Pilot CITE-seq experiments captured 10,000-15,000 cells with 33,000-56,000 reads/ cell on one MRD-positive BM and paired PB sample. CITE-seq results for remaining patients will be presented at the conference. Conclusion: This phase 2 trial applies a novel clinical trial design with an adaptive strategy to explore use of MRD testing as a guide to maintenance therapy cessation in MM patients and represents one of the first studies introducing transcriptome analysis of the tumor and immune microenvironment in the maintenance setting. Ongoing results will be reported at the conference.

E3 Ubiquitin Ligase TRIM21 Enhances Macrophage-Mediated Bortezomib Resistance By Inducing M2 Polarization in Multiple Myeloma

Background: Multiple myeloma (MM) is a malignant plasma cell hematologic tumor with an increasing incidence and has become the second most common hematologic malignancy after non-Hodgkin lymphoma. Macrophage is an abundant component of the MM bone marrow microenvironment and contributes to the enhancement of MM drug resistance. Our previous study found that the expression of the E3 ubiquitin ligase TRIM21 was reduced in MM cells, and MM cells with low expression of TRIM21 showed reduced sensitivity to Bortezomib (Bort). This study aims to investigate the role and mechanism of TRIM21 in macrophage-mediated MM Bort resistance. Objective ：Explore the effect and mechanism of TRIM21 in mediating multiple myeloma Bortezomib resistance. Methods ：1. Immunofluorescence to analyze the expression of TRIM21 on macrophages in bone marrow biopsy specimens from patients with MM; 2. QPCR, western blot (WB) and flow cytometry (FCM) to detect the level of macrophage polarization markers after constructing overexpression or knockdown of TRIM21; 3. WB and FCM to detect the sensitivity of MM cells to Bort after co-culture of MM cells and macrophage; 4. Transcriptome sequencing to identify TRIM21-mediated pathway changes in macrophage; 5. QPCR and WB to verify the effect of TRIM21 on macrophage polarization after treatment with pathway inhibitors. Results:1. Immunofluorescence analysis showed increased expression of TRIM21 in macrophage from relapsed and refractory MM (RRMM) patients compared to newly diagnosed multiple myeloma (NDMM) patients;2. QPCR, WB and FCM results showed that overexpression of TRIM21 in macrophage led to decreased polarization markers of M1 phenotype and increased the polarization markers of M2 phenotype. In contrast, knockdown of TRIM21 increased M1 polarization and decreased M2 polarization; 3. WB and FCM results demonstrated that co-culture of MM cells with TRIM21-overexpressing macrophages significantly enhanced MM cell tolerance to Bortezomib and decreased MM cell apoptosis; 4. Transcriptome sequencing revealed activation of the JAK-STAT3 pathway in macrophages after TRIM21 overexpression; 5. QPCR and WB results showed that the macrophage polarization effect induced by TRIM21 overexpression was reversed after treatment with the STAT3 inhibitor C188-9. Conclusions: Our study shows that TRIM21 is overexpressed in macrophages in patients with relapsed and refractory MM. In addition, TRIM21 induces M2 polarization by activating the JAK-STAT3 pathway, thereby enhancing the protective effect of macrophage on MM cells. These findings provide a new insight into the role of TRIM21 in MM drug resistance and lay an important theoretical foundation for targeting macrophages in MM. Key words: TRIM21, Macrophage, Bortezomib, JAK-STAT3

Health-Related Quality of Life in Polish Patients with Multiple Myeloma Treated in the Phase 3 ATLAS Trial of Post-Transplant Maintenance with Carfilzomib, Lenalidomide, Dexamethasone or Lenalidomide Alone

