ALBERT

Description: Key Points Pomalidomide-cyclophosphamide-prednisone is an active combination in multiple myeloma patients who are relapsed/refractory to lenalidomide.

Description: Abstract 446 Background: The outcome of myeloma (MM) patients who are no longer responding to thalidomide, lenalidomide or bortezomib is poor, with a median event-free survival of 5 months and median overall survival (OS) of 9 months (Kumar SK et al, Leukemia 2012). The newer immunomodulatory drug pomalidomide, has shown significant activity in these clinical conditions. Aims: We assessed dosing, efficacy and safety of pomalidomide-cyclophosphamide-prednisone (PCP) in MM patients relapsed/refractory to lenalidomide. Methods: Pomalidomide was administered in doses ranging from 1 to 2.5 mg/day on days 1–28, cyclophosphamide at 50 mg every other day on days 1–28 and prednisone at 50 mg every other day on days 1–28 for 6 cycles, followed by maintenance therapy with pomalidomide-prednisone. Thromboprophylaxis with aspirin 100 mg/day or low-molecular weight heparin was recommended at physician's discretion. Results: The maximum tolerated dose (MTD) of pomalidomide was defined as 2.5 mg/day. Fifty-two patients were enrolled at the MTD and evaluated after completing at least 1 PCP cycle. Median age was 69 years (range 41–83). The median time from diagnosis to enrolment was 55 months (range 15–203). Best responses to PCP included 6% of complete response (CR), 19% of at least very good partial response (VGPR), 54% of at least partial response (PR) and 75% of at least minimal response (MR). Time to PR was rapid (median 1.8 months). After a median follow-up of 11 months (range 1–18), 1-year progression-free survival (PFS) and OS rates were 52% and 78%, respectively. PFS was not significantly different in patients with high-risk cytogenetic compared with patients with standard-risk disease and in patients younger or older than 75 years. Toxicities were primarily hematologic and included grade 4 neutropenia (13%) and thrombocytopenia (4%). At least grade 3 non-hematologic toxicities included infections (8%), rash (6%) and neurologic (6%). Thromboembolism occurred in 1 patient. Four patients discontinued treatment for toxicity (2 infections, 1 neurologic and 1 hepatic toxicity). Conclusions: PCP induced high response rates and prolonged PFS after prior exposure to lenalidomide and bortezomib (Table), without adding significant toxicity. PCP could be considered a valuable salvage option for pre-treated MM patients. Disclosures: Palumbo: Celgene: Consultancy, Honoraria. Larocca:Celgene: Honoraria. Sciacca:Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees. Guglielmelli:Celgene: Honoraria. Giuliani:Celgene: Research Funding. Boccadoro:Celgene: Consultancy, Honoraria.

Description: In vitro evidences suggest that bisphosponates (BP) may exert some anti-myeloma activities. Indeed, the use of BP has been associated with better survival in selected subgroups of myeloma patients. We have previously reported that pamidronate, a second generation BP, is not useful to prevent or to delay the need of chemo-radiotherapy in patients with early stage or smouldering myeloma, who do not require specific treatments at diagnosis, although such a therapy may reduce skeletal events at the time of disease progression (Musto et al, Leuk Lymphoma2003; 44: 1545). Based on this limited evidence, the recently updated ASCO guidelines still not recommend the use of BP in this specific setting of patients (Kyle et al, J Clin Oncol2007; 25: 2464). On June, 2001, we started a randomised clinical trial comparing zoledronate (ZOL), a third generation, more potent BP, vs simple observation in patients with monoclonal gammopathy fulfilling the diagnostic criteria of stage IA, IIA or smouldering myeloma, not requiring further treatments. These criteria substantially correspond to the current definition of “asymptomatic myeloma”, recently suggested by the International Myeloma Working Group (IMWG, Br J Haematol2003; 121: 749). Accrual was completed on June, 2004. One-hundred-sixty patients were enrolled and randomised (1:1) to receive (n. 80) or not (n. 80) ZOL (Zometa, Novartis Pharmaceuticals. Origgio, Italy) for one year, on an out-patient basis, at the dose of 4 mg as 15′ i.v. single monthly infusion. The two groups were comparable at baseline for time from diagnosis, levels and type of M-component and percentage of bone marrow plasma cells. The most frequent adverse effects observed in ZOL-treated patients were moderate, not clinically relevant hypocalcemia (15 patients: all received oral substitutive therapy and continued the treatment) and fever (7 patients, one of whom stopped drug administration after two cycles). One patient developed reversible osteonecrosis of the jaw, none evidenced renal failure under ZOL therapy. Eight patients (two in the ZOL-treated group and six within controls) died due to unrelated reasons or were lost at follow-up after 6–26 months. No significant reduction of M-component (〉 25%) was observed throughout the study in both groups. After a median follow-up of 55 months (range 36–72), there were 35 (46%) progressions to “symptomatic” myeloma in the ZOL group and 37 (50%) within the controls (p n.s.). Median time-to-progression was 42.2 and 40.7 months, respectively (p n.s.). Bone lesions and/or hypercalcemia at the time of progression were significantly lower (17/35, 48.5%) in ZOL-treated patients than in controls (30/37, 81%) (p 〈 0.02). These mature data suggest that the monthly use of ZOL for one year in patients with early-stage, asymptomatic myeloma is safe, reduces the development of skeletal events at progression, but does not decrease the number of evolutions and does not prolong the time to transformation into “overt” myeloma.

