ALBERT

Description: Introduction: Daratumumab (DARA) is a first-in-class human CD38 IgG1κ monoclonal antibody that has demonstrated activity as monotherapy and in combination with standard of care regimens for multiple myeloma (MM). Population pharmacokinetics (PPK) analyses were conducted to describe the PK characteristics of DARA following its administration in combination therapies, to evaluate the influence of covariates on its disposition in patients with MM who had received ≥1 prior therapy, and to compare its PK in combination therapies with that of monotherapy. Exposure-efficacy/safety analyses were performed to investigate the relationship between DARA exposure and selected efficacy and safety endpoints. Methods: The PPK analysis primarily included data from two phase 3 studies in which DARA was combined with background regimens: MMY3003 (POLLUX; lenalidomide [R]/dexamethasone [d]) and MMY3004 (CASTOR; bortezomib [V]/d). Data from two phase 1/2 studies (GEN503 [Rd] and MMY1001 [pomalidomide/d; Vd; V-thalidomide-d; V-melphalan-d]) were also used. Most patients included in the analysis (684 of 694) received 16 mg/kg DARA intravenously. A PPK model based on previous monotherapy studies was used to fit the concentration-time data from combination studies. Subgroup analyses were conducted to evaluate the influence of patient and disease characteristics on exposure to DARA. Based on data from MMY3003 and MMY3004, the exposure-efficacy analyses investigated the relationship between maximal trough concentrations (Cpre-infusion,max) and progression-free survival (PFS), duration of response (DOR), and overall response rate (ORR), while the exposure-safety relationship was explored for infusion-related reactions (IRRs), thrombocytopenia, anemia, neutropenia, lymphopenia, and infections. Results: Exposure to DARA was similar between the monotherapy and combination therapies. Based on combination therapy data, the effects of the intrinsic and extrinsic factors (age, sex, race, renal and hepatic impairment, baseline albumin, type of MM, region, type of combination therapy, ECOG, refractory status, and number of prior lines of therapy) were similar to or smaller than those in the monotherapy studies. Consistent with the monotherapy studies, none of the investigated intrinsic and extrinsic factors had clinically important effects on the exposure to DARA as all the covariate effects were within 25%. Although the clearance and volume of distribution of DARA increased with increasing body weight, the exposure to DARA was relatively consistent across the range of body weights after administration on a mg/kg-basis. Despite the decreasing concentration of DARA over time due to less frequent dosing, the current dosing schedule was adequate to produce concentration levels that maintained target saturation during the Q4W dosing period in the dosing schedules for MMY3003 (QW for 8 weeks, Q2W for 16 weeks, and Q4W, thereafter) and MMY3004 (QW for 9 weeks, Q3W for 15 weeks, and Q4W, thereafter). The exposure-efficacy analyses on the data from combination therapies suggest that maximum clinical benefit to PFS, DOR, and ORR was attained for the majority of the patients with an acceptable safety profile at the recommended dose of 16 mg/kg. No apparent relationships between drug exposure and IRRs, thrombocytopenia, anemia, neutropenia, and lymphopenia were identified within the studied concentration range. Although the overall rate of infection (any grade) appeared to increase with drug exposure, this trend was not observed for grade ≥3 infections. These findings were consistent with results from the monotherapy studies. Conclusion: The PK of DARA was similar between monotherapy and combination studies. No clinically relevant demographic or clinical characteristics were identified. Therefore, no dose adjustment based on these factors is recommended. Population PK and exposure-response analyses for combination therapies support the recommended body weight-based 16 mg/kg dose and the dosing schedules for the MMY3003 and MMY3004 studies. Disclosures Xu: Janssen: Employment, Equity Ownership. Liao:Pharmax: Employment; Janssen Research & Development: Consultancy; Johnson & Johnson: Equity Ownership. Dimopoulos:Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Genesis: Consultancy, Honoraria; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees. Sonneveld:Amgen, Celgene, Janssen, Karyopharm, Takeda: Consultancy, Honoraria; Amgen, Celgene, Janssen, Karyopharm: Research Funding. Ho:Janssen, Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees. Belch:Amgen, Celgene, Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees. Capra:Janssen: Speakers Bureau. Gomez:Janssen, Bristol Myers Squibb, Celgene, Amgen: Consultancy. Medvedova:Oregon Health & Science University: Employment. Iida:Janssen Pharmaceuticals, Takeda Pharmaceuticals Co, Celgene, Bristol-Myers Squibb, Ono Pharmaceuticals Co: Honoraria; Janssen Pharmaceuticals, Takeda Pharmaceuticals Co, Celgene, Bristol-Myers Squibb, Chugai Pharmaceuticals, Kyowa Hakko Kirin Co, Eli Lilli Japan, Novartis Pharma, Sanofi, Bayer Yakuhin, Toyama Chemical Co, Teijin Pharma, Astellas Pharma: Research Funding. Qi:Janssen: Employment. Schecter:Janssen: Employment, Equity Ownership. Khokhar:Janssen: Employment. Yan:Janssen: Employment; Johnson & Johnson: Equity Ownership. Zhang:Janssen: Employment, Equity Ownership. Clemens:Johnson & Johnson: Equity Ownership; Janssen: Employment.

