Outcomes of Autologous Transplantation for Treatment-Related AML and MDS in Previously Treated Multiple Myeloma Patients (pts)

Abstract Introduction: Therapy related myelodysplastic syndrome (t-MDS) and acute myeloid leukemia (t-AML) are significant long-term complications of MM treatment. We have treated pts on standard therapy protocols including TT2, TT3, TT4 and TT5. These protocols include an induction, tandem melphalan-based ASCT and consolidation, followed by three years of maintenance. As a part of the protocols, multiple bone marrow examinations including metaphase cytogenetics are performed at regular intervals, giving us the unique opportunity to examine the development of t-MDS/t-AML and understand the efficacy of subsequent treatment. Here we investigate the outcome of t-AML and t-MDS treated with autologous stem cell transplantation (ASCT) in MM patients. Materials and Methods, Results: During the period between 1998 to 2015, a total of 1558 pts were treated for MM with standard therapy protocols. We identified 68 pts out of 1558 who developed t-AML + t-MDS. Thirty-one had a confirmed diagnosis of t-AML, and thirty-seven had a diagnosis of t-MDS. The median age at diagnosis was 60 years (range 45-76). The median time from diagnosis MM of t-AML and t-MDS was 66 months (range, 9.6-155.4) and 63 months (range, 8-130), respectively. Baseline cytogenetics were as follows: complex cytogenetics in 34 pts out of 68, del(7) in 24 pts, del(5) in 17 pts, and del(17p) in 5 pts. Eighteen out of thirty-one t-AML pts were treated with ASCT. The remaining 13 pts did not receive ASCT. The treatment related mortality (TRM) at day100 (D100) in the ASCT group was 33% (6/18 pts). Neutrophil and platelet engraftment was achieved in all 18 pts by D21. Complete remission was achieved in 50% (9 out of 18) of pts. When we compared pts who received ASCT to those who were treated with chemotherapy only, the median overall survival (OS) was 11.28 months after ASCT vs 1.32 months without ASCT (p < 0.05). Nineteen out of thirty seven t-MDS pts were treated with ASCT. When we compared pts who received ASCT to chemotherapy only for t-MDS, there was no difference in survival between the groups. A mortality rate of 47% (9/19) was recorded at D200 after transplantation due to severe infections and lack of engraftment. Conclusion: t-AML and t-MDS treatment is a significant therapeutic challenge for the elderly, who often have poor risk cytogenetic markers, significant comorbidities and a compromised performance status. In our case series of post MM therapy t-AML, ASCT prolonged survival. In contrast, there was no change in survival of t-MDS pts, most likely due to high rate of infectious complications seen in this group. To our knowledge, this is the first analysis suggesting a survival benefit from ASCT in treating t-AML. Although the numbers in our study are small, we recommend that ASCT can be safely considered for t-AML patients who are physically fit, have autologous stem cells in storage and are overseen by a good supportive care team. These results need to be validated in large prospective studies. Disclosures Atrash: University of Arkansas for Medical Sciences: Employment. Barlogie:Millennium: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; European School of Haematology- International Conference on Multiple Myeloma: Other: Travel Stipend; ComtecMed- World Congress on Controversies in Hematology: Other: Travel Stipend; International Workshop on Waldenström's Macroglobulinemia: Other: Travel Stipend; Dana Farber Cancer Institute: Other: Travel Stipend; Multiple Myeloma Research Foundation: Other: Travel Stipend; Myeloma Health, LLC: Patents & Royalties: Co-inventor of patents and patent applications related to use of GEP in cancer medicine licensed to Myeloma Health, LLC. Zangari:Onyx: Research Funding; Novartis: Research Funding; Millennium: Research Funding; University of Arkansas for Medical Sciences: Employment. van Rhee:University of Arkansa for Medical Sciences: Employment. Waheed:University of Arkansas for Medical Sciences: Employment. Bailey:University of Arkansas for Medical Sciences: Employment. Petty:University of Arkansas for Medical Sciences: Employment. Heuck:Celgene: Consultancy; Janssen: Other: Advisory Board; Millenium: Other: Advisory Board; Foundation Medicine: Honoraria; University of Arkansas for Medical Sciences: Employment. Morgan:Bristol Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; MMRF: Honoraria; Weismann Institute: Honoraria; CancerNet: Honoraria; University of Arkansas for Medical Sciences: Employment; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees. Jethava:University of Arkansas for Medical Sciences: Employment.

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High Risk Multiple Myeloma Demonstrates Marked Spatial Genomic Heterogeneity Between Focal Lesions and Random Bone Marrow; Implications for Targeted Therapy and Treatment Resistance

Blood ◽

10.1182/blood.v126.23.20.20 ◽

2015 ◽

Vol 126 (23) ◽

pp. 20-20 ◽

Cited By ~ 5

Author(s):

Niels Weinhold ◽

Shweta S. Chavan ◽

Christoph Heuck ◽

Owen W Stephens ◽

Ruslana Tytarenko ◽

...

Keyword(s):

High Risk ◽

Board Of Directors ◽

Research Funding ◽

Advisory Board ◽

Driver Mutations ◽

University Of Arkansas ◽

Medical Sciences ◽

Clonal Heterogeneity ◽

Advisory Committees ◽

Site Specific

Abstract Introduction: Recent next generation sequencing studies have defined the mutation spectrum in multiple myeloma (MM) and uncovered significant intra-clonal heterogeneity, showing that clinically relevant mutations are often only present in sub-clones. Longitudinal analyses demonstrated that tumor clones under therapeutic pressure behave in a "Darwinian" fashion, with shifting dominance of tumor clones over time. Recently, stratification of clonal substructures in distinct areas of the tumor bulk has been shown for multiple cancer types. So far, spatial genomic heterogeneity has not been systematically analyzed in MM. This stratification in space is becoming increasingly important as we begin to understand the contribution of Focal Lesions (FL) to tumor progression and emergence of drug resistance in MM. We have recently shown that high numbers of FL are associated with gene expression profiling (GEP) defined high risk (HR). A comparison of GEP data of 170 paired random bone marrow (RBM) and FL aspirates showed differences in risk signatures, supporting the concept of spatial clonal heterogeneity. In this study we have extended the analysis by performing whole exome sequencing (WES) and genotyping on paired RBM and FL in order to gain further insight into spatial clonal heterogeneity in MM and to find site-specific single nucleotide variant (SNV) spectra and copy number alterations (CNA), which contribute to disease progression and could form the basis of adaptation of the tumor to therapeutic pressure. Materials and Methods: We included 50 Total Therapy MM patients for whom paired CD138-enriched RBMA and FL samples were available. Leukapheresis products were used as controls. For WES we applied the Agilent qXT kit and a modified Agilent SureSelect Clinical Research Exome bait design additionally covering the immunoglobulin heavy chain locus and sequences located within 1Mb of the MYC locus. Paired-End sequencing to a minimum average coverage of 120x was performed on an Illumina HiSeq 2500. Sequencing data were aligned to the Ensembl GRCh37/hg19 human reference using BWA. Somatic variants were identified using MuTect. For detection of CNA we analyzed Illumina HumanOmni 2.5 bead chip data with GenomeStudio. Subclonal reconstruction was performed using PhyloWGS. Mutational signatures were investigated using SomaticSignatures. The GEP70 risk signature was calculated as described previously. Informed consent in accordance with the Declaration of Helsinki was obtained for all cases included in this study. Results: Analyzing RBM and FL WES data, we detected between 100 and 200 somatic SNVs in covered regions, with approximately 30% of them being non-synonymous, and less than 5% stop gained or splice site variants. A comparison of paired RBM and FL WES data showed different extents of spatial heterogeneity. Some pairs had very similar mutation profiles with up to 90% shared variants, whereas others demonstrated marked heterogeneity of point mutations. We did not detect differences in mutational signatures between RBM and FL using the 'SomaticSignatures' package. We found site-specific driver mutations with high variant allele frequencies, indicating replacement of other clones in these areas. For example we observed a clonal KRAS mutation exclusively in the RBM, whereas a NRAS variant was only identified in the paired FL. The same holds true for large-scale CNAs (>1 Mb). We identified a case in which the high risk CNAs gain(1q) and del(17p) were only detectable in the FL. Further examples for site-specific CNAs were a del(10q21) and a gain(4q13) detected in FLs only. As a prominent pattern, we observed outgrowth of sub-clonal RBM CNAs as clonal events in the FL. Based on mutation and CNA data we identified different forms of spatial evolution, including parallel, linear and branching patterns. Of note, a stratified analysis by GEP70-defined risk showed that a more pronounced spatial genomic heterogeneity of SNVs and CNAs was associated with HR disease. Conclusion: We show that spatial heterogeneity in clonal substructure exists in MM and that it is more pronounced in HR. The existence of site-specific HR CNAs and driver mutations highlights the importance of heterogeneity analyses for targeted treatment strategies, thereby facilitating optimal personalized MM medicine. Disclosures Weinhold: University of Arkansas for Medical Sciences: Employment; Janssen Cilag: Other: Advisory Board. Chavan:University of Arkansas for Medical Sciences: Employment. Heuck:Millenium: Other: Advisory Board; Janssen: Other: Advisory Board; Celgene: Consultancy; University of Arkansas for Medical Sciences: Employment; Foundation Medicine: Honoraria. Stephens:University of Arkansas for Medical Sciences: Employment. Tytarenko:University of Arkansas for Medical Sciences: Employment. Bauer:University of Arkansas for Medical Sciences: Employment. Peterson:University of Arkansas for Medical Sciences: Employment. Ashby:University of Arkansas for Medical Sciences: Employment. Stein:University of Arkansas for Medical Sciences: Employment. Johann:University of Arkansas for Medical Sciences: Employment. Johnson:University of Arkansas for Medical Sciences: Employment. Yaccoby:University of Arkansas for Medical Sciences: Employment. Epstein:University of Arkansas for Medical Sciences: Employment. van Rhee:University of Arkansa for Medical Sciences: Employment. Zangari:Novartis: Research Funding; Onyx: Research Funding; Millennium: Research Funding; University of Arkansas for Medical Sciences: Employment. Schinke:University of Arkansas for Medical Sciences: Employment. Thanendrarajan:University of Arkansas for Medical Sciences: Employment. Davies:Millenium: Consultancy; Onyx: Consultancy; Celgene: Consultancy; University of Arkansas for Medical Sciences: Employment; Janssen: Consultancy. Barlogie:University of Arkansas for Medical Sciences: Employment. Morgan:University of Arkansas for Medical Sciences: Employment; MMRF: Honoraria; CancerNet: Honoraria; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees; Weismann Institute: Honoraria; Bristol Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees.

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Defining the Impact of Tandem Autologous Stem Cell Transplantation in Multiple Myeloma: A Case-Match Analysis in the Total Therapy Trials

Blood ◽

10.1182/blood.v126.23.3182.3182 ◽

2015 ◽

Vol 126 (23) ◽

pp. 3182-3182

Author(s):

Sharmilan Thanendrarajan ◽

Caleb K. Stein ◽

Faith E Davies ◽

Frits van Rhee ◽

Maurizio Zangari ◽

...

Keyword(s):

Board Of Directors ◽

Research Funding ◽

Advisory Board ◽

P Value ◽

University Of Arkansas ◽

Medical Sciences ◽

Advisory Committees ◽

Data Set ◽

Baseline Characteristics ◽

Total Therapy

Abstract Introduction The introduction of melphalan-based high-dose chemotherapy and autologous stem cell transplantation (MEL-ASCT) has markedly improved the survival of patients with multiple myeloma (MM). The initial clinical studies suggested conditioning with melphalan (MEL) 200 mg/m2 was optimum compared to MEL 140mg/m2 or MEL/TBI. Following on from the introduction of a single MEL-ASCT, the use of tandem transplantation was explored and highlighted the potential of this approach to improve outcome. With the introduction of consolidation and maintenance approaches, questions still remain regarding which patients are most appropriate for the tandem approach and what dose of melphalan should be delivered. The Total Therapy (TT) trials were initiated more than 25 years ago and have used tandem MEL-ASCT since their inception. Not all patients treated in our facility received a 2nd MEL-ASCT due to a number of reasons including adverse events during 1st MEL-ASCT or a lack of funding for 2nd ASCT thus limiting access to a tandem treatment approach. A dose-reduced MEL (140 mg/m2) was given to patients with renal impairment or advanced age at 1st and / or 2nd ASCT. Consolidation/Maintenance chemotherapy was introduced from TT2 onwards. This large data set therefore allows us to perform a retrospective pair-matched analysis to address a number of important clinical questions including the role of single versus tandem MEL-ASCT and standard versus dose-reduced tandem MEL-ASCT in the era of novel agents for induction and consolidation/maintenance therapy. Materials and Methods We have analyzed data from 1918 patients who were enrolled in Total Therapy 1 - 6 trials. Given the changing chemotherapy regimens within TT trials due to the introduction of novel agents coupled with diverse baseline characteristics, we designed a retrospective pair-matched analysis framework in order to account for differences in patient and treatment variables. This was achieved by generating identical treatment and control group subsets from within the full data set that are identical across key covariates including baseline characteristics of ISS stage, age, and creatinine; protocol anti-myeloma treatment regimens such as dexamethasone, thalidomide, bortezomib, and lenalidomide; and variations in transplantation such as melphalan dosage. The majority of the patients in the TT trials completed induction chemotherapy and received the 1st MEL-ASCT (TT1: 88.3%, TT2: 86.0%, TT3: 97.6%, TT4: 95.0%, TT5: 100% and TT6: 95.1%). Fewer patients received the 2nd MEL-ASCT (TT1: 66.7%, TT2: 68.2%, TT3: 85.0%, TT4: 70.0%, TT5: 74.0%, and TT6: 52.4%). MEL 200 mg/m2 was the predominant dose, administered with MEL 140 mg/m2 given to a smaller fraction of patients due to age and renal impairment restrictions. TT3 has the highest percentage of patients receiving a 2nd MEL-ASCT at 85.0% and most of those at standard dose (MEL 200 mg/m2). Results After balancing treatment and control groups with identical treatment, baseline characteristics, and dose of 1st ASCT (140 or 200 mg/m2), we found 289 tandem and 289 single transplant pairs with no significant differences across any of our balancing covariates (all paired Wilcoxon rank test p-values = 1.00). Analysis of these pair-matched cases strongly supported tandem transplantation as superior in outcome-cases with tandem transplantation had 5-year OS rate of 74.8% compared to 54.1% in single transplant cases (logrank p-value: 1.44e-06). For cases with tandem transplantation, we pair-matched 164 cases with tandem 200 mg/m2 transplants to 164 cases with either 140 mg/m2 received as 1st ASCT, 2nd ASCT, or both transplants. Analysis of these pair-matched cases strongly supported tandem 200 mg/m2 over 140 mg/m2 as the 5-year OS rates were 78.5% and 63.6%, respectively (logrank p-value: 1.23e-03). Conclusion MEL-ASCT is the backbone for treatment of MM. From our study, there is overwhelming evidence that application of tandem MEL-ASCT delivers superior clinical outcome compared to single MEL-ASCT. In order to achieve the best clinical results tandem MEL-ASCT should be performed using standard dose MEL 200 mg/m2; dose reduction (140 mg/m2) leads to unfavorable clinical outcome. Ongoing analysis aims to reveal the benefits of MEL-ASCT treatment across specific subgroups to better understand differential response and optimal therapy for patients across distinct molecular and risk subgroups. Figure 1. Figure 1. Figure 2. Figure 2. Disclosures Thanendrarajan: University of Arkansas for Medical Sciences: Employment. Stein:University of Arkansas for Medical Sciences: Employment. Davies:Celgene: Consultancy; Janssen: Consultancy; Millenium: Consultancy; Onyx: Consultancy; University of Arkansas for Medical Sciences: Employment. van Rhee:University of Arkansa for Medical Sciences: Employment. Zangari:Onyx: Research Funding; University of Arkansas for Medical Sciences: Employment; Millennium: Research Funding; Novartis: Research Funding. Heuck:Millenium: Other: Advisory Board; Janssen: Other: Advisory Board; Celgene: Consultancy; Foundation Medicine: Honoraria; University of Arkansas for Medical Sciences: Employment. Schinke:University of Arkansas for Medical Sciences: Employment. Waheed:University of Arkansas for Medical Sciences: Employment. Jethava:University of Arkansas for Medical Sciences: Employment. Weinhold:University of Arkansas for Medical Sciences: Employment; Janssen Cilag: Other: Advisory Board. Matin:University of Arkansas for Medical Sciences: Employment. Mathur:University of Arkansas for Medical Sciences: Employment. Mohan:University of Arkansas for Medical Sciences: Employment. Radhakrishnan:University of Arkansas for Medical Sciences: Employment. Barlogie:University of Arkansas for Medical Sciences: Employment. Morgan:Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; University of Arkansas for Medical Sciences: Employment; Bristol Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; CancerNet: Honoraria; MMRF: Honoraria; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees; Weismann Institute: Honoraria.

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A Prognostic 51-Gene Signature Linked to Abnormal Metaphase Cytogenetics Identifies Myeloma Patients Who Benefit from Fractionated Melphalan Dosing and Added Bortezomib, Thalidomide and Dexamethasone As Conditioning for Autologous Stem Cell Transplant

Blood ◽

10.1182/blood.v126.23.3181.3181 ◽

2015 ◽

Vol 126 (23) ◽

pp. 3181-3181

Author(s):

Frits van Rhee ◽

Alan Mitchell ◽

Maurizio Zangari ◽

Jeffery Sawyer ◽

Sarah Waheed ◽

...

Keyword(s):

Board Of Directors ◽

Clinical Outcomes ◽

Research Funding ◽

Gene Signature ◽

Advisory Board ◽

Phase Iii ◽

University Of Arkansas ◽

Medical Sciences ◽

Gene Model ◽

Advisory Committees

Abstract Introduction: Total Therapy 4 (TT4) comprises a randomized phase III trial enrolling 289 patients with gene expression profiling defined low-risk MM in which patients were allocated to a standard arm (TT4-S) or a light arm (TT4-L) with as principal goal to reduce toxicity yet maintain efficacy in TT4-L. Methods: The TT4-S regimen was similar to TT3b and utilized 2 cycles of VDTPACE induction, tandem transplantation with melphalan 200mg/m2, 2 cycles of dose reduced VDTPACE consolidation and 3 years maintenance with VRD. In TT4-L the number of induction and consolidation cycles was reduced to one each and melphalan was given in a fractionated fashion (50mg/m2/d x 4days) to avoid peak levels of melphalan and reduce mucosal toxicity. Bortezomib and thalidomide were added to the fractionated melphalan conditioning regimen to explore synergistic effects and compensate for potential loss of efficacy. Results: Grade ≥3 toxicities in TT4-S and L occurred with similar frequencies. With a median follow-up of 4.5 years, the OS and PFS were similar in TT4-S and TT4-L at 90 and 87% respectively. The same applied to PFS (TT4-S 84% versus TT4-L 79%). The presence of metaphase defined cytogenetic abnormalities (CA) affected clinical outcomes. In TT4-S, patient with CA had a strong trend toward inferior OS compared to patients with no CA (2 year estimate 83 versus 94%, p=0.08), while the reverse applied to TT4-L (95 versus 81%, p=0.07). Non-significant trends in similar directions were noted for PFS. Complete remission duration tended to be inferior in patients with CA-type MM in TT4-S (2 year estimate, 79 vs. 92%, p=013) with no significant differences in TT4-L. Time to relapse was significantly shorter for CA patients on the TT4-S arm (2 year estimate, 15.4 versus 3.9%), but was not affected by CA in the TT4-L (15.8 vs 7.9%, p=0.79. The observation of CA's favorable OS impact in TT4-L was not anticipated. We next analyzed whether the presence or absence of metaphase CA was linked to specific gene probes which could help to explain better outcomes in TT4-L. Among a training set of 266 untreated patients enrolled in TT3a with available baseline GEP studies, 90 (34%) exhibited CA. Among a test set of 164 patients with baseline GEP accrued to TT3b, 67 (41%) qualified as having CA. Fifty-one probes were different in patients with and without CA (q<0.0001). Seven of the 51 genes had functions in DNA replication, recombination, and repair; five in nucleic acid metabolism, and 4 in RNA post-translational modification and RNA damage and repair. Pathway analysis identified a network of eight interrelated genes that were overexpressed in the CA group, indicating that these MM cells have a higher proliferative activity. We next examined clinical outcomes by the GEP51-CA prediction model in the 2 arms of TT4. In TT4-S, GEP51/no-CA had superior OS and PFS compared to GEP51/CA, which was not observed in TT4-L (Figure 1A, B). Conclusions: A prognostic CA-linked GEP signature can identify patients who benefit from conditioning with fractionated melphalan dosing together bortezomib, thalidomide and dexamethasone which negates the adverse impact of CA. Patients who lacked a CA-type gene signature were best served with single high dose melphalan. These exploratory findings need to be confirmed in a prospective randomized trial. Figure 1. PFS according to 51-gene model predicting CA versus no-CA according to arm (TT4-S, 1A; TT4-L, 1B) Figure 1. PFS according to 51-gene model predicting CA versus no-CA according to arm (TT4-S, 1A; TT4-L, 1B) Disclosures van Rhee: University of Arkansa for Medical Sciences: Employment. Mitchell:Cancer Research and Biostatistics: Employment. Zangari:Millennium: Research Funding; Novartis: Research Funding; University of Arkansas for Medical Sciences: Employment; Onyx: Research Funding. Sawyer:University of Arkansas for Medical Sciences: Employment. Waheed:University of Arkansas for Medical Sciences: Employment. Heuck:Millenium: Other: Advisory Board; Janssen: Other: Advisory Board; Celgene: Consultancy; Foundation Medicine: Honoraria; University of Arkansas for Medical Sciences: Employment. Thanendrarajan:University of Arkansas for Medical Sciences: Employment. Schinke:University of Arkansas for Medical Sciences: Employment. Jethava:University of Arkansas for Medical Sciences: Employment. Grazziutti:University of Arkansas for Medical Sciences: Employment. Petty:University of Arkansas for Medical Sciences: Employment. Steward:University of Arkansas for Medical Sciences: Employment. Panozzo:University of Arkansas for Medical Sciences: Employment. Bailey:University of Arkansas for Medical Sciences: Employment. Hoering:Cancer Research and Biostatistics: Employment. Crowley:Cancer Research and Biostatistics: Employment. Davies:University of Arkansas for Medical Sciences: Employment; Celgene: Consultancy; Janssen: Consultancy; Onyx: Consultancy; Millenium: Consultancy. Barlogie:University of Arkansas for Medical Sciences: Employment. Morgan:MMRF: Honoraria; Bristol Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; Weismann Institute: Honoraria; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; CancerNet: Honoraria; University of Arkansas for Medical Sciences: Employment; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees.

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Differential ICAM3 Gene Expression Correlates with Susceptibility to Natural Killer Cell-Mediated Lysis in Multiple Myeloma

Blood ◽

10.1182/blood.v126.23.2990.2990 ◽

2015 ◽

Vol 126 (23) ◽

pp. 2990-2990

Author(s):

Tarun K. Garg ◽

Ricky D Edmondson ◽

Shweta S. Chavan ◽

Katie Stone ◽

Justin M Stivers ◽

...

Keyword(s):

Gene Expression ◽

Multiple Myeloma ◽

Flow Cytometry ◽

Natural Killer ◽

Board Of Directors ◽

Advisory Board ◽

University Of Arkansas ◽

Medical Sciences ◽

Advisory Committees ◽

Myeloma Cells

Abstract Introduction We previously reported on the generation of highly activated/expanded natural killer cells (ENKs) after coculture with K562 cells modified to express membrane bound IL15 and 41BB-ligand. These cells have potent antimyeloma properties in vitro, in a NGS mouse model, and are safe when given to advanced multiple myeloma (MM) patients. (Szmania et al, J Immunother 2015) A potential obstacle to the effectiveness of ENK-based immunotherapy of MM is the evasion of immune recognition. We have generated 4 MM cell lines (OPM2, JJN3, ANBL6, and INA-6) which are resistant to ENK-mediated lysis to study mechanisms of resistance. These lines were derived from parental lines by repeated challenge with ENKs and maintained resistance long term when cultured without further exposure to ENKs.(Garg et al, Blood 2012, 120:4020) We have shown by stable isotope labeling with amino acids in cell culture-mass spectrometry, gene expression profiling (GEP), and flow cytometry that ICAM3 is downregulated in the ENK-resistant version of OPM2 (OPM2-R) compared to the parental OPM2. (OPM2-P; Garg et al, Blood 2013, 122:3105) We investigated OPM2-P and OPM2-R by whole exome sequencing (WES) and RNA sequencing (RNAseq) with a focus on ICAM3, evaluated ICAM3 cell surface expression on patient myeloma cells, and studied the importance of ICAM3 expression on ENK functionality. Methods DNA and RNA were extracted from OPM2-P and OPM2-R cells using the Qiagen AllPrep kit. WES libraries were prepared with the Agilent qXT and Agilent SureSelect Clinical Research Exome kits with additional baits covering the Ig and MYC loci. RNAseq libraries were prepared using the Illumina TruSeq stranded mRNA kit. Samples were sequenced 100bp PE on an Illumina HiSeq2500. Samples for WES were sequenced to a mean coverage of >120x and RNAseq to a target of >100M reads. WES data were aligned to the Ensembl GRCh37/hg19 human reference using BWA mem. Somatic variants were called MuTect. RNAseq data were analyzed using Tuxedo Suite. Data were aligned to the Ensembl GRCh37/hg19 human reference using TopHat with Bowtie2. Transcriptome reconstruction, quantification and differential analysis was performed using CuffLinks. ENK-mediated lysis of myeloma cells was measured by 4 hour chromium release assay in the presence of isotype or ICAM3 blocking antibody. Bone marrow aspirates were obtained from MM patients after informed consent in accordance with the Declaration of Helsinki. Primary myeloma cells were selected with CD138-coated immunomagnetic beads and ICAM3 expression was assessed by flow cytometry gated on viable CD138 positive cells. Results There was no mutation in ICAM3 in OPM2-R by WES, but RNAseq found a significant reduction in ICAM3 RNA in OPM2-R compared to OPM2-P (p <0.008). Loss of ICAM3 expression on OPM2-R correlated with a reduction in sensitivity to ENK-mediated lysis compared to OPM2-P (mean 83%, range 77-88%, N=7 assays; E:T ratio 10:1). Blocking of ICAM3 on OPM2-P similarly reduced susceptibility to ENK-mediated cytotoxicity (mean 45%, range 30-56%, N=4 assays; E:T ratio 10:1). We next examined ICAM3 expression on primary myeloma cells by flow cytometry (N=49; GEP-defined high-risk n=43) and found that there is considerable biological inter-patient variation in ICAM3 expression (median MFI 922; range 97-5882, Figure 1A). Further, the majority of patients studied exhibited ICAM3-negative myeloma subpopulations (0.01%-19.4% of CD138 positive myeloma cells, Figure 1B). Functional studies will be presented to correlate the level of ICAM3 expression on primary myeloma cells with sensitivity to ENK-mediated lysis and resulting data shall be presented. Conclusion Our findings demonstrate that MM patients harbor ICAM3-negative myeloma populations in varying frequencies, and we hypothesize that these cells may be similarly resistant to ENK-mediated lysis. Functional assays exploring this question are in progress. By understanding the mechanisms of ENK resistance and immune escape in MM, we hope to elucidate a surrogate biomarker which will allow us to select subjects who are most likely to benefit from cellular immunotherapeutic strategies for enrollment in future ENK-based clinical trials. Additionally, the ICAM3/LFA-1 interaction is also important for adhesion of T cells to their targets; therefore, down-regulation of ICAM3 may also have functional implications in the efficacy of T cell-based therapies for MM. Disclosures Garg: University of Arkansas for Medical Sciences: Employment. Chavan:University of Arkansas for Medical Sciences: Employment. Stone:University of Arkansas for Medical Sciences: Employment. Stivers:University of Arkansas for Medical Sciences: Employment. Warden:University of Arkansas for Medical Sciences: Employment. Skinner:University of Arkansas for Medical Sciences: Employment. Lingo:University of Arkansas for Medical Sciences: Employment. Greenway:University of Arkansas for Medical Sciences: Employment. Khan:University of Arkansas for Medical Sciences: Employment. Johann:University of Arkansas for Medical Sciences: Employment. Heuck:Millenium: Other: Advisory Board; Celgene: Consultancy; Janssen: Other: Advisory Board; University of Arkansas for Medical Sciences: Employment; Foundation Medicine: Honoraria. Barlogie:University of Arkansas for Medical Sciences: Employment. Morgan:University of Arkansas for Medical Sciences: Employment; Weismann Institute: Honoraria; MMRF: Honoraria; Bristol Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; CancerNet: Honoraria; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees. Epstein:University of Arkansas for Medical Sciences: Employment. van Rhee:University of Arkansa for Medical Sciences: Employment.

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Melphalan Affects Genes Critical for Myeloma Survival, Homing, and Response to Cytokines and Chemokines

Blood ◽

10.1182/blood.v126.23.1808.1808 ◽

2015 ◽

Vol 126 (23) ◽

pp. 1808-1808

Author(s):

Shmuel Yaccoby ◽

Joshua Epstein ◽

Pingping Qu ◽

Frits van Rhee ◽

Maurizio Zangari ◽

...

Keyword(s):

Cell Surface ◽

Board Of Directors ◽

Research Funding ◽

Advisory Board ◽

Cxcr4 Expression ◽

Cell Surface Receptors ◽

University Of Arkansas ◽

Medical Sciences ◽

Advisory Committees ◽

Surface Receptors

Abstract Introduction: We have previously used global gene expression (GEP)-based clinical pharmacogenomics of dexamethasone, thalidomide, pomalidomide and bortezomib (Bor) to understand their mechanism of actions and how this impacts their clinical efficacy in multiple myeloma (MM) patients. High dose therapy with melphalan (Mel) followed by autologous stem cell transplantation is a major treatment regimen for MM and consequently assessing the pharmacogenomics of Mel is clinically relevant. Importantly not all patients benefit from Mel exposure and, therefore, it remains important to understand the molecular mechanism of its actions and how they underlie treatment resistance. Materials and methods: 252 newly diagnosed MM patients randomized to Total Therapy (TT)4 (GEP70 low-risk, N=210) and TT5 (GEP70 high-risk, n=42) clinical trials received single administration of Bor (1.0mg/m2) followed after 48 hrs latter by a single administration of Mel (10mg/m2). BM aspirates were obtained at baseline, 48 hrs post-Bor and 48 hrs Post-Mel. Purified CD138-selected MM cells underwent GEP analysis using the Affymetrix U133plus2 microarrays and the results generated were analyzed using Gene Set Enrichment Analysis (GSEA) and Ingenuity. The effect of Mel on expression of cell surface receptors in MM cell lines was validated by flow cytometry. Results: Expression of 176 probe sets was changed 48 hours after a single Bor administration at FDR < 0.01, and expression of 5117 additional probe sets was further changed after Mel. Expression of 6309 probe sets was changed when comparing post-Mel to baseline, of these 108 were also changed post-Bor and 4043 overlapped with changes observed between post-Mel and post-Bor. By utilizing GSEA and Ingenuity we identified the top pathways associated with Mel activity including activation of p53, nitrogen metabolism and metabolism of xenobiotics by p450, whereas Bor was associated with proteasome activation. Bor and Mel both downregulated pathways related to cell cycle and DNA replication and damage response. Top listed genes differentially expressed between baseline and post-Mel and/or post-Bor and post-Mel and reportedly linked to MM pathogenesis include underexpression of IRF4, ASPM, MYC and NEK2, and upregulation of TNFSF10 (TRAIL), MDM2, BAX and KLF9. Among the top upregulated genes by Mel were also set of 7 cell surface receptors (MERTK, CXCR4, OGFRL1, INSR, TGFBR2, S1PR1, IL1R2) and 5 cytokines (AREG, TNFSF8, BDNF, IGF1, TNFSF15). We initially focused our analysis on MERTK and CXCR4 which have been previously implicated in MM and whose expression was upregulated by 2.5 (FDR < 4.6x10-39) and 1.8 (FDR < 3.9x10-36) folds, respectively. Increased expression of MERTK and CXCR4 was associated with shorter progression-free survival (PFS) and over survival (OS) in our Total Therapy trials, including analysis restricted to GEP70 high-risk patients in TT3 and TT5. Moreover, GEP of paired MM cell samples obtained from focal lesion and random BM sites of the same patient (n=170) showed reduced CXCR4 expression in MM cells residing within focal lesions (FDR < 6.1x10-5), further implicating intra-patient heterogeneity of CXCR4 expression in distinct BM niches with response to Mel. To validate direct effect of Mel on these factors at the protein level, flow cytometry analysis for MERTK and CXCR4 was performed on MM cell lines (n=3) following treatment with Mel (5-10µM) or Bor (2.5-5nM) for 72 hrs. Mel but not Bor increased mean fluorescent intensity of MERTK and CXCR4 by 3.1±0.5 (p < 0.05) and 5.1±0.5 (p<0.04) folds, respectively, and the percentage of MERTK- and CXCR4-expressing MM cells by 11.9±2.5 (p < 0.04) and 4.1±0.1 (p < 0.002) folds, respectively, compared to control vehicle-treated cells. Conclusions: The upregulation of cell surface receptors and growth factors by Mel suggests that exposure to the drug promotes the retention of MM cells within the BM and their reliance on the BM microenvironment. This pharmacogenomics approach is useful as it can identify previously unrecognized biomarkers and pathways associated with Mel activity and drug resistance in MM patients. Disclosures Epstein: University of Arkansas for Medical Sciences: Employment. Qu:Cancer Research and Biostatistics: Employment. van Rhee:University of Arkansa for Medical Sciences: Employment. Zangari:Millennium: Research Funding; University of Arkansas for Medical Sciences: Employment; Onyx: Research Funding; Novartis: Research Funding. Heuck:Janssen: Other: Advisory Board; Foundation Medicine: Honoraria; Millenium: Other: Advisory Board; Celgene: Consultancy; University of Arkansas for Medical Sciences: Employment. Davies:Millenium: Consultancy; University of Arkansas for Medical Sciences: Employment; Onyx: Consultancy; Celgene: Consultancy; Janssen: Consultancy. Mitchell:Cancer Research and Biostatistics: Employment. Crowley:Cancer Research and Biostatistics: Employment. Barlogie:University of Arkansas for Medical Sciences: Employment. Morgan:Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees; CancerNet: Honoraria; Bristol Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; MMRF: Honoraria; Weismann Institute: Honoraria; University of Arkansas for Medical Sciences: Employment; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees.

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Upfront 28-Day Metronomic Therapy for High-Risk Multiple Myeloma (HRMM)

Blood ◽

10.1182/blood.v126.23.1843.1843 ◽

2015 ◽

Vol 126 (23) ◽

pp. 1843-1843 ◽

Cited By ~ 1

Author(s):

Sharmilan Thanendrarajan ◽

Daisy V. Alapat ◽

Maurizio Zangari ◽

Carolina Schinke ◽

Christoph Heuck ◽

...

Keyword(s):

High Risk ◽

Board Of Directors ◽

Research Funding ◽

Advisory Board ◽

Proliferation Index ◽

University Of Arkansas ◽

Medical Sciences ◽

Advisory Committees ◽

Cytogenetic Abnormalities ◽

Metronomic Therapy

Abstract Introduction: Despite major advances in MM therapy with the inclusion of novel agent combinations for induction prior to and after autotransplant-supported high-dose melphalan, the 15% of patients with GEP-defined HRMM continue to fare poorly with PFS and OS not exceeding 2 and 3 years, respectively. This poor outcome has not been improved with less dose-intense and more dose-dense Total Therapy 5. Having previously reported on 16-day metronomic therapy with low-dose doxorubicin (DOX) and cisplatin (DDP) plus VTD (Papanikolaou, Haematologica), we explored further extension of such metronomic treatment to 28 days (metro-28) also in newly diagnosed HRMM patients. Patients and Methods: All patients signed a written informed consent and data analysis was approved by our IRB. In the outpatient setting, a single cycle of metro-28 comprised DOX and DDP each at 1.0mg/m2/d for 28d by continuous infusion (CI), along with VTD (bortezomib 1.0mg/m2 on days 1-4, 7-10, 13-16, 19-22, 25-28; DEX 12mg on days 1-4, 7-10, 13-16, 19-22, 25-28; thalidomide 50-100mg/d x 28d; some patients also received vincristine [VCR] at a flat daily dose of 0.07mg/d x 28d by CI. Results: Fourteen patients were initiated on metro-28. Their characteristics included age >=65y in 12; albumin <3.5g/dL in 8; B2M >5.5mg/L in 7; cytogenetic abnormalities [CA] were present in 10; GEP70 HRMM in 9/13; PR subgroup in 8/13 (Table 1). The median follow up is 11mo. As portrayed in Figure 1A, no patient has died; the 6mo PFS estimate was 85% (Figure 1B); responses included CR in 3/14, VGPR in 7/14 and PR in 10/14 (Figure 1C); and the PR duration estimate at 6mo is 80% (Figure 1D). Of interest, GEP70 scores morphed to low risk in 3/13. Vascular density (CD34) decreased markedly in most patients evaluated. Toxicities were minor; myelosuppression was virtually absent; alopecia was not encountered. Subsequent salvage therapies included repeat metro-28, combination chemotherapy (PACMED) and autotransplants. Conclusion: We conclude that metro-28 is a promising and safe strategy for elderly patients with HRMM, and we hypothesize an anti-angiogenic mechanism of action in addition to direct anti-MM effects. Table 1. Patient characteristics Factor n/N (%) Age >= 65 yr 12/14 (86%) Albumin < 3.5 g/dL 8/14 (57%) B2M >= 3.5 mg/L 9/12 (75%) B2M > 5.5 mg/L 7/12 (58%) Hb < 10 g/dL 10/14 (71%) Cytogenetic Abnormalities 10/14 (71%) CA within 1 Year of Therapy 10/14 (71%) CA within 90 Days of Therapy 9/14 (64%) GEP 70-Gene High Risk 9/13 (69%) GEP PR Subgroup 8/13 (62%) GEP Proliferation Index >= 10 7/13 (54%) GEP Centrosome Index >= 3 7/13 (54%) n/N (%): n- Number with factor, N- Number with valid data for factor Figure 1. Figure 1. Disclosures Thanendrarajan: University of Arkansas for Medical Sciences: Employment. Alapat:University of Arkansas for Medical Sciences: Employment. Zangari:University of Arkansas for Medical Sciences: Employment; Onyx: Research Funding; Millennium: Research Funding; Novartis: Research Funding. Schinke:University of Arkansas for Medical Sciences: Employment. Heuck:Millenium: Other: Advisory Board; Janssen: Other: Advisory Board; Foundation Medicine: Honoraria; Celgene: Consultancy; University of Arkansas for Medical Sciences: Employment. van Rhee:University of Arkansa for Medical Sciences: Employment. Rosenthal:Cancer Research and Biostatistics: Employment. Epstein:University of Arkansas for Medical Sciences: Employment. Yaccoby:University of Arkansas for Medical Sciences: Employment. Davies:Janssen: Consultancy; Onyx: Consultancy; University of Arkansas for Medical Sciences: Employment; Millenium: Consultancy; Celgene: Consultancy. Morgan:MMRF: Honoraria; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees; CancerNet: Honoraria; Bristol Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; Weismann Institute: Honoraria; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; University of Arkansas for Medical Sciences: Employment. Barlogie:University of Arkansas for Medical Sciences: Employment.

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The Impact of Combination Chemotherapy and Tandem Stem Cell Transplant on Clonal Substructure and Mutational Pattern at Relapse of MM

Blood ◽

10.1182/blood.v126.23.372.372 ◽

2015 ◽

Vol 126 (23) ◽

pp. 372-372 ◽

Cited By ~ 1

Author(s):

Christoph Heuck ◽

Niels Weinhold ◽

Erich Allen Peterson ◽

Michael Bauer ◽

Caleb K. Stein ◽

...

Keyword(s):

High Risk ◽

Board Of Directors ◽

Research Funding ◽

Clonal Evolution ◽

Advisory Board ◽

Proliferation Index ◽

University Of Arkansas ◽

Medical Sciences ◽

Advisory Committees ◽

The Impact

Abstract Introduction: Next generation sequencing of over 800 newly diagnosed multiple myeloma (NDMM) cases has established the mutational landscape and key cancer driver pathways. The mutational basis of relapse has not been systematically studied. Two previous studies (Keats et al.; Bolli et al.) identified 4 patterns of clonal evolution. Neither study included uniformly treated patients and looked at the impact of therapy on clonal structure at relapse. Understanding the mutational patterns underlying relapse and how they relate to specific therapies is crucial in order to improve MM outcomes, especially for high-risk (HR) MM. In this study we compare the clonal structure at presentation (PRES) and at relapse (REL), after exposure to Total Therapy (TT). Materials and Methods: We studied 33 pairs of tumor samples collected at PRES and REL. 9 patients were treated on TT2, 13 on TT3, 10 on TT4 and 1 on TT5-like regimen. Eleven patients had HR disease at PRES. DNA was extracted from CD138+ selected cells from random bone marrow aspirates. Germline controls were obtained from leukapheresis products. Whole exome sequencing libraries were prepared using the Agilent qXT kit and the Agilent SureSelect Clinical Research Exome kit with additional baits covering the Ig and MYC loci. All samples were sequenced on an Illumina HiSeq2500 to a median depth of 120x. Sequencing data were aligned to the Ensembl GRCh37/hg19 human reference using BWA. Somatic variants were called using MuTect. Translocations were identified using MANTA. Copy number variations were inferred using TITAN. Gene expression profiles (GEP), generated using the Affymetrix U133plus2 microarray, were available for all tumor samples. Nonnegative matrix factorization (NMF) was used to define mutation signatures. Results: The median time to progression was 30 months with a median follow up of 9.5 years. 22 cases achieved a complete remission (CR) or near CR. There were 11 cases of HR at PRES. Of the 22 cases with low risk (LR) MM, 7 relapsed with HR disease. There were on average 478 SNVs per sample at PRES and 422 at REL. All but 2 cases had evidence of new mutations at REL. There were no consistent patterns or number of mutation associated with REL or GEP-defined risk. Patients of the MF molecular subgroup had more mutations compared to other molecular subgroups (657 vs. 379) and were enriched for mutations with an APOBEC signature. We did not detect any mutation signature consistent with chemotherapy-induced alterations, providing evidence that TT itself does not cause additional mutations. Primary recurrent IgH translocations called by MANTA were confirmed by GEP data. A number of new translocations were identified , several only at REL. In particular we demonstrate a case with a newly acquired MYC translocation at relapse, indicating that it contributed to progression. We identified 5 patterns of clonal evolution (Figure 1): A) genetically distinct relapse in 3 patients, B) linear evolution in 8 patients, C) clonal selection in 9 patients, D) branching evolution in 11 patients, and E) stable clone(s) in 2 patients. Patterns A (distinct) and B (linear) were associated with low risk and longer survival, whereas patterns D (branching) and E (stable) were associated with high risk and shorter time to relapse and overall survival (Table 1). Conclusion: This is the first study to systematically analyze the pattern of clonal evolution using NGS in patients treated with combination chemotherapy and tandem ASCT. We identified 5 patterns of evolution, which correlate with survival. We identified 3 cases with a loss of the original clone and emergence of a new clone, suggesting high effectiveness of Total Therapy for those patients. The persistence of major clones despite multi agent chemotherapy in most other cases supports a concept of a tumor-initiating cell population that persist in a protective niche, for which new therapies are needed. Table 1. Pattern of Evolution GEP70 Pres.(high risk: ≥0.66) Proliferation Index Pres. GEP70 Rel.(high risk: ≥0.66) Proliferation Index Rel Mean OS Mean TTR A: distinct (n=3) -0.690 -3.34 -0.015 2.04 8.18 5.00 B: linear (n=8) -0.171 -0.34 0.618 9.22 5.70 4.05 C: selection (n=9) 0.366 3.20 0.569 6.97 3.95 2.64 D: branching (n=11) 0.710 5.17 1.173 11.15 3.84 2.21 E: stable (n=2) 1.532 7.42 1.124 2.54 0.96 0.35 Pres.: Presentation; Rel.: Relapse; OS: Overall Survival; TTR: Time to Relapse Figure 1. Patterns of Relapse Figure 1. Patterns of Relapse Disclosures Heuck: Foundation Medicine: Honoraria; Millenium: Other: Advisory Board; Janssen: Other: Advisory Board; Celgene: Consultancy; University of Arkansas for Medical Sciences: Employment. Weinhold:Janssen Cilag: Other: Advisory Board; University of Arkansas for Medical Sciences: Employment. Peterson:University of Arkansas for Medical Sciences: Employment. Bauer:University of Arkansas for Medical Sciences: Employment. Stein:University of Arkansas for Medical Sciences: Employment. Ashby:University of Arkansas for Medical Sciences: Employment. Chavan:University of Arkansas for Medical Sciences: Employment. Stephens:University of Arkansas for Medical Sciences: Employment. Johann:University of Arkansas for Medical Sciences: Employment. van Rhee:University of Arkansa for Medical Sciences: Employment. Waheed:University of Arkansas for Medical Sciences: Employment. Johnson:University of Arkansas for Medical Sciences: Employment. Zangari:University of Arkansas for Medical Sciences: Employment; Millennium: Research Funding; Onyx: Research Funding; Novartis: Research Funding. Matin:University of Arkansas for Medical Sciences: Employment. Petty:University of Arkansas for Medical Sciences: Employment. Yaccoby:University of Arkansas for Medical Sciences: Employment. Davies:University of Arkansas for Medical Sciences: Employment; Millenium: Consultancy; Janssen: Consultancy; Onyx: Consultancy; Celgene: Consultancy. Epstein:University of Arkansas for Medical Sciences: Employment. Barlogie:University of Arkansas for Medical Sciences: Employment. Morgan:Weismann Institute: Honoraria; MMRF: Honoraria; Bristol Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; University of Arkansas for Medical Sciences: Employment; CancerNet: Honoraria; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees.