Introduction Results of the unplanned interim analysis of the ATLAS trial (Dytfeld, Lancet Oncology 2023) suggest a progression-free survival benefit of carfilzomib, lenalidomide, and dexamethasone (KRd) post-transplant maintenance over single-agent lenalidomide (R). Use of triplet combination, with frequent hospital visits and repeated intravenous infusions raises questions about its long-term tolerability and the impact on health-related quality of life (HRQoL) compared with relatively convenient and well-tolerated single-agent oral lenalidomide. Here, we present a descriptive, longitudinal assessment of HRQoL in Polish patients with multiple myeloma treated in the ATLAS trial. Methods ATLAS is an ongoing phase 3 trial that randomized 180 patients with newly-diagnosed multiple myeloma after ASCT to receive maintenance therapy with KRd or R. In the KRd arm, patients with standard-risk cytogenetics who achieved MRD-negativity after cycle 6 de-escalated therapy to receive R alone after cycle 8. HRQoL assessment was not required by the study protocol, however, the FACT/GOG-Ntx questionnaires were collected according to local protocols for post-transplant data collection at 7 Polish sites at screening (approximately 3 months post-transplant) and after cycles (C) 6, 12, 18, 24, 30, and 36. Therefore, the modified intention-to-treat (mITT) population in this analysis consisted of 134 patients enrolled in these sites. The domains evaluated by the FACT/GOG-Ntx questionnaire include physical well-being (PWB), social well-being (SWB), emotional well-being (EWB), functional well-being (FWB), and neurotoxicity (Ntx). The outcomes are summarized in FACT/GOG-Ntx Trial Outcome Index (TOI, combining PWB, FWB, and Ntx), FACT-G Total Score (PWB, SWB, EWB, and FWB), and FACT/GOG-Ntx Total Score (all five domains). Based on previous reports, the minimally important difference (MID) was defined as a change of at least 10% of the instrument range (Tremblay, BMC Cancer 2021). Student's t-test was used for comparisons between normally distributed variables and Wilcoxon rank-sum test for not normally distributed. Rates of patients experiencing MID were compared using chi-square test. Results HRQoL questionnaires were available for 123 out of 134 patients (92%). The numbers of completed questionnaires at screening, C6, C12, C18, C24, C30, C36 were 115 (86% of randomized patients / 86% of expected patients), 111 (83%/86%), 102 (76%/85%), 93 (69%/85%), 82 (61%/86%), 74 (55%/87%), and 56 (42%/80%), respectively. Throughout the analyzed timepoints, the mean PWB, SWB, EWB, FWB, NTx scores (Figure 1), FACT/GOG-NTx TOI, FACT-G Total Score, and FACT/GOG-Ntx Total Score (Figure 2) did not differ between the two study arms. A similar pattern was observed in the changes in individual patient scores compared to baseline. During the treatment course, the rates of patients experiencing a decrease in HRQoL scores, reaching the MID threshold in at least one evaluation, were consistent in both groups - 19 out of 59 (32%) patients treated with KRd and 20 out of 52 (38%) patients in the R arm (p=0.49) in the FACT/GOG-NTx TOI, 23/59 (39%) in the KRd arm and 21/52 (40%) in the R arm in the FACT-G Total Score (p=0.88), and 24/59 (41%) in the KRd arm and 19/52 (37%) in the R arm in the FACT/GOG-Ntx Total Score (p=0.65). Similarly, there were no differences in the respective results in terms of patients experiencing an increase in HRQoL scores, reaching the MID threshold in at least one evaluation - 8 out of 59 (14%) patients treated with KRd and 11 out of 52 (21%) patients in the R arm (p=0.28) in the FACT/GOG-NTx TOI, 10/59 (17%) in the KRd arm and 13/52 (25%) in the R arm in the FACT-G Total Score (p=0.29), and 8/59 (14%) in the KRd arm and 6/52 (12%) in the R arm in the FACT/GOG-Ntx Total Score (p=0.75). Conclusions The results of this analysis do not imply a negative impact of post-transplant maintenance with carfilzomib, lenalidomide, and dexamethasone compared to single-agent lenalidomide on the HRQoL.

Demographic Disparities in Clinical Trial Enrollment of US Patients with Newly-Diagnosed Multiple Myeloma