Description: ADAMTS-13 is a protease, member of the ADAMTS family (A Disintegrin and Metalloproteinase with ThromboSpondin type 1 repeats-13), which cleaves the cell bound large ultrapolymeric von Willebrand factor (vWF) strings. Circulating ADAMTS-13 is primarily synthesized and released from hepatic stellate and endothelial cells. Acquired functional deficiency of ADAMTS-13, usually due to inhibitory IgG autoantibodies, results in excessive platelet aggregation and disseminated vWF/platelet-rich thrombus formation. A possible association of low levels of ADAMTS-13 Ag with arterial thrombosis and endothelial dysfunction has also been reported. Hivert and colleagues (Blood 2012;120:3214-21) and our group have shown that increased levels of vWF, the only known substrate of ADAMTS-13, are associated with poorer prognosis in patients with symptomatic Waldenstrom’s Macroglobulinemia (WM). Thus, our aim was to investigate the possible association of ADAMTS-13 antigen (Ag) levels with features of WM and possible biologic implications of the ADAMTS-13 / vWF interaction in WM patients’ prognosis. Our study included 42 patients with symptomatic WM who were treated and followed in the Department of Clinical Therapeutics of the University of Athens (Greece), from 1999 to 2012, 22 patients with asymptomatic WM and 19 healthy controls of matched gender and age. For the purpose of this study we used stored serum, which had been collected before initiation of any therapy. ADAMTS-13 antigen levels were measured using a commercially available kit (R&D Systems, Minneapolis, MN, USA), which has a detection limit for ADAMTS-13 13 (ng/mL) with intra- and inter-Assay Precisions of

Description: Advances in the management of multiple myeloma (MM) led to a significant prolongation of overall survival (OS), mainly of the younger patients; almost 10% of them experience more than 10-year OS. Although long progression-free survival (PFS) correlates with extended OS, there is very limited information for the characteristics of patients who manage to be progression-free for a long period after first-line therapy. The aim of this analysis was to evaluate the characteristics of patients who achieved at least 7-year of PFS after frontline therapy and compare them with those of all other patients who were treated in a single center during the same time period. Between January 1994 and December 2010, 406 consecutive newly diagnosed MM patients received first line therapy in the Department of Clinical Therapeutics (Athens, Greece). All patients had symptomatic disease, based on the IMWG criteria of that period (at least one CRAB symptom to start anti-myeloma therapy). Thirty-six (8.8%; 23M/13F) patients achieved a PFS of at least 7 years (long PFS group) after frontline treatment. The median PFS of these 36 patients is 10 years, while the other patients had a median PFS of 22 months. Long PFS patients were younger (median age 56 vs 68 years; p

Description: Introduction: Achievement of MRD negativity in MM is associated with prolonged progression-free survival (PFS) and is being investigated as a potential surrogate for established clinical endpoints, such as PFS and overall survival (OS). Here, we evaluated the predictive utility of MRD in patients (pts) with MM for PFS and OS using a systematic literature review (SLR) and meta-analysis, and investigated how hazard ratios (HR) for PFS and OS, stratified by MRD status, changed for various pt subgroups. Methods: A SLR was conducted to identify all studies in MM reporting survival outcomes by MRD status (through 8 June 2019). In these studies, MRD was assessed by various assays (multiparametric flow cytometry [MFC], next generation sequencing [NGS], and polymerase chain reaction [PCR]), sensitivity thresholds (10-4, 10-5, and 10-6), and disease settings (relapsed/refractory MM [RRMM], transplant-eligible [TE] and transplant-ineligible [TIE] newly diagnosed MM [NDMM]). Studies with allogeneic transplant, where MRD was measured in peripheral blood or using PET-CT, or from which PFS and OS data could not be extracted were excluded from the analysis. To obtain a pooled effect estimate of MRD status on PFS and OS HRs, a meta-analysis was performed. Subgroup analyses were performed to adjust for variables expected to impact the association of MRD and PFS/OS outcomes. Variables were selected based on available qualitative evidence from studies. Statistical analyses were performed using the 'metafor' R package for meta-analyses. Results: 143 publications met the inclusion criteria; 86 publications were included in the meta-analysis based on data availability (65 PFS and 28 OS HRs). Outcomes for PFS (N = 8590) and OS (N = 3392) were significantly improved for MRD-negative pts: PFS HR 0.35 (95% confidence interval [CI], 0.31-0.39) and OS HR 0.48 (95% CI, 0.41-0.55; P

Description: Background: Survival of patients (pts) with multiple myeloma (MM) decreases with increased age (Pulte, Oncologist, 2011). In addition, MM pts with advanced disease who have exhausted treatment (Tx) with novel agents have a poor prognosis (Kumar, Leukemia, 2012). Pomalidomide (POM) is a new oral agent with antimyeloma, stromal cell inhibitory, and immune modulatory effects (Quach, Leukemia, 2010; Mark, Leuk Res, 2014). In the pivotal MM-003 trial, POM in combination with low-dose dexamethasone (LoDEX) demonstrated significant progression-free survival (PFS) and overall survival (OS) benefits vs. high-dose dexamethasone, with a tolerable safety profile in refractory or relