Characteristics and Outcome of Multiple Myeloma Patients Presenting with Anemia Only: a Retrospective Multi-Center Study

Abstract Background: Multiple myeloma (MM) is defined as bone marrow monoclonal plasmocytosis combined with either specific laboratory or imaging findings (SLIM criteria) or one or more of the following myeloma defining events (MDE) including anemia, hypercalcemia, renal failure or lytic bone lesions (CRAB criteria). Patients who presents with anemia but without additional CRAB criteria are scarce, and their clinical course has not yet been characterized in the literature. The current study was designed to evaluate the characteristics, responsiveness to treatment, progression free and overall survival in newly diagnosed MM patients presenting with anemia only. Methods: We retrospectively analyzed the clinical features and outcomes of MM patients that presented with anemia as the only CRAB criteria (i.e. having no evidence of skeletal involvement by PETCT, MRI or total body CT, no renal involvement and no hypercalcemia), that were diagnosed and treated in 9 Israeli and Greek centers between 2010 and 2018. Baseline characteristics at diagnosis, ISS score, treatment regimens, depth and duration of response (by IMWG criteria), hemoglobin (HB) levels during treatment and overall survival (OS) were collected and analyzed. Results: 63 (28 females) patients were included in the analysis. The median age was 72.2 (range 34.4-91.9) years. The median HB level at diagnosis was 9.4 g/l (IQR 6.0-12.0) and median platelets level was 172000 (IQR 59000-454000). The median percent of plasma cells (PCs) in bone marrow at diagnosis was 60% (range 20% to 99%). 11 out of 56 (19%) patients had a high-risk FISH (t 4;14, t 14;16 or del 17p). Bortezomib -based induction was administered in 83%, and upfront autologous hematopoietic stem cell transplantation (autoHCT) was employed in 32%. ORR to 1st line was 87%. 37 (62%) achieved ≥ VGPR, 16 (25%) PR and 7 (13%) SD/PD. Significant predictors for achieving at least VGPR vs. SD or PD were higher albumin level at diagnosis (3.9±0.5 g/l vs. 3.5±0.4g/l, p<0.00), maximal HB level during treatment (13.0±1.0g/l vs. 11.5±1.2 g/l respectively, p<0.00) and maximal improvement in HB level during treatment (median 3.2 [IQR 2.2-4.5]g/l vs 2.2 [IQR 1.1-3.2]g/l, respectively, p<0.00). Median PFS in the entire cohort was 22.1±5.82 months. Predictors for PFS duration on first-line therapy were bone marrow plasmocytosis (HR 1.012 [95% CI 1.001-1.037] p=0.03) and maximal improvement in hemoglobin level (HR 0.71 [95% CI 0.55-0.91] p< 0.00). Multivariate analysis confirmed bone marrow plasmocytosis (HR 1.03 [95% CI 1.01-1.05], p<0.00), higher HB level at diagnosis (HR 0.43 [95% CI 0.27-0.67], p<0.00) and maximal improvement in HB level during therapy (HR 0.37 [95% CI 0.25-0.56] p<0.00) to be associated with longer PFS. In multivariate analysis restricted to non-transplanted patients, factors associated with longer PFS were bone marrow plasmocytosis>60% (HR 4.6 [95% CI 1.5-14.0] p<0.00), HB level at diagnosis (HR 0.32 [95% CI 0.17-0.60], p<0.00), maximal HB improvement (HR 0.23 [95% CI 0.13-0.41] p<0.00) and older age (HR 0.92 [95% CI 0.87-0.97], p<0.00). Within a median follow-up of 34 months, 19 (31%) patients have died; 12 due to PD. The median OS for the entire cohort was 65.93 months and the 3 years mortality rate was 17.5%. Predictors of mortality were high risk cytogenetics (HR 3.01 [95% CI 1.02-8.88] p= 0.04), maximal HB improvement during therapy (HR 0.73, [95% CI 0.54-0.99] p=0.04), and bone marrow plasmocytosis (HR 1.04 [95% CI 1.01 to 1.07] p= 0<.00). Furthermore, median OS for patients <60% plasmocytosis was not reached, compared to 45.3 months for patients with plasmocytosis ≥60% (p=0.048) (figure 1). Only bone marrow plasmocytosis remained as significant factor for mortality in a multivariate analysis (HR 1.04 [95% CI 1.01-1.08], p=0.01). Conclusion: MM patients presenting with anemia only, often have a remarkable bone marrow plasmocytosis Responsiveness to therapy, PFS and OS, depend on the degree of BM plasmocytosis and HB level at diagnosis, both reflecting disease burden. In line with that, response to therapy and long -term PFS can be accurately predicted by the degree of improvement in HB level. In general , patients presenting with anemia only , although they do not have renal impairment or bone disease, seem to have a relatively poor OS of approximately 5 years only , suggesting that these patients may have a relatively "rapidly growing tumor", precluding the development of bone and renal disease. Disclosures No relevant conflicts of interest to declare.

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Multiple Copies of MLL Is The Most Commonly Detected Cytogenetic Abnormality In Newly Diagnosed Multiple Myeloma and May Modify Disease Risk

Blood ◽

10.1182/blood.v122.21.1910.1910 ◽

2013 ◽

Vol 122 (21) ◽

pp. 1910-1910 ◽

Cited By ~ 2

Author(s):

Chrystal Landry ◽

Dory Londono ◽

Sean M. Devlin ◽

Alex Lesokhin ◽

Nikoletta Lendvai ◽

...