Background: Racial, ethnic and gender disparities impact the real-world reproducibility of clinical trials leading to drug approvals for hematologic malignancies. Interestingly, a prior abstract (Boisclair et al., 2022) has shown an equitable enrollment between US demographic groups in frontline trials for newly-diagnosed non-Hodgkin lymphoma. Although disparities in multiple myeloma (MM) trial participation have been oftentimes demonstrated, prior studies (Kanapuru et al., 2022; Alqazaqi et al., 2022) predominantly involved patients with relapsed/refractory MM (RRMM). To further assess this gap, we conducted a cross-sectional analysis of US demographic representation in phase II or III trials for newly-diagnosed MM (NDMM). Methods: Clinicaltrials.gov was searched for completed NDMM trials with a recruitment period between 01/01/2007-12/31/2020. Studies limited to phase I data (n=10), enrolling <30 patients (n=35), including RRMM or other malignancies (n=18), and/or recruiting outside the US (n=93) were excluded. We subdivided patients according to gender, race, and ethnicity. For each subgroup, total new cases of MM from 2007-2020 were identified via the Surveillance, Epidemiology and End Results (SEER) Cancer Statistics Explorer Network, with subsequent calculation of a trial enrollment fraction (TEF; number of trial enrollees divided by incident US cases). Pearson's chi-square test was used to compare TEF between subgroups, yielding odds ratio (OR) and 95% confidence interval (95%CI) values, with P<0.05 deemed significant. Results: Among the 194 trials found on initial review, 25 met the established criteria for inclusion (Figure 1). All studies (n=3,559) described the participants' gender, while only 18 (72%; n=3,129) reported race and 9 (36%; n=2,319) reported ethnicity. Overall, women showed a significantly lower TEF compared to men (OR, 0.88; 95%CI, 0.82-0.94; P<0.001). When compared to White Americans, TEF was significantly lower for African Americans (OR, 0.71; 95%CI, 0.64-0.78; P<0.001) and Asian Americans/Pacific Islanders (AAPIs; OR, 0.64; 95%CI, 0.22-0.41; P<0.001). In studies reporting ethnicity, TEF was significantly lower for Hispanics compared to non-Hispanics (OR, 0.18; 95%CI, 0.14-0.24; P<0.001). Conclusion: Our cross-sectional analysis reveals an underrepresentation of women, African Americans, AAPIs, and Hispanics in NDMM trials conducted around the US. These findings are complementary to the enrollment disparities previously shown in RRMM trials. Through the implementation of a comprehensive diversity plan, MM trials must include a more inclusive representation of the US population affected by this blood cancer. Such an approach will not only enhance the external validity of these trials but also mitigate the impact of ascertainment bias and promote healthcare equity.

Phase 3 Randomized Study of Daratumumab (DARA) + Bortezomib, Lenalidomide, and Dexamethasone (VRd) Versus Vrd Alone in Patients (Pts) with Newly Diagnosed Multiple Myeloma (NDMM) Who Are Eligible for Autologous Stem Cell Transplantation (ASCT): Primary Results of the Perseus Trial

Introduction: DARA plus bortezomib, thalidomide, and dexamethasone (D-VTd) quadruplet therapy has shown clinical benefit versus VTd alone and is approved for transplant-eligible pts with NDMM. VRd induction followed by autologous stem cell transplant (ASCT), VRd consolidation, and lenalidomide (R) maintenance is also considered a standard of care for transplant-eligible NDMM. In the phase 2 GRIFFIN study, intravenous DARA combined with VRd (D-VRd) induction/consolidation followed by D-R maintenance improved depth of response and progression-free survival (PFS) versus VRd induction/consolidation and R maintenance in transplant-eligible pts with NDMM after >4 years of follow-up. The phase 3 PERSEUS study is evaluating subcutaneous DARA (DARA SC) in combination with VRd induction/consolidation followed by D-R maintenance versus VRd induction/consolidation and R maintenance in transplant-eligible NDMM. Here we report the primary analysis of PERSEUS. Methods: Pts with NDMM who were aged 18-70 years and eligible for high-dose therapy and ASCT were randomized 1:1 to D-VRd or VRd, stratified by International Staging System (ISS) stage and cytogenetic risk. All pts received up to six 28-day cycles (4 pre-ASCT induction, 2 post-ASCT consolidation) 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 therapy (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 co-formulated with recombinant human hyaluronidase PH20 [rHuPH20; 2,000 U/mL; ENHANZE® drug delivery technology, Halozyme, Inc.]) weekly in Cycles 1-2, every 2 weeks in Cycles 3-6, and every 4 weeks during maintenance until PD. The primary endpoint is PFS; key secondary endpoints include overall complete response or better (≥CR) rate, overall minimal residual disease (MRD)-negativity rate (10-5 threshold; clonoSEQ®), and overall survival. Response and disease progression were assessed using a computerized algorithm based on IMWG response criteria. Overall MRD-negativity rate was defined as the proportion of pts who achieved MRD negativity and ≥CR at any time. Results: 709 pts were randomized (D-VRd, n=355; VRd, n=354). Median (range) age was 60 (31-70) years; 14.8% had ISS stage III disease, and 21.7% had high cytogenetic risk (t[4;14], t[14;16], or del[17p]). At clinical cutoff, 314 pts in the D-VRd arm and 299 pts in the VRd arm had completed all 4 induction and 2 consolidation cycles, 309 and 294 pts had undergone ASCT, and 322 and 300 pts entered maintenance. At a median follow-up of 47.5 months, PFS was significantly improved with D-VRd versus VRd (HR, 0.42; 95% CI, 0.30-0.59; P <0.0001 [crossing the prespecified stopping boundary of 0.0126]; Figure). Median PFS was not reached in either arm; estimated 48-month PFS rates were 84.3% for D-VRd versus 67.7% for VRd. Prespecified subgroup analyses showed a consistent PFS improvement with D-VRd versus VRd across clinically relevant subgroups, including pts with ISS stage III disease and pts with high cytogenetic risk. Overall rates of ≥CR (87.9% vs 70.1%; P <0.0001) and MRD negativity (75.2% vs 47.5%; P <0.0001) were significantly higher with D-VRd versus VRd. Overall survival was immature, with 78 deaths on study (D-VRd, 34 [9.6%]; VRd, 44 [12.4%]). Overall, 7 deaths due to COVID-19 occurred (D-VRd, 4; VRd, 3). The most frequent (≥10%) grade 3/4 treatment-emergent adverse events (TEAEs) for the D-VRd/VRd arms were neutropenia (62.1%/51.0%), thrombocytopenia (29.1%/17.3%), diarrhea (10.5%/7.8%), pneumonia (10.5%/6.1%), and febrile neutropenia (9.4%/10.1%). For D-VRd and VRd, serious TEAEs occurred in 57.0% versus 49.3% of pts, and TEAEs leading to treatment discontinuation occurred in 8.8% versus 21.3% of pts. Conclusions: DARA SC combined with VRd in transplant-eligible pts with NDMM significantly improved PFS and increased depth of response (≥CR and MRD negativity), with consistent PFS benefit across clinically relevant subgroups. The safety profile was consistent with the known safety profiles for DARA SC and VRd. These data, together with results from the phase 2 GRIFFIN study, demonstrate the consistent and clinically meaningful benefit of quadruplet DARA plus VRd followed by D-R maintenance versus triplet VRd followed by R maintenance and support the combination of DARA plus VRd followed by D-R maintenance as a new standard of care for transplant-eligible NDMM.

A prospective, multicenter study on hematopoietic stemcell mobilization with cyclophosphamide plus granulocyte colony-stimulating factor and 'on-demand' plerixafor in multiple myeloma patients treated with novel agents.

High-dose melphalan plus autologous stem cell transplantation (ASCT) is a standard of care for transplant-eligible patients with newly diagnosed multiple myeloma (NDMM), and adequate hematopoietic stem cell (HSC) collection is crucial to ensure hematologic recovery after ASCT. In this prospective, observational study we evaluated HSC mobilization with granulocyte colony-stimulating factor (G-CSF), cyclophosphamide, and 'on-demand' plerixafor (in patients with <20×106 CD34+ cells/L after at least 4 days of G-CSF or failing to collect ≥1×106 CD34+ cells/kg after the first apheresis) in NDMM patients treated with novel agent-based induction therapy. The primary endpoint was the rate of poor mobilizers (patients collecting <2×106 CD34+ cells/kg or requiring plerixafor rescue to reach an adequate HSC harvest). Secondary endpoints included the rate of patients collecting ≥2×106 CD34+ cells/kg after plerixafor administration and the identification of factors predicting mobilization failure or plerixafor need. Overall, 301 patients (median age 60 years) were enrolled. Two hundred and eighty-seven of 301 (95%) and 274 of 301 (93%) patients collected ≥2×106 and ≥4×106 CD34+ cells/kg, respectively, with a median of 9.9×106 CD34+ cells/kg collected. Poor mobilizers were 48 of 301 (16%): 34 of 301 (11%) required plerixafor rescue, and 14 of 301 (5%) failed HSC collection regardless of plerixafor. Thirty-four of 38 (90%) patients receiving plerixafor collected ≥2×106 CD34+ cells/kg. Bone marrow plasmacytosis at diagnosis >60% (odds ratio [OR]=4.14), lenalidomide use (OR=4.45), and grade 3-4 hematologic toxicities during induction (OR=3.53) were independently associated with a higher risk of mobilization failure or plerixafor need. Cyclophosphamide plus G-CSF and 'on-demand' plerixafor is an effective strategy in NDMM patients treated with novel agents, resulting in a high rate of HSC collection and high HSC yield (clinicaltrials gov. identifier: NCT03406091).

Real-World Outcomes of Newly Diagnosed Multiple Myeloma (NDMM) Patients Treated before the Anti-CD38 Antibodies Era in France, the Emmy Cohort 2017 to 2020

Background In randomized clinical trials (RCTs), patients (pts) with comorbidities or a very aggressive presentation of myeloma may be excluded. The results of RCTs may not be generalizable to pts in the real-world setting. Therefore, RCT data need to be backed up by results from real-world studies. Methods EMMY is a non-interventional, prospective study conducted in 73 IFM (Intergroupe Francophone du Myélome) sponsor sites in France. Any patient initiating treatment for multiple myeloma (MM) over a 3-month (mo) period, from October to December, is included, since 2017. It is a dynamic cohort with 900 pts on average, enrolled each year. Here, we present the results of NDMM pts for the first 4 years of inclusion (2017 to 2020). Pts with NDMM who receive front-line therapy with an autologous stem cell transplant (ASCT group) are described separately from non-transplant eligible pts (NTE group). Results 1597 pts with NDMM were included in EMMY over the 2017-2020 period. Of these, 1036 were in the NTE group (64.9%) and 561 in the ASCT group (35.1%). Data are presented with a median follow-up of 23.7 mo (IQR 12.3 - 39.0). ASCT group These pts had a median age of 60.6 years (range 23.4 - 78.5). 5.2 % were older than 70 years at ASCT. In routine practice, cytogenetic tests were carried out for 75.7% of pts, 19.6% of them harboured high-risk (HR) anomalies of t(4;14) or del(17p). The period 2017-2020 was marked by a shift in induction treatment from Velcade Thalidomide dexamethasone (VTd) (n = 163, 29.1% of pts who received ASCT) to Velcade Revlimid dexamethasone (VRd) (n = 309, 55.1%). Fifty-three (9.5%) pts received a double transplantation which was stable over time. 22.8 % of pts with HR anomalies received a double transplant. NTE group The 1036 NTE pts had a median age of 74.9 years (range 33.8 - 97.8), and more than 30.4% (n = 315) were aged ≥ 80 years. Among these pts, 65.9% were considered frail, with 33.6% having an Eastern Cooperative Oncology Group-Performance Status (ECOG-PS) ≥ 2 and almost half (47.1%) had comorbidities. Significant renal impairment (glomerular filtration rate [GFR] &amp;lt; 30 mL/min) was observed in 118 (13%) pts at treatment initiation. A subgroup of 126 younger pts (age &amp;lt; 65 years) was considered ineligible for transplantation. Regarding cytogenetics 56.4% of the pts were tested in regular practice (mean age 73.3 years). NTE pts mostly received three main combinations: VRd (28.4% of pts, n = 294), Velcade Melphalan prednisone (VMp) (21.9% of pts, n = 21.9%) and Revlimid dexamethansone (Rd) (21.1%, n = 219). During the study period, VMp use decreased from 36.9% to 6.5% of pts, VRd use increased from 10.6% to 48.5% and Rd use remained constant, at around 20%. Other bortezomib-based regimens, including Velcade dexamethasone (Vd) and Velcade Cyclophosphamide dexamethasone (VCd), were used steadily, in approximately 12% and 7% of pts, respectively, over the period. Survival data Median progression-free survival (mPFS) was 25.8 mo (95% CI: 23.5-29.1) in the overall NDMM population, 46.5 mo (95% CI: 37.8-50.6) in pts who received ASCT and 18.7 mo (95% CI: 16.3-20.8) in NTE pts ( P &amp;lt; 0.0001). (Figure 1). The median PFS2 (mPFS2) was estimated at 50.6 mo (95% CI: 47.6-NA) in all pts with NDMM. mPFS2 was 36.4 mo (95% CI: 34.7-39.9) in NTE pts; it was not reached in the ASCT group. The median overall survival (OS) had not yet been reached. The estimated OS rate was 72.9% (95% CI: 69.8-75.9) at 48 mo for the total NDMM population. (Figure 2). AE leading to discontinuation. 139 pts experienced an adverse event (AE) leading to treatment discontinuation (6.8 % of ASCT pts and 14.5% in the NTE group). This occurred at a median of 4.3 mo after treatment initiation and was mainly reported with the most used agents (lenalidomide, bortezomib or melphalan). The most frequently reported AEs were neuropathy (n = 14; 10.1%), digestive disorders (n = 13; 9.4%), rash (n = 12; 8.6%), deterioration of general condition (n = 12; 8.6%), cardiovascular AEs (n = 10; 7.2%) and acute renal failure (n = 10; 7.2%). Conclusion The 2017-2020 period for pts with NDMM in France was marked by the expansion of the use of lenalidomide in first line for the majority of pts. A major difference in PFS and OS is still observed between ASCT and NTE pts. A shorter PFS than in IFM2009 trial (PFS 50 mo) was observed in EMMY ASCT pts.