Description: Abstract 128 Background. In newly diagnosed myeloma patients the combination of bortezomib with melphalan-prednisone (VMP) was superior to MP. In relapsed-refractory patients the 4 drug combination bortezomib-melphalan-prednisone-thalidomide (VMPT) induced a high proportion of complete responses (CR). Aims. This prospective, randomized, phase III trial, compared VMPT with a maintenance regimen including bortezomib and thalidomide with VMP without a maintenance regiment. The primary end point was PFS. Methods. Patients (N=511) older than 65 years were randomly assigned to receive VMPT followed by maintenance with bortezomib and thalidomide (N=254) or VMP (N=257). Initially, patients were treated with nine 6-week cycles of VMPT (induction: bortezomib 1.3 mg/m2 days 1,4,8,11,22,25,29,32 in cycles 1–4 and days 1,8,22,29 in cycles 5–9; melphalan 9 mg/m2 days 1–4; prednisone 60 mg/m2 days 1–4 and thalidomide 50 mg days 1–42; maintenance: bortezomib 1.3 mg/m2 every 15 days and thalidomide 50 mg/day) or VMP (bortezomib, melphalan and prednisone at the same doses and schedules previously described without maintenance). In March 2007, the protocol was amended: both VMPT and VMP induction schedules were changed to nine 5-week cycles and bortezomib schedule was modified to weekly administration (1.3 mg/m2 days 1,8,15,22 in cycles 1–9). Results. All patients have been evaluated in intention-to-treat. Patient characteristics were similar in both groups, median age was 71 years. The response rates were always superior in the VMPT group: at least PR rate (86% vs 79%, p=0.02), at least VGPR rate (55% vs 47%, p=0.07) and CR rate (34% vs 21% p=0.0008), respectively. Maintenance treatment did not increase the best response achieved during VMPT induction. After a median follow-up of 17.8 months, the 2-year PFS was 70.0% in the VMPT group and 58.2% in the VMP group (HR=0.62, 95% CI 0.44–0.88, p=0.008). The achievement of CR significantly prolonged PFS in both VMPT (p

Description: Background: In newly diagnosed myeloma patients the combination of bortezomib with melphalan-prednisone (VMP) was superior to MP. In relapsed-refractory patients the 4 drug combination of bortezomib-melphalan-prednisone-thalidomide (VMPT) induced a high proportion of complete responses (CR). Methods: Newly diagnosed myeloma patients (N=393) older than 65 years, from 58 centers in Italy, were randomly assigned to receive VMPT (N=193) or VMP (N=200). Initially, patients were treated with nine 6-week cycles of VMPT (bortezomib 1.3 mg/m2 days 1,4,8,11,22,25,29,32 in cycles 1–4 and days 1,8,22,29 in cycles 5–9; melphalan 9 mg/m2 days 1–4; prednisone 60 mg/m2 days 1–4 and thalidomide 50 mg days 1–42, followed by bortezomib 1.3 mg/m2 every 15 days and thalidomide 50 mg/day as maintenance) or VMP (bortezomib, melphalan and prednisone at the same doses and schedules previously described without maintenance). In March 2007, the protocol was amended: both VMPT and VMP schedules were changed to nine 5-week cycles and bortezomib schedule was modified to weekly administration (bortezomib 1.3 mg/m2 days 1,8,15,22 in cycles 1–9). Primary end-point was progression-free survival (PFS). Results: Patient characteristics were similar in both groups: median age was 71 years, 23% of patients were aged 〉 75 years. Patients who received at least 1 cycle were evaluated: 152 patients for VMPT (62 received bortezomib bi-weekly infusion and 90 weekly infusion) and 152 patients for VMP (62 received bortezomib bi-weekly infusion and 90 weekly infusion). Data were analyzed in intention-to-treat. The very good partial response (VGPR) rate was higher in the VMPT group (55% versus 42%, p=0.02), including a CR rate of 31% in the VMPT group and 16% in the VMP group (p=0.003). In the subgroup treated with weekly infusion of bortezomib, VGPR was 59% for VMPT and 37% for VMP (p=0.004), including 28% CR for VMPT and 10% for VMP (p=0.004). Subgroup analyses did not show any statistical difference between responses and either age, B2-microglobulin or chromosomal abnormalities, such as del13, t(4;14), t(14;16) and del17. After a median follow-up of 13.6 months, the 2-year PFS was 83.9% in the VMPT group and 75.7% in the VMP group (HR=0.73, 95% CI 0.38–1.42, p=0.35). In patients who received weekly infusion of bortezomib, the 2-year PFS was 86.8% in the VMPT group and 78.1% in the VMP group (HR=0.65, 95% CI 0.24–1.8, p=0.41). In patients who achieved CR after induction, the 2-year PFS was 100% for VMPT and 79% for VMP (p=0.02). The 3-year overall survival (OS) was 89.5% in the VMPT group and 88.7% in the VMP group (HR=1.02, 95% CI 0.43–2.46, p=0.96). The incidence of grade 3–4 adverse events (AEs) was similar in both groups. In the VMPT patients and in the VMP patients, the more frequent AEs were neutropenia (36% vs 31%), thrombocytopenia (20% vs 19%), peripheral neuropathy (18% vs 12%), infections (14% vs 10%), and gastrointestinal complications (7% vs 8%), respectively. The weekly infusion of bortezomib significantly decreased the incidence of grade 3–4 peripheral neuropathy (9% for VMPT and 3% for VMP). Conclusion: VMPT is superior to VMP in terms of response rates. Longer follow-up is needed to assess their effects on PFS and OS. The weekly infusion of bortezomib significantly reduced the incidence of grade 3–4 peripheral neuropathy without influencing outcome. Table. Complete responses, progression-free survival and peripheral neuropathy in all patients and in those who received weekly infusion of bortezomib VMPT group (n=152) VMP group (n=152) All patients (n=152) Subgroup with bortezomib weekly infusion (n=90) All patients (n=152) Subgroup with bortezomib weekly infusion (n=90) CR rate (%) 31 28 16 10 2-year PFS (%) 84 87 76 78 Grade 3–4 peripheral neuropathy (%) 18 9 12 3

Description: Introduction: The mammalian target of rapamycin (mTOR) is a serine/threonine-specific protein kinase, downstream of the phoshatidylinositol 3-kinase (P13-K/AKT) pathway. Constitutive activation of the mTOR related upstream and downstream effectors including P13-K, AKT, P70S6K and 4E-BP1 have been found in numerous malignancies. Previous studies demonstrated that rapamycin has preclinical potential as therapy for multiple myeloma (MM), especially when associated with other drugs. Methods. We performed immunohistochemical analysis with p-AKT (Ser 473), p-mTOR (Ser2448), p-P70S6K (Thr389) and p-4E-BP1 (Thr37,Trh46) on bone marrow sections of 73 symptomatic MM patients. Mielomatous plasmacells were identified and counted by mouse monoclonal CD138 nd all cases were analyzed using a semiquantitative histologic score (HSCORE) method. Specifically, immunostaining intensity of each case was semiquantitatively scored as follow: 0, no staining; 1,weak staining; 2, moderate staining; and 3, strong staining. For each case, a value designed HSCORE was obtained multiplying each intensity with the corresponding percentage of positive cells [HSCORE =∑(1XPC), where 1 and PC represent intensity and percentage of cells, respectively]. Specimen with an HSCORE of ≥30 were classified as p-AKT, p-mTor, p-P706SK and p-4E-BP1 positive. Wilcoxon test was used to compare mTOR expression with clinical data of all patients (including age, presence of bone lesions, isotype, Beta2-microglobulin, haemoglobin, creatinine and albumin serum levels). Common cytogenetic abnormalities (t(11;14), t(4;14), del 13q14 and del p53) were also detected in 61 of 73 (83.5%) patients by FISH analysis on CD138 purified plasma cells. Results. Fouty-four (60.2%) and 46 of 73 (63%) patients stained positive for p –AKT and p-mTOR with a cytoplasmic staining pattern, respectively. P-mTOR immunoreactivity was strongly, moderately and weakly positive in 23.9 %, 34.8 % and 41.3 % of the 46 positive samples, respectively. P-P70S6K and p-4E-BP1 was detected in 53 (72.6%) and 40 (54.8%) patients with a predominantly nuclear staining pattern. The intensity of positivity was distributed as follows: p-P70S6K strongly, moderately and weakly positive, 54.7 (%), 26.4 (%) and 18.9 (%),respectively; p-4E-BP1 strongly, moderately and weakly positive, 62.5 (%), 17.5 (%) and 20 (%), respectively; Of the 46 myelomas stained positive for p-mTOR, 35 expressed p-AKT, 33 expressed p-4E-BP1 and 40 demonstrated p-P70S6K positivity. P-mTOR expression significantly correlated with p-AKT (p=0.003), p-P70S6K (p

Description: We assessed efficacy, safety, and reversal of renal impairment (RI) in untreated patients with multiple myeloma given bortezomib-melphalan-prednisone-thalidomide followed by bortezomib-thalidomide (VMPT-VT) maintenance or bortezomib-melphalan-prednisone (VMP). Exclusion criteria included serum creatinine ≥ 2.5 mg/dL. In the VMPT-VT/VMP arms, severe RI (estimated glomerular filtration rate [eGFR] ≤ 30 mL/min), moderate RI (eGFR 31-50 mL/min), and normal renal function (eGFR 〉 50 mL/min), were 6%/7.9%, 24.1%/24.9%, and 69.8%/67.2%, respectively. Statistically significant improvements in overall response rates and progression-free survival were observed in VMPT-VT versus VMP arms across renal cohorts, except in severe RI patients. In the VMPT group, severe RI reduced overall survival (OS). RI was reversed in 16/63 (25.4%) patients receiving VMPT-VT versus 31/77 (40.3%) receiving VMP. Multivariate analysis showed male sex (P = .022) and moderate RI (P = .003) significantly predicted RI recovery. VMP patients achieving renal response showed longer OS. In both arms, greater rates of severe hematologic adverse events were associated with RI (eGFR 〈 50 mL/min), however, therapy discontinuation rates were unaffected. VMPT-VT was superior to VMP for cases with normal renal function and moderate RI, whereas VMPT-VT failed to outperform VMP in patients with severe RI, although the relatively low number of cases analyzed preclude drawing definitive conclusions. VMPT-VT had no advantage in terms of RI reversal over VMP. This study is registered at http://www.clinicaltrials.gov as NCT01063179.

Description: Although efficacy of thalidomide (thal) monotherapy in relapsed/refractory Multiple Myeloma (MM) is proven, the optimal duration of treatment is unknown. Here, we analysed individual patient data of 852 patients (pts.) with relapsed/refractory MM from 21 centres who received thal monotherapy in a trial or in a compassionate use program. To assess the influence of treatment duration, pts. who discontinued thal because of lack of efficacy, progression or death were excluded, so we analysed only pts. who continued on thal as long as they tolerated it or until the study they were enrolled in was complete. 162 pts. were evaluable; 32 completed the trial, 57 had severe neurotoxicity, 2 severe somnolence, 72 other adverse events leading to discontinuation of thal. The median age was 65 years (interquartile range 58–72), 92 (56%) were male, 96 (59%) had relapsed MM. Sixteen (10%) achieved complete remission (CR), 64 (39%) partial remission (PR), 29 (18%) minimal response, 34 (21%) no change, 9 (6%) had progressive disease, 9 (6%) were unevaluable for response. The median daily dose at 3 months was 200 mg/d (100–400), the cumulative dose after 3 months 23200 mg (9025–34150). Median time to response was 3.6 months (3–7), median treatment duration 5 months (2.3–12). Median event-free survival (EFS) was 16 months (95%CI 12–21), median overall survival (OS) 33 months (95%CI 22–44). In univariate analysis, prognostic factors for EFS/OS were leukocyte/platelet count, haemoglobin, cumulative dose at 3 months, duration of treatment and CR/PR. In multivariate analysis, duration of treatment, CR/PR and platelet count remained independent prognostic factors for EFS/OS. If pts. took thal for ≥ 10 months (n=51), median EFS was 31 (95%CI 14–48) vs 12 (9–14, p

Description: INTRODUCTION The mammalian target of rapamycin (mTOR) is a serine/threonine-specific protein kinase, downstream of the phoshatidylinositol 3-kinase (P13K)/AKT pathway. It controls many aspects of cellular physiology, including transcription, translation, cell size, cytosckeletal organization, autophagy and progression from the G1 to S phase of the cell cycle. Constitutive activation of the mTOR related downstream effectors including P13K, AKT, p70S6K and 4EPB1 was found in numerous malignancies. Rapamycin and its analogues are mTOR inhibitor currently being tested in solid and hematological tumours. Previous studies demonstrated that rapamycin have preclinical potential as therapy for multiple myeloma, especially when associated with other drugs. We first determined the frequency of the activation status of AKT/mTOR/p70S6K pathway in multiple myeloma patients and correlated its activation with FISH analysis and clinical data. METHODS Immunohistochemical analysis with phospo-AKT (Ser 473), phospho-mTOR (Ser2448) and phosphor-p70S6K (Thr389) (Cell Signaling Technology) was performed on a series of 44 multiple myeloma bone marrow sections. Slides were scored by two independent observers and staining was defined as weakly positive (〉10–30, +), moderately positive (〉30–70, ++) and strongly positive (〉70, +++). FISH analysis was performed on CD138 purified plasma cells of 31 myeloma patients with specific probes for the detection of the t (4;14)(p16.3;q32) and del 13q14 (Vysis). Clinical data of all patients including age, presence of bone lesion, isotype, serum beta2-microglobulin, C-reactive protein, haemoglobin level and albumin were evaluated and Fisher exact test was used to compare the expression of p-mTOR with p-AKT and p-p70S6K signaling protein and clinical data. RESULTS p-mTOR and p-AKT were expressed respectively in 26 of 44 (59.9%) and 23 of 44 (52.3%) patients, with a predominance of cytoplasmic staining pattern. p-mTOR immunoreactivity was strongly, moderately and weakly positive in 36%, 36% and 28% of the samples, respectively. p-p70S6S was detected in 26 patients (59.9%) with a predominantly nuclear staining pattern. Of the 26 myelomas stained positive for p-mTOR, 22 expressed p-AKT and all of them demonstrated p-p70S6S positivity. p-mTOR expression significantly correlated with both p-AKT (p

Description: Although preclinical work with rapalogs suggests potential in treatment of multiple myeloma (MM), they have been less successful clinically. These drugs allostearically inhibit the mammalian target of rapamycin kinase primarily curtailing activity of the target of rapamycin complex (TORC)1. To assess if the mammalian target of rapamycin within the TORC2 complex could be a better target in MM, we tested a new agent, pp242, which prevents activation of TORC2 as well as TORC1. Although comparable to rapamycin against phosphorylation of the TORC1 substrates p70S6kinase and 4E-BP-1, pp242 could also inhibit phosphorylation of AKT on serine 473, a TORC2 substrate, while rapamycin was ineffective. pp242 was also more effective than rapamycin in achieving cytoreduction and apoptosis in MM cells. In addition, pp242 was an effective agent against primary MM cells in vitro and growth of 8226 cells in mice. Knockdown of the TORC2 complex protein, rictor, was deleterious to MM cells further supporting TORC2 as the critical target for pp242. TORC2 activation was frequently identified in primary specimens by immunostaining for AKT phosphorylation on serine 473. Potential mechanisms of up-regulated TORC2 activity in MM were stimulation with interleukin-6 or insulin-like growth factor 1, and phosphatase and tensin homolog or RAS alterations. Combining pp242 with bortezomib led to synergistic anti-MM effects. These results support TORC2 as a therapeutic target in MM.