Keyword(s):

Multiple Myeloma ◽

Bone Marrow ◽

Overall Survival ◽

Disease Risk ◽

Conflicts Of Interest ◽

Prognostic Significance ◽

Protein Translation ◽

Response To Therapy ◽

Cytogenetic Abnormality ◽

Newly Diagnosed

Abstract Background Multiple myeloma (MM) is a heterogeneous condition with variable disease course, response to therapy, and survival outcome. Cytogenetics and fluorescent in-situ hybridization (FISH) have identified several recurrent chromosomal aberrations in MM and play important and independent roles in risk stratification (Munshi et al. Blood 2011). However, the pathogenesis of the disorder remains poorly understood. Next-generation sequencing has recently identified that MM involves mutations of genes with roles in protein translation, histone methylation, and blood coagulation (Chapman et al. Nature 2011). Based on the observation that extra copies of MLL, a histone methyltransferase known to regulate the homeotic transcription factor HOXA9 that is highly expressed in MM, is frequently detected in MM, we sought to define the incidence and prognostic significance of excess MLL in MM patients. Methods We identified 188 patients with newly diagnosed MM who had cytogenetics and/or FISH performed on initial, pre-treatment bone marrow specimens at Memorial Sloan-Kettering Cancer Center between January 2009 and December 2012. Standard karyotype and FISH were performed as previously described (Cigudosa et al. Blood 1998, Gerritsen et al. Blood 1992). Probes included LSI IgH/FGF3, LSI IgH/CCND1, LSI IgH/MAF, LSI MLL, LSI p53/cep17, LSI13q14.3/13q34, LSI ETV6, LSI CBFB, LSI 1p36/1q25, and LSI 5,9,15 from Abbott Molecular. Fisher's exact test evaluated the association between MLL and selected abnormalities. Kaplan-Meier methodology estimated overall survival from the date of BM evaluation, and survival was compared using a logrank test. Results In unselected bone marrow specimens, abnormalities were detected by karyotype in 17% (27/156) and FISH in 47% (87/186) of patients tested. Hyperdiploidy, which has been associated with longer survival, was identified in 23% (43/187) of patients, while the unfavorable risk abnormalities, including loss of p53, deletion 13q (by karyotype), translocation (4;14) and excess 1q were seen in 8% (15/179), 8% (12/156), 4% (7/176) and 16% (29/178) of patients, respectively. Translocation (11;14) was seen in 4 patients; translocation (14;16) was not identified in any patient. 28% (51/183) of patients had extra copies of MLL, which was the most frequent genetic abnormality identified. Unexpectedly, this abnormality was significantly associated with both favorable (hyperdiploidy, P = <0.001) and unfavorable (deletion 13q, P = 0.043; excess 1q P = 0.001) risk genetics. While having excess MLL had no impact on the overall survival of standard-risk patients, defined as neither hyperdiploid nor with unfavorable genetics (N = 100), patients with poor-risk genetics (N = 46) and extra copies of MLL had a trend toward better survival, P = 0.06 (Figure 1). Conclusions Karyotype and FISH studies identified excess MLL as the most frequent cytogenetic abnormality in a large cohort of newly diagnosed MM patients. In patients with MM and unfavorable cytogenetics, the presence of excess MLL may ameliorate some of the adverse impact of associated with these abnormalities. Understanding the functional significance of excess MLL, perhaps as it relates to frequently dysregulated HOXA9 in MM, may provide insight into disease pathogenesis and/or identify drugable targets. Disclosures: No relevant conflicts of interest to declare.

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Superior Rate of Complete Response with up-Front Velcade-Thalidomide-Dexamethasone Versus Thalidomide-Dexamethasone in Newly Diagnosed Multiple Myeloma Is Not Affected by Adverse Prognostic Factors, Including High-Risk Cytogenetic Abnormalities.

Blood ◽

10.1182/blood.v112.11.1662.1662 ◽

2008 ◽

Vol 112 (11) ◽

pp. 1662-1662

Author(s):

Michele Cavo ◽

Nicoletta Testoni ◽

Carolina Terragna ◽

Giulia Marzocchi ◽

Sandra Durante ◽

...

Keyword(s):

Multiple Myeloma ◽

Bone Marrow ◽

Multivariate Analysis ◽

Prognostic Factors ◽

High Risk ◽

Light Chain ◽

Complete Response ◽

Phase Iii ◽

Newly Diagnosed ◽

Cox Regression Analysis

Abstract Complete response (CR) is an important objective of autologous stem-cell transplantation (ASCT) in multiple myeloma (MM). In comparison with conventional induction treatments, newer combinations of novel agents may effect increased rates of CR and near CR (nCR), a benefit potentially translating into even higher frequencies of CR/nCR after ASCT and improved clinical outcome. We designed a phase III study to detect an increase in CR+nCR rates from 10–15% with conventional Thalidomide-Dexamethasone (TD) to 20–30% with Velcade added to TD (VTD) in newly diagnosed MM. Both TD and VTD were given as three 21-day cycles in preparation for double ASCT. In the present analysis, CR+nCR rates by the two induction treatments were examined in relationship to baseline prognostic variables in 399 evaluable pts aged ≤65 years, of whom 199 randomized to VTD and 200 to TD. All analyses were intent to treat. In comparison with TD, VTD effected higher rates of CR+nCR (12% vs 33%, P<0.001) and of ≥very good partial response (VGPR) (30% vs 61%, P<0.001). By univariate analysis, superiority of VTD to TD was maintained across all sub-group analyses according to standard prognostic factors, including β2-m, albumin, stage (ISS), Hb, PLTs, bone marrow PC, M protein isotype, LDH, CRP. In particular, the rates of CR+nCR with VTD vs TD in pts with standard poor prognostic factors were as follows: ISS stage 3 (23.5% vs 6%, P=0.03), Hb<10 g/dL (24% vs 4%, P=0.002), PLTs<150.000/μL (35% vs 4%, P=0.009), bone marrow PC ≥50% (31% vs 13%, P<0.001), IgA isotype (63% vs 15%, P<0.001), LDH >190 U/L (33% vs 9%, P<0.001), CRP ≥8 mg/L (29% vs 10%, P=0.004). We next examined CR+nCRs by treatment arms in relationship to cytogenetics (FISH data available in 93% to 99% of all pts). Superior CR+nCR rates were effected by VTD vs TD in the presence of high-risk cytogenetics, including del(13) (39% vs 10%, P<0.001), t(4;14) (39.5% vs 10%, P=0.002), combined t(4;14) and del(13) (32% vs 0%, P=0.001), and del(17p) (28.5% vs 0%, P=0.03). Remarkably, when examined in the context of the VTD arm, high-quality response rates were significantly higher for pts carrying del(13) and t(4;14) vs those who lacked these abnormalities [del(13): CR+nCR:39% vs 24%, P=0.03; ≥VGPR: 71% vs 48%, P=0.001] [t(4;14): ≥VGPR:79% vs 55%, P=0.007)]. An opposite trend was noted for pts in the TD arm, whose probability to attain ≥VGPR was adversely affected by the presence of del(13) (P=0.07) and del(17p) (P=0.03). Variables associated with achievement of CR+nCR in the two arms that retained statistical significance when assessed by multivariate Cox regression analysis included randomization to VTD (P<0.001), light chain only subtype (P<0.001), IgA isotype (P<0.001) and Hb>10 g/dL (P=0.01). In the VTD arm, a positive correlation was observed with del(13) (P=0.006) and t(4;14) (P=0.02). Response to first ASCT with melphalan 200 mg/m2 could be evaluated in 297 pts, of whom 145 randomized to VTD and 152 to TD. Randomization to VTD was closely associated with increased CR+nCR rates (54% vs 29% with TD, P<0.001) and remained statistically significant (P<0.001) also in the multivariate analysis. Additional factors predicting for superior post-ASCT CR+nCR rates in the multivariate setting included light chain only subtype (P<0.001) and IgA isotype (P=0.005). We conclude that randomization to up-front VTD was the strongest and independent factor associated with increased rates of CR+nCR before ASCT. Superiority of VTD to TD pertained in both low-risk and high-risk sub-groups, including the traditionally unfavorable sub-groups carrying del(13), t(4,14) and del(17p). Remarkably, in the VTD arm improved postinduction CR+nCR rates were significantly associated with the presence of del(13) and t(4;14) in the multivariate analysis. Benefit from VTD vs TD as primary induction therapy translated into significantly improved CR+nCR rates after the first ASCT and remained statistically significant when assessed by multivariate analysis.

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AL Amyloidosis and Concomitant Myeloma: Time to Reconsider Assumptions

Blood ◽

10.1182/blood.v116.21.4044.4044 ◽

2010 ◽

Vol 116 (21) ◽

pp. 4044-4044

Author(s):

Wesley Witteles ◽

Ronald Witteles ◽

Michaela Liedtke ◽

Sally Arai ◽

Richard Lafayette ◽

...

Keyword(s):

Bone Marrow ◽

Overall Survival ◽

Plasma Cell ◽

Research Funding ◽

Plasma Cells ◽

Renal Involvement ◽

World Health ◽

Bone Lesions ◽

Al Amyloidosis ◽

Bone Marrow Biopsies

Abstract Abstract 4044 Background: Conventionally, multiple myeloma is believed to coexist in approximately 10% of AL amyloidosis patients. However, it is unclear whether this figure is too low based on current World Health Organization criteria. These criteria, mainly created to differentiate myeloma from monoclonal gammopathy of undetermined significance, include the presence of ≥ 10% plasma cells on a bone marrow biopsy or aspirate as being diagnostic of myeloma. Aims: To define the frequency and relevance of a concomitant diagnosis of myeloma in patients with AL amyloidosis. Methods: Records from consecutive patients with biopsy-proven AL amyloidosis treated at the Stanford University Amyloid Center were reviewed. Plasma cell percentages were determined by manual counts from bone marrow aspirate smears and by CD138 immunohistochemistry (IHC) performed on bone marrow core biopsies. Results: A total of 41 patients (median age 61 years, 32% female) were evaluated. The median number of organs involved with amyloidosis was 2 (range 1–4), with 28 patients (68%) having cardiac involvement, 22 patients (54%) having renal involvement, 15 patients (37%) having gastrointestinal involvement, 12 patients (29%) having soft tissue involvement, and 10 patients (24%) having nervous system involvement. All patients had bone marrow biopsies and aspirates performed at the time of amyloid diagnosis, with most undergoing both manual counts of plasma cells from aspirates and IHC from core biopsies. Based on conventional criteria, manual aspirate counts defined 15/28 (54%) patients as having myeloma, and IHC defined 26/31 (84%) patients as having myeloma (p=0.01). Only nine patients had a detectable serum paraprotein on immunofixation (median 1.1 g/dl, range 0.4–2.6). 81% of patients had an elevated serum free light chain (85% lambda), with a median level of 37.3 mg/dl (range 8.6–256 mg/dl). Compared to the frequency of elevated plasma cells, the prevalence of anemia (29%), hypercalcemia (14%), impaired kidney function (21%), and lytic lesions (7%) was low. After a median follow-up of 13 months (range 1–127 months), the one-year overall survival (74% vs. 58%) and three-year overall survival (50% vs. 50%) was not significantly different between patients with ≥10% plasma cells and patients with <10% plasma cells (p=NS). Discussion: As defined by bone marrow plasma cell involvement, a strikingly high percentage (84%) of AL amyloidosis patients would be considered to have concurrent myeloma. This figure is much higher than has been traditionally quoted in the literature, likely due to the utilization of newer methods of counting plasma cells. There was a low prevalence of myeloma-associated end-organ effects (hypercalcemia, anemia, renal insufficiency, lytic bone lesions), and a myeloma diagnosis had no impact on survival. Conclusion: In this cohort of AL amyloid patients, concomitant myeloma was present in the vast majority of patients using modern diagnostic techniques. The significance of this diagnosis appears to be minimal – calling into question whether the diagnostic criteria for myeloma should be redefined in this population. Disclosures: Witteles: Celgene: Research Funding. Liedtke:Celgene: Lecture fee, Research Funding. Schrier:Celgene: Research Funding.

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Rising Plasma Cell Proliferation By Ki67/CD138 Ratio at Relapse Is a Marker of High Risk Disease in Multiple Myeloma

Blood ◽

10.1182/blood.v126.23.2991.2991 ◽

2015 ◽

Vol 126 (23) ◽

pp. 2991-2991

Author(s):

Peter A. Forsberg ◽

Tomer M Mark ◽

Sujitha Yadlapati ◽

Adriana C Rossi ◽

Roger N Pearse ◽

...

Keyword(s):

Multiple Myeloma ◽

Bone Marrow ◽

Cell Proliferation ◽

Overall Survival ◽

High Risk ◽

Plasma Cell ◽

Plasma Cells ◽

Initial Therapy ◽

First Line ◽

High Risk Disease

Abstract Background: Assessment of malignant plasma cell cycling via plasma cell labeling index (PCLI) has been a validated prognostic tool in multiple myeloma (MM) for years but utilization remains limited. We recently developed a novel immunohistochemical (IHC) co-staining technique for CD138 and Ki67 expression to quantify plasma cells in active cycling. Previously presented results from newly diagnosed patients demonstrate that having an elevated ratio of plasma cells in active cycle by co-expression of CD138 and Ki67 (>5%) is associated with aggressive disease and poor outcomes including shorter overall survival (OS). The expansion of subclones with higher proliferative capacity following initial therapy may be an indicator of a higher risk relapse event and indicate poor prognosis. Here we assess MM patients (pts) with Ki67/CD138 co-staining on bone marrow samples both at diagnosis and relapse to assess the impact of changes in cell cycling ratio on outcomes with subsequent therapy and overall clinical course. Methods: A retrospective cohort study of pts with treated symptomatic MM was performed by interrogation of the clinical database at the Weill Cornell Medical College / New York Presbyterian Hospital (WCMC/NYPH). For inclusion in the analysis, pts must have had bone marrow evaluation with double-staining for Ki67 and CD138 by immunohistochemistry both at diagnosis and relapse. Pts must have completed their first line and relapse treatments at WCMC/NYPH. The Ki67% was calculated as the ratio of plasma cells expressing CD138 that were also found to express Ki67. Treatment outcomes were stratified and compared based on alterations in Ki67% between diagnosis and relapse. Results: We identified 37 pts with bone marrow sampling that was evaluated for CD138 and Ki67 co-expression both at diagnosis and at the time of relapse. These pts had undergone a median of 2 lines of prior treatment at the time of relapse bone marrow biopsy (range 1-7). 19 pts were identified to have a rising Ki67% between diagnosis and relapse defined at a 5% or greater increase, the other 18 pts had stable or decreased Ki67%. Pts with a rising Ki67% at relapse had a shorter OS with a median of 72 months vs not reached (p=0.0069), Figure 1. Pts who had rising Ki67% at relapse had shorter progression free survival (PFS) on first line treatment with a median of 25 vs 47 months (p=0.036), Figure 2. Additionally pts with rising Ki67% had a trend towards shorter PFS with the treatment they received after relapse with median of 12.5 vs 3.5 months (p=0.09). Relapse regimens were most commonly carfilzomib (n=9), pomalidomide (5) or ixazomib (4) based. 37% of pts (7/19) with rising Ki67% achieved PR or better on relapsed treatment vs 67% (12/18) with stable Ki67%. Discussion: The presence of clonal evolution and selection of higher risk clones under therapeutic pressure in multiple myeloma is a key feature of disease progression. The ability to improve risk stratification at the time of relapse may help guide clinical decision making to best suit individual patient needs. We have identified rising plasma cell proliferation through quantification of Ki67/CD138 co-expression at relapse to be a useful marker of high risk disease evolution. This appears to help identify the emergence of higher risk clones which are ultimately responsible for treatment resistant disease. Patients with rising Ki67% were more likely than patients with stable Ki67% to have early relapses to initial therapy, were less likely to achieve responses to relapse regimens or to maintain their response and had shorter overall survival. Further evaluation is needed to identify if different approaches to patients with increasing proliferation may improve outcomes in these patients. Figure 1. Figure 1. Figure 2. Figure 2. Disclosures Mark: Calgene: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau. Rossi:Calgene: Speakers Bureau. Pearse:Celegen: Consultancy. Pekle:Celgene: Speakers Bureau; Takeda: Speakers Bureau. Perry:Celgene: Speakers Bureau; Takeda: Speakers Bureau. Coleman:Celgene: Speakers Bureau; Takeda: Speakers Bureau. Niesvizky:Celgene: Consultancy, Speakers Bureau.

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Prognostic Value of Bone Marrow Angiogenesis in Newly Diagnosed Multiple Myeloma: A Comparison with Conventional Prognostic Factors.

Blood ◽

10.1182/blood.v106.11.5111.5111 ◽

2005 ◽

Vol 106 (11) ◽

pp. 5111-5111

Author(s):

Shaji Kumar ◽

Jessica L. Haug ◽

Linda Wellik ◽

Thomas E. Witzig ◽

John A. Lust ◽

...

Keyword(s):

Multiple Myeloma ◽

Bone Marrow ◽

Overall Survival ◽

Multivariate Analysis ◽

Prognostic Factors ◽

Prognostic Value ◽

Staging System ◽

Continuous Variable ◽

Newly Diagnosed ◽

Grade Group

Abstract Background: Abnormally increased tumor associated neovasculature plays an important role in tumor progression in solid tumors and hematological malignancies. In multiple myeloma (MM) bone marrow angiogenesis, measured in terms of microvessel density (MVD), has prognostic value, and appear to increase with disease progression from monoclonal gammopathy of undetermined significance to relapsed MM. We have shown that MVD has prognostic value in patients with newly diagnosed MM including patients undergoing upfront high dose therapy and stem cell transplantation, but comparison with other known prognostic factors has been limited by sample size. It is also not known whether the MVD adds prognostic value once the recently described International Staging System (ISS) is applied. The goal of this study was to determine the prognostic effect of bone marrow MVD in newly diagnosed MM relative to the ISS and other known prognostic factors. Methods: We studied 400 patients with newly diagnosed MM seen at the Mayo Clinic between March of 1988 and December 2001. Sections from bone marrow biopsy blocks from the time of initial diagnosis were studied by immunohistochemistry using antibodies against CD34 antigen to high light the endothelial cells. Under low power (100X); three areas with maximum number of microvessels (hotspots) were identified. Each of these areas was further studied at 400X magnification and the number of microvessels per high power field counted. The average of the three readings was taken as the MVD for the sample. In addition, the samples were graded as low, intermediate or high by using a visual estimate as previously described. Additional clinical data was extracted from medical records. Some of the patients have been included in previous studies related to angiogenesis. Results: A total of 400 patients in whom a bone marrow biopsy from within 30 days of diagnosis was available were studied. The pts were followed for a median of 37 months (Range: 1 month to 16.5 years) and 318 pts (80%) had died at the time of this analysis. The median MVD for the entire group was 14.7 (Range 0–168). The median overall survival for the three groups according to the MVD grade was lower for the high grade group (31.9 months) compared to the intermediate grade group (37.2 months) and the low grade group (not reached); P <0.029, log rank test. We examined this group of patients for other factors prognostic for overall survival. Factors significant on univariate analysis included ISS stage, platelet count (<150 vs. >= 150 X 106/L), and plasma cell labeling index (<1 vs >=1). In a multivariate analysis using these variables and MVD as a continuous variable, high MVD and the ISS staging system were significantly associated with poorer survival (Table). Conclusion: In this large group of pts with newly diagnosed MM, we confirm the prognostic value of increased bone marrow angiogenesis. We examined the MVD as a continuous variable in the multivariate analysis for a closer evaluation of this measure in this comparison. More importantly, the prognostic value appears to be independent of the ISS and other major prognostic factors. The resultsof this study reinforces the biological relevance of this finding in MM. HR 95% CI P value MVD 1.006 (1.001, 1.011) 0.0279 ISS Stage I 0.37 (0.25, 0.56) <0.001 ISS Stage II 0.58 (0.41, 0.83) 0.0025

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Cytogenetic Analysis and Correlation Study in Prognosis of Patients with Multiple Myeloma

Blood ◽

10.1182/blood.v120.21.5006.5006 ◽

2012 ◽

Vol 120 (21) ◽

pp. 5006-5006

Author(s):

Chengcheng Fu ◽

Xue Xin ◽

Wu Depei

Keyword(s):

Multiple Myeloma ◽

Bone Marrow ◽

Chromosome Aberration ◽

Conflicts Of Interest ◽

Response To Therapy ◽

Chromosome 1 ◽

Banding Technique ◽

Hematopoietic Stem ◽

The Impact ◽

Abnormal Group

Abstract Abstract 5006 Multiple myeloma (MM) is a fatal neoplasm characterized by the accumulation of malignant plasma cells within the bone marrow (BM) and the presence of a monoclonal immunoglobulin in the serum and/or urine, it was reported that patients with abnormal metaphases by conventional cytogenetics at diagnosis had active disease and a reduced survival rate compared with those normal metaphase. To further explore the cytogenetic characteristics of multiple myeloma and its correlation with clinical treatment and prognosis, 38 cases of MM were collected and chromosome specimens of bone marrow cells were prepared by 24-hour culture. R-banding technique combined with interphase fluorescence in situ hybridization(i-FISH) was used for karyotype analysis. The impact of different treatments and chromosome aberrations on progression-free survival(PFS) and overall survival(OS) time as well as related prognosis factors of MM were analyzed. The detected total chromosome aberration rate was 34. 2% (13/38), with chromosome complex aberration 53. 8%(7/13). The detection rate of R-banding technique was 23. 7%(9/38) and 21. 1%(8/38) by FISH. The most frequent chromosome aberration was chromosome 1 abnormality. The median PFS time of abnormal group was 16 months and was not reached of normal group after median follow up for 36 months(P=0. 045). Also, the median PFS time of complex abnormal group was 15 months, and the median PFS time of non-complex abnormal group was not reached(P=0. 012). The median OS time of complex abnormal group was 22 months and the median OS time of non-complex abnormal group was not reached(P=0. 041). Boretizomib or autologous hematopoietic stem cell transplantation prolonged the PFS and OS of the chromosome aberration group compared with traditional chemotherapy, but there were no significant statistical differences between the two groups(P>0. 05). It was concluded that chromosome complex aberration is the mainly cytogenetic characteristics of multiple myeloma, and multiple numerous and structural aberrations are involved. The patients with chromosome complex aberration have poor prognosis. Chromosome abnormalities detected in metaphases from multiple myeloma (MM) cells have a clear impact on prognosis and response to therapy. Techniques to explore cytogenetic and molecular genetic changes of myeloma cells should be used to improve chromosomal aberration detection to guide clinical treatments and evaluate prognosis. Disclosures: No relevant conflicts of interest to declare.

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Extramedullary Multiple Myeloma Associated With Reduced Overall Survival: A Retrospective Single-Center Study

Blood ◽

10.1182/blood.v122.21.5317.5317 ◽

2013 ◽

Vol 122 (21) ◽

pp. 5317-5317 ◽

Cited By ~ 1

Author(s):

Ido Barkay ◽

Richard T. Maziarz ◽

Andy I. Chen ◽

William Dibb ◽

Yiyi Chen ◽

...

Keyword(s):

Multiple Myeloma ◽

Overall Survival ◽

Multivariate Analysis ◽

High Risk ◽

Staging System ◽

Novel Agents ◽

Cell Transplant ◽

Disease Characteristics ◽

Staging Systems ◽

Risk Patients

Abstract Introduction Multiple Myeloma (MM) is an incurable neoplasm, however recent advancements in therapies have led to median overall survival of 7-10 years in standard risk patients. High risk patients still succumb to the disease within 3 to 5 years. Traditionally used clinical prognostic markers such as the International Staging System (ISS), the Durie-Salmon (DS) staging system, and cytogenetics do not adequately predict response to novel agents or overall prognosis. We previously presented data identifying high risk sub-groups that succumb to shorter progression free survival (PFS) and overall survival (OS) after hematopoietic stem cell transplant (HSCT). Extramedullary disease (EMD) was a highly significant risk factor for poor survival. Methods A retrospective single institution cohort study was performed of 251 patients who underwent HSCT for MM between 1/1/2001 and 12/31/2011. Of these 251 patients, 18 were identified as having EMD, which was defined by the presence of ≥ 2 plasmacytomas in organs other than bone marrow or bone at any stage of disease. Data points collected included patient and disease characteristics, ISS and DS stage, cytogenetics and FISH, induction therapy, type and number of HSCT, treatment type and cycles, as well as maintenance therapy. Outcome measures included overall response rate (ORR), PFS and OS. Descriptive statistical analysis was conducted for all primary and secondary endpoints. Univariate and multivariate analysis were conducted using the Cox proportional hazards regression model. Results Patients with EMD represented 6.6% of our total population. Patient and disease characteristics are found in table 1. Seven of 18 patients had died by the time of data collection. With a median follow up time of 29 months, the median PFS and OS for the entire group (n= 251) compared to the EMD group (n= 18) were PFS: 22.3 months (95% CI 19.75 – 30.32) vs. 12.9 and OS: 57.3 months (95% CI: 46.52 - 77.77) vs. 17.2 (Figs 1 and 2). Results of univariate and multivariate analysis are in table 2. Conclusion Extramedullary multiple myeloma represents a small but highly aggressive subgroup of multiple myeloma. It prevails as a poor prognostic indicator despite the use of novel agents, yet it is not included in traditionally used staging systems. Further confirmatory studies are needed, and likely, new therapeutic approaches will be required for MM patients with EMD. Disclosures: Chen: Genzyme: supported database used for this study Other. Scott:Millenium Pharmaceuticals: Membership on an entity’s Board of Directors or advisory committees, Research Funding.

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Outcome of Autologous Hematopoietic Stem Cell Transplantation in Relapsed and Refractory Multiple Myeloma

Blood ◽

10.1182/blood.v128.22.4626.4626 ◽

2016 ◽

Vol 128 (22) ◽

pp. 4626-4626

Author(s):

Lauren Westfall Veltri ◽

Denái R. Milton ◽

Nina Shah ◽

Krina Patel ◽

Yago Nieto ◽

...

Keyword(s):

Multiple Myeloma ◽

Overall Survival ◽

Stem Cell ◽

High Risk ◽

Hematopoietic Stem Cell Transplantation ◽

Stem Cell Transplantation ◽

Progression Free Survival ◽

Hemoglobin Level ◽

Hematopoietic Stem ◽

Free Survival

Abstract Introduction: Despite the introduction of highly effective novel agents, the outcome of patients with relapsed and refractory multiple myeloma (RRMM) remains poor, particularly in those with disease refractory to both proteasome inhibitors (PI) and immunomodulatory agents (IMiDs). Limited available data suggests that autologous hematopoietic stem cell transplantation (auto-HCT) may be an effective therapy in this patient population. Methods: We retrospectively analyzed all patients with RRMM who underwent first auto-HCT at our center between March 2000 and October 2015. RRMM was defined as never achieving a response (stable disease [SD]) or having progressed while on therapy or within 60 days after discontinuation of therapy. Patients with disease refractory to at least one PI and at least one IMiD either in combination or administered separately were classified as double refractory (DR-MM). Results: 233 patients with RRMM were identified. Of these, 105 (45%) had DR-MM. The remaining 128 (55%) patients were classified as refractory (R)-MM and included all patients with RRMM but without history of being double refractory. Median age at auto-HCT was 59 years (DR-MM 60 vs. 56 years in R-MM, p=0.005). High-risk cytogenetics (IMWG criteria) were noticed in 67 of 140 (48%) patients (DR-MM, 35/89 [39%] vs. R-MM, 32/51 [63%], p=0.009). Median number of prior lines of therapy was 2 (range 1 - 7) (DR-MM, 2 (1 - 7) vs. R-MM, 1 (1 - 5), p<0.001). Eighty-two (35%) patients received induction with triplet chemotherapy regimens (DR-MM, n=55 [52%] vs. R-MM, n=27 [21%], p<0.001). Chemomobilization was used in 94 (40%) patients (DR-MM, n=54 [51%] vs. R-MM, n=40 [31%], p=0.002). Median time from diagnosis to auto-HCT was 9.4 months (DR-MM 12 vs. 8 months in R-MM, p<0.001). Conditioning regimen consisted of melphalan alone in 168 (72%) and various combinations with melphalan in 65 (28%) patients with no significant difference between DR-MM and R-MM. Maintenance therapy was used in 113 (49%) patients (DR-MM, n=63 [60%] vs. R-MM, n=50 [39%], p=0.001). With a median follow up of 36 months post auto-HCT, at least partial response was seen in 188 (81%) patients (DR-MM, n=83 [79%]; R-MM, n=105 [82%], p=0.50). Near complete remission or better was seen in 52 (22%) patients (DR-MM, n=25 (24%); R-MM, n=27 (21%), p=0.64). The cumulative incidence of non-relapse mortality (NRM) at day 100 and 6 months was 1% and 2% (DR-MM, 0% and 1%; R-MM 2% each at day 100 and 6 months, p=0.56), respectively. The median progression-free survival (PFS) was 17.6 months (14.4 months in the DR-MM and 18.2 months in the R-MM, p=0.40) (Figure 1). Median overall survival (OS) was 48 months (39 months in DR-MM and 57 months in R-MM, p=0.27) (Figure 2). When accounting for other significant measures (i.e., hemoglobin level and β2 microglobulin), having high-risk chromosomal abnormalities was significantly associated with worse PFS (p=0.006) while worsening of PFS for patients with ISS stage II or III disease approached significance (p=0.06). A significant association between OS and hemoglobin level, β2 microglobulin, high risk cytogenetics, ISS stage, and induction treatment was observed, however, none of these measures remained significant in the multivariable model. Conclusions: Our findings highlight that auto-HCT is an effective and safe therapy in patients with RRMM including those who are refractory to an IMiD and PI Figure 1 Progression Free Survival Figure 2. Overall Survival Figure 1. Progression Free Survival Figure 2. Overall Survival Figure 2 Figure 2. Disclosures Ciurea: Cyto-Sen Therapeutics: Equity Ownership; Spectrum Pharmaceuticals: Other: Advisory Board.