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Extending Metronomic Therapy to 28 Days (metro28) for Relapsed Refractory Multiple Myeloma (RRMM)

Blood ◽

10.1182/blood.v126.23.5395.5395 ◽

2015 ◽

Vol 126 (23) ◽

pp. 5395-5395

Author(s):

Xenofon Papanikolaou ◽

Carolina Schinke ◽

Sharmilan Thanendrarajan ◽

Adam Rosenthal ◽

Nathan Petty ◽

...

Keyword(s):

Overall Survival ◽

Board Of Directors ◽

Clinical Outcomes ◽

Research Funding ◽

Progression Free Survival ◽

Advisory Board ◽

University Of Arkansas ◽

Medical Sciences ◽

Advisory Committees ◽

Free Survival

Abstract Introduction: Despite the enormous progress in MM therapy brought about by the rapid development of many novel agents, many patients end up with limited treatment options. We have previously reported on the efficacy and safety of metro16 in RRMM (Papanikolaou, Haematology 2013). Here we are reporting on an extension of such treatment to 28 d (metro28). Patients and Methods: The treatment consisted of a cycle of 28d continuous iv infusions of ADR and DDP each at 1mg/m2/d, along with thalidomide 50 to 100mg/d x 28; bortezomib 0.8 to 1.0mg/m2 on days 1, 4, 7, 10, 13, 16, 19, 22, 25, 28; DEX 8 to 12mg on days 1-4, 7-10, 13-16, 19-22, 25-28; some patients also received vincristine 0.07mg flat dose by CI for 28 days. This was off-protocol therapy that patients provided written informed consent for. The IRB permitted data retrieval and analysis. Results: 150 patients were identified, virtually all had received prior tandem transplants, bortezomib, lenalidomide, carfilzomib and pomalidomide. The median age was 64yr; B2M was elevated >=3.5mg/L in 48%, abnormal cytogenetics (CA) were present in 86%, and 44% had GEP70-defined high risk MM. Figure 1 portrays clinical outcomes. As of April 2015, 60 patients had died, and the 2-yr OS estimate was 45% (Figure 1A); the 6-mo PFS estimate was 31% although 15% had no progression at 18mo (Figure 1B). Analysis by GEP70 and GEP5 risk revealed 18-mo OS estimates of 80% among the 53 patients with low risk in both models, whereas the presence of high risk (HRMM) in either model conferred a significantly reduced 18-mo OS estimate of 25% (p<0.0001) (Figure 1C). On Cox regression analysis, OS was independently adversely affected by GEP5 HRMM (47%, HR=3.43, p<0.001), LDH >=ULN (25%, HR=3.46, p<0.001), low albumin (39%, HR=2.68, p=0.003), B2M >=3.5mg/L (51%, HR+2.63, p=0.014) and thrombocytopenia <50,000/uL (15%, HR=2.3, p=0.043). GEP5 HRMM was the sole adverse variable affecting PFS (HR=2.37, p<0.001). Most patients received metro28 in the outpatient setting, and side effects were mild. Conclusion: Metro28 represents a well-tolerated additional tool in the treatment armamentarium for RRMM. Figure 1. Clinical outcomes A: Overall survival B: Progression-free survival C: Overall survival according to GEP70 and GEP5 risk designations Figure 1. Clinical outcomes. / A: Overall survival. / B: Progression-free survival. / C: Overall survival according to GEP70 and GEP5 risk designations Figure 2. Figure 2. Figure 3. Figure 3. Disclosures Schinke: University of Arkansas for Medical Sciences: Employment. Thanendrarajan:University of Arkansas for Medical Sciences: Employment. Rosenthal:Cancer Research and Biostatistics: Employment. Petty:University of Arkansas for Medical Sciences: Employment. Zangari:University of Arkansas for Medical Sciences: Employment; Onyx: Research Funding; Millennium: Research Funding; Novartis: Research Funding. Heuck:Celgene: Consultancy; Foundation Medicine: Honoraria; Janssen: Other: Advisory Board; University of Arkansas for Medical Sciences: Employment; Millenium: Other: Advisory Board. van Rhee:University of Arkansa for Medical Sciences: Employment. Epstein:University of Arkansas for Medical Sciences: Employment. Yaccoby:University of Arkansas for Medical Sciences: Employment. Morgan:Weismann Institute: Honoraria; CancerNet: Honoraria; MMRF: Honoraria; University of Arkansas for Medical Sciences: Employment; Bristol Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees. Davies:University of Arkansas for Medical Sciences: Employment; Celgene: Consultancy; Janssen: Consultancy; Millenium: Consultancy; Onyx: Consultancy. Barlogie:University of Arkansas for Medical Sciences: Employment.

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Assessment of Total Lesion Glycolysis and Metabolic Tumor Volume Improve the Clinical Value of Focal Lesion Assessment By FDG PET/CT in Myeloma

Blood ◽

10.1182/blood.v126.23.724.724 ◽

2015 ◽

Vol 126 (23) ◽

pp. 724-724

Author(s):

James E McDonald ◽

Marcus M Kessler ◽

Michael Gardner ◽

Amy Buros ◽

Sarah Waheed ◽

...

Keyword(s):

Multiple Myeloma ◽

Board Of Directors ◽

Research Funding ◽

Metabolic Tumor Volume ◽

Total Lesion Glycolysis ◽

University Of Arkansas ◽

Medical Sciences ◽

Focal Lesions ◽

Advisory Committees ◽

Pet Ct

Abstract Introduction: Focal lesions are important anatomical features seen in the bone marrow of multiple myeloma patients that contribute to drug resistance and disease relapse. Fluroine-18 fluorodexyglucose positron emission tomography with CT attenuation correction (18F-FDG PET/CT) is useful in the detection and enumeration of focal lesions and in semi-quantitative characterization of metabolic activity by calculation of glucose uptake reported as a standardized uptake value (SUV). Lesion count and SUV are predictors of outcome. Two additional variables, total lesion glycolysis (TLG) and metabolic tumor volume (MTV) can also be assessed and have the potential to improve the value of this approach. The purpose of this study was to determine whether TLG and MTV can predict progression free survival (PFS) and overall survival (OS), and to determine whether they are superior to traditional assessment methods. Materials and Methods: 191 patients underwent whole body PET/CT in the Total Therapy 3A trial and were evaluated using 3 dimensional region of interest analysis with TLG, MTV, and standard measurement parameters derived for all focal lesions with peak SUV above the background red marrow signal. Survival analysis was performed using Kaplan-Meier and log-rank tests. Univariate and multivariate analyses were performed using Cox proportional hazards regression. Results: Baseline characteristics show that 43/191 patients (23%) had no detectable lesions by PET. 1-3 lesions were present in 55/191 (28%) of patients and over 3 lesions in 93/191 (49%) of patients. A baseline TLG >205g was seen in 18% (34/191) of patients, with a TLG >620g being seen in 7% (14/191). A baseline MTV >210cm3 was seen in 7% (14/191). The distribution of patients with high TLG scores between molecular subgroups was not even with patients in the PR, MF and HY subgroups having higher scores. The 3 year PFS and OS for patients with no PET focal lesions was 83.1% and 88.3%, for patients with 1-3 lesions was 83.9%, and 85.5%, and for patients with >3 lesions 59.6% and 63.5% (p<0.0001). The 3 year PFS and OS for patients with a baseline TLG of less than 205g was 82.8% and 86.0%, compared to patients with a baseline TLG between 205g and 620g of 75.0% and 80.0%, and to patients with a baseline TLG of greater than 620g of 14.3% and 21.4% (p<0.0001). A similar pattern was seen for complete response (CR) duration. The MTV also had prognostic importance with 3 year PFS and OS for patients with a baseline MTV of less than 210cm3 at 81.4% and 84.7%, compared to patients with a baseline MTV of greater than 210cm3 of 21.4% and 28.6% (p<0.0001). Pearson Correlation Coefficient (r) between MTV and TLG was 0.94232 (p-value <.0001). On univariate analysis baseline PET/CT with >3 focal lesions (HR 1.92, 95% CI 1.22-3.04, p=0.004), TLG >205g (HR 2.99, 95% CI 1.83-4.88, p<0.0001), baseline TLG > 620g (HR 6.90, 95% CI 3.67-12.97, p<0.0001), and MTV >210cm3 (HR 6.20, 95% CI 3.33-11.54, p<0.0001) were statistically significant in predicting OS and PFS. In multivariate analysis baseline TLG>620g retained prognostic significance for predicting PFS and OS together with high B2M, LDH and GEP based proliferation. Importantly baseline TLG >620g and baseline MTV >210cm3 were statistically more predictive of poor PFS and OS than baseline PET with >3 focal lesions in both univariate and multivariate models. Conclusion : TLG assessment is superior to counting the number of focal lesions. It is the optimum method for evaluating the extent of focal lesions and to predict clinical outcome. As this measurement can be standardized using FDA approved software, it should be utilized clinically and in trials going forward. Disclosures McDonald: University of Arkansas for Medical Sciences: Employment. Waheed:University of Arkansas for Medical Sciences: Employment. Ntambi:University of Arkansas for Medical Sciences: Employment. van Rhee:University of Arkansa for Medical Sciences: Employment. Zangari:University of Arkansas for Medical Sciences: Employment; Novartis: Research Funding; Onyx: Research Funding; Millennium: Research Funding. Heuck:Janssen: Other: Advisory Board; Millenium: Other: Advisory Board; Foundation Medicine: Honoraria; Celgene: Consultancy; University of Arkansas for Medical Sciences: Employment. Petty:University of Arkansas for Medical Sciences: Employment. Schinke:University of Arkansas for Medical Sciences: Employment. Thanendrarajan:University of Arkansas for Medical Sciences: Employment. Mitchell:Cancer Research and Biostatistics: Employment. Hoering:Cancer Research and Biostatistics: Employment. Barlogie:International Workshop on Waldenström's Macroglobulinemia: Other: Travel Stipend; ComtecMed- World Congress on Controversies in Hematology: Other: Travel Stipend; European School of Haematology- International Conference on Multiple Myeloma: Other: Travel Stipend; Celgene: Consultancy, Research Funding; Millennium: Consultancy, Research Funding; Myeloma Health, LLC: Patents & Royalties: Co-inventor of patents and patent applications related to use of GEP in cancer medicine licensed to Myeloma Health, LLC; Dana Farber Cancer Institute: Other: Travel Stipend; Multiple Myeloma Research Foundation: Other: Travel Stipend. Morgan:Weisman Institute: Honoraria; CancerNet: Honoraria; MMRF: Honoraria; University of Arkansas for Medical Sciences: Employment; Bristol Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; Takeda-Millennium: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Davies:Array-Biopharma: Membership on an entity's Board of Directors or advisory committees; Takeda-Millennium: Membership on an entity's Board of Directors or advisory committees; University of Arkansas for Medical Sciences: Employment; Onyx-Amgen: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees.

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A Phase I Study of Bendamustine Combined with Lenalidomide and Dexamethasone in Patients with Refractory or Relapsed Multiple Myeloma.

Blood ◽

10.1182/blood.v114.22.1856.1856 ◽

2009 ◽

Vol 114 (22) ◽

pp. 1856-1856 ◽

Cited By ~ 1

Author(s):

Suzanne Lentzsch ◽

Amy O’Sullivan ◽

Silvana Lalo ◽

Carrie Kruppa ◽

Diane Gardner ◽

...

Keyword(s):

Multiple Myeloma ◽

Partial Response ◽

Board Of Directors ◽

Dose Level ◽

Research Funding ◽

Advisory Board ◽

Clinical Activity ◽

Advisory Committees ◽

Equity Ownership ◽

Grade 3

Abstract Abstract 1856 Poster Board I-882 Background: Lenalidomide is an analog of thalidomide that has shown significant clinical activity in patients with relapsed or refractory multiple myeloma (MM), both as a single agent and in combination with dexamethasone. Bendamustine is a bifunctional alkylating agent that is approved for the treatment of chronic lymphocytic leukemia and indolent non-Hodgkin's lymphoma that has progressed during or relapsed within 6 months following a rituximab-containing regimen. Bendamustine combined with lenalidomide may be an effective treatment option for MM patients, particularly those with preexisting or bortezomib-induced neuropathy. Our primary objective was to determine the maximum tolerated dose (MTD) and safety profile of bendamustine and lenalidomide when administered with dexamethasone for patients with relapsed or refractory MM. Methods: Patients aged ≥18 years with confirmed, measurable stage 2 or 3 MM that was refractory to or progressed after 1 or more prior therapies, including lenalidomide, received bendamustine by intravenous infusion on days 1 and 2, oral lenalidomide on days 1–21, and oral dexamethasone on days 1, 8, 15, and 22 of each 28-day cycle. Treatment was continued until a plateau of best response, as determined by the IBMTR/ABMTR, was reached. Study drug doses were escalated through 4 levels (Table), with 3–6 patients enrolled at each level depending on the rate of dose-limiting toxicity (DLT). After determining the MTD, up to an additional 12 patients will be enrolled in an MTD expansion arm to better evaluate toxicity and clinical activity. Secondary endpoints included preliminary efficacy, as evidenced by objective response, time to disease progression, and overall survival. Results: To date, 11 patients have been enrolled, with a median age of 63 years (range, 38–75 years). The MTD of bendamustine and lenalidomide has not been identified at this point; currently, patients are enrolling on dose level 3 with 100 mg/m2 bendamustine and 10 mg lenalidomide. Thus far, DLT included 1 grade 4 neutropenia at dose level 2. Nine of 11 patients are currently eligible for response assessment. A partial response was observed in 67% of patients, including 1 very good partial response and 5 partial responses (PR). Two patients experienced stable disease and 1 exhibited progressive disease. Grade 3/4 adverse events included grade 3 neutropenia, thrombocytopenia, anemia, hyperglycemia, and prolonged QTC, and 1 grade 4 neutropenia. Conclusions: Bendamustine, lenalidomide, and dexamethasone form a well-tolerated and highly active regimen even in heavily pretreated MM patients, with a PR rate of 67%. Additional updates on response and MTD will be available at the time of presentation. Disclosures: Lentzsch: Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Cephalon: Consultancy, Membership on an entity's Board of Directors or advisory committees. Off Label Use: Bendamustine is not FDA approved for the treatment of multiple myeloma in the USA. Burt:Millennium: Honoraria; Celgene: Honoraria. Mapara:Resolvyx: Consultancy, Research Funding; Genzyme: Membership on an entity's Board of Directors or advisory committees; Gentium: Equity Ownership; Celgene: Spouse is consultant , has received research funding, and participates on advisory board; Cephalon: Spouse has received funding for clinical trial and participates on advisory board. Redner:Biogen: Equity Ownership; Wyeth: Equity Ownership; Glaxo-Smith-Kline: Equity Ownership; Pfizer: Equity Ownership; Genzyme: Membership on an entity's Board of Directors or advisory committees. Roodman:Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Research Funding, Speakers Bureau; Celgene: Consultancy; Acceleron: Consultancy. Zonder:Amgen: Consultancy; Pfizer: Consultancy; Cephalon: Consultancy; Millennium: Consultancy, Speaking (CME only); no promotional talks.

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