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Outcomes of 252 Patients with High Risk Multiple Myeloma Treated with Hematopoietic Stem Cell Transplantation: Identification of Risk Factors Associated with Early Relapse, Shortened Progression Free and Overall Survival

Blood ◽

10.1182/blood.v120.21.3957.3957 ◽

2012 ◽

Vol 120 (21) ◽

pp. 3957-3957

Author(s):

Emma C. Scott ◽

Stephen D. Smith ◽

Andy I. Chen ◽

Nicky Leeborg ◽

Tarunpreet Bains ◽

...

Keyword(s):

Multiple Myeloma ◽

Overall Survival ◽

Stem Cell ◽

High Risk ◽

Hematopoietic Stem Cell ◽

Chromosome 1 ◽

Cell Transplant ◽

Hematopoietic Stem ◽

Factors Associated ◽

Secondary Endpoints

Abstract Abstract 3957 Currently used clinical prognostic markers for patients with multiple myeloma (MM) such as the international staging system (ISS) and cytogenetics are inadequate predictors of response and survivorship after hematopoietic stem cell transplant (HSCT). Recently published large studies of HSCT as consolidation after primary therapy have demonstrated 3-year progression free survival (PFS) and overall survival (OS) rates of 45% and 78% respectively after tandem HSCT (BMT CTN 0102; Krishnan, Lancet Onc, 2011) and median time to progression of 46 and 27 after single autologous transplant, with and without lenalidomidemaintenance (CALGB 10104; McCarthy, NEJM, 2012). These studies (which include patients in the current cohort) have established expected PFS and OS benchmarks that allow identification of higher risk subsets. The aim of this study is to describe and further sub- stratify patients with high-risk myeloma (HRMM), with the goal to identify ‘higher’ risk groups that may benefit from alternative treatment strategies. Methods: A retrospective cohort study of HRMM patients who received an HSCT at OHSU between 01/01/2001 and 12/31/2011 was performed. We defined HRMM by the following: FISH and cytogenetic findings of del17p, t(4:14), t(14;16), t(14;20), chromosome (ch) 1 abnormalities, del 13q by cytogenetics; the presence of multiple extra-medullary plasmacytomas; plasmablastic morphology; higher ISS categories (II and III); Salmon- Durie(S-D) stages 2 and 3; recurrence or less than a partial remission (PR) to 2 consecutive lines of therapy prior to HSCT. Outcome measures included PFS and OS. Descriptive statistical analysis was conducted for all primary and secondary endpoints, patients' individual and clinical characteristics, and gene profiles. Kaplan-Meier method was used to estimate the OS and PFS function. Log-rank test was used to assess whether the survival function differs across the groups. Factors that are significantly associated with the primary and secondary endpoints were identified using univariateanalysis. Multivariate analysis is ongoing. Results: Patient and HSCT characteristics are found in table 1. With a median follow up of 40 months, relapse occurred in 127 patients, of which 77 (60%) occurred within 18 months post HSCT. Median PFS and OS are 22.3 (95% CI: 19.7 – 29.3) and 56.67 (95% CI: 40.1–69.9) months respectively. The 2-year PFS and OS rates were 47%, and 72% respectively. Univariate data analysis revealed the following factors that are highly associated with reduced PFS: del 17p (2- year PFS 26.2%; p= 0.09); ch 1 abnormalities (27.4%; p=0.0026); recurrence or < PR after 2 consecutive lines of chemotherapy prior to HSCT (27.5%; p= 0.07). For patients with chromosome 1 abnormalities, the presence of del 13q by cytogenetics further decreased the PFS (22%; p= 0.04;)(Figure 1). Factors associated with highly with a reduced OS are: ch 1 abnormalities (2-year OS 52.5%; p=0.0042); both chromosome 1 and del13q (46.2%; p=0.0016) and having multiple extra-medullary plasmacytomas (55.2%; p= 0.026 (Figure 2). Conclusion: Within the broad group of HRMM, certain groups have significantly inferior outcomes post HSCT, the worst being those with recurrence or < PR to 2 consecutive lines of chemotherapy prior to HSCT, those with any ch 1 abnormality and particularly those with additional del 13q by cytogenetics. Investigation of novel therapeutic and more aggressive strategies is warranted in these groups. Disclosures: Scott: Genzyme: Research Funding; Millenium: Speakers Bureau.

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Treosulfan Conditioning for Allogeneic Transplantation in Multiple Myeloma Improved Overall Survival in Upfront Hematopoietic Stem Cell Transplantation — a Large Retrospective Study By the Chronic Malignancies Working Party of the EBMT

Blood ◽

10.1182/blood-2018-99-114402 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 3464-3464

Author(s):

Charlotte Gran ◽

Junfeng Wang ◽

Hareth Nahi ◽

Linda Koster ◽

Goesta Gahrton ◽

...

Keyword(s):

Multiple Myeloma ◽

Overall Survival ◽

Multivariate Analysis ◽

Stem Cell ◽

Hematopoietic Stem Cell Transplantation ◽

Relapse Rate ◽

Research Funding ◽

Myeloablative Conditioning ◽

Hematopoietic Stem ◽

Significant Difference

Abstract Background Allogeneic hematopoietic stem cell transplantation (AlloSCT) for treatment of multiple myeloma (MM) is controversial mainly due to high non-relapse mortality (NRM) with myeloablative conditioning. However, AlloSCT is probably the only treatment that result in cure of a small fraction of patients. Treosulfan is a prodrug of a bifunctional alkylating agent which has both myelotoxic and immunosuppressive properties. Conditioning regimes with treosulfan have been tried in various hematologic neoplasia such as AML and MDS indicating low NRM and increased progression free survival (PFS). Previous studies on use of treosulfan condition in AlloSCT for MM indicated feasibility, stable engraftment and low NRM. In the present study we have analysed the results of low and high dose treosulfan respectively on OS, RFS, relapse incidence and NRM as well as results of Treosulfan conditioning compared to non-Treosulfan reduced intensity conditioning (RIC) and non-Treosulfan myeloablative conditioning (MAC). Patients and Methods We conducted a retrospective analysis of 4544 patients with MM undergoing AlloSCT 2008-2016 reported to the EBMT data registry. Out of 537 patients receiving Treosulfan based conditioning the impact of dose could be analysed in 441. Three hundred and twenty-seven patients received a total dose of >36g/m2 and 114 <=36g/m2.These patients were compared to 2830 patients receiving RIC, and 1177 receiving MAC. 1103 patients were transplanted upfront and 3441 patients in later lines following relapse/progression. Patient characteristics shown in table 1. Results The 5-year OS in upfront Treosulfan conditioned patients was 62%, which was significantly superior to both non-Treo RIC and MAC patients respectively, apparently due to a tendency for lower NRM (10%) albeit a higher relapse rate (Table 2). Patients in later lines of conditioning had either low NRM (3rd line) or no significant difference (2nd line) (Table 2). Heterogeneity in the material makes it difficult to interpret results in the patients transplanted late in the course of the disease. A higher total treosulfan dose, >36g/m2, showed a tendency for improved OS and RFS compared to the lower dose treosulfan as well as RIC and MAC (table 2) respectively. In multivariate analysis of upfront transplanted patients, with a model adjusted for ISS score at diagnosis, age, Karnofsky score, response at AlloSCT, interval between diagnosis and transplant, donor type and donor - patient sex match, treosulfan and RIC retained significance for OS, HR 0.57 (P=0.006) and RFS, HR 0.65 (P=<0.005). For 2nd line Treosulfan RFS was significantly worse, HR 1.46 (P=<0.005) while there was no significant difference for OS between conditioning regimes in 2nd or for OS and RFS in 3rd line (table 2). The factors associated with most inferior OS in upfront line of conditioning was Karnofsky <90 and ISS score III at diagnosis. ISS score III at diagnosis was also associated with inferior OS also in 2nd and 3rd line (Table 2) A less then partial response at AlloSCT was consistently a factor associated with inferior RFS regardless of line of treatment with HR 1.67 (P=<0.005) in upfront, HR 1,63 (P=<0.005) in 2nd line and HR 1,66 (P=<0.005) for 3rd line or later (Table 2) In multivariate analysis of treosulfan based conditioning regimes, upfront line of conditioning was superior for OS, PFS and relapse as expected (Table 3). Notably was an increased hazard ratio for donor-patient sex match other than female to male in OS, PFS as well as relapse, HR 1.64 (P=0.02), HR 1.66 (P=0.004) and HR 1.83 (P=0.003) respectively (Table 3). Conclusions Conditioning upfront with Treosulfan containing regimens for AlloSCT in multiple myeloma, is associated with a superior overall survival and a low NRM, however with a slightly higher relapse rate compared to other regimens. A higher dose > 36g/m2 tends to further improve OS, RFS and relapse rate without increasing NRM. The better results of Treo conditioning in female to male transplants as compared to other sex combinations and in contrast to MAC transplants may be due to the overall lower NRM with treosulfan, thus utilizing the GVM more effectively as indicated by the trend for lower relapse rate. In conclusion, Treosulfan containing regimens appear to be of value in upfront AlloSCT. Prospective studies on Treosulfan conditioning are warranted to further define the best dosing in MM AlloSCT. Disclosures Niederwieser: Miltenyi: Speakers Bureau; Novartis: Research Funding. Beelen:Medac: Consultancy, Other: Travel Support. Stelljes:Pfizer: Consultancy, Honoraria, Research Funding; MSD: Consultancy; JAZZ: Honoraria; Amgen: Honoraria; Novartis: Honoraria. Finke:Novartis: Consultancy, Honoraria, Other: travel grants, Research Funding; Medac: Consultancy, Honoraria, Other: travel grants, Research Funding; Neovii: Consultancy, Honoraria, Other: travel grants, Research Funding; Riemser: Consultancy, Honoraria, Research Funding. Garderet:Amgen: Consultancy; Celgene: Consultancy; Takeda: Consultancy. Kroeger:Celgene: Honoraria, Research Funding; Riemser: Honoraria, Research Funding; JAZZ: Honoraria; Novartis: Honoraria, Research Funding; Sanofi: Honoraria; Neovii: Honoraria, Research Funding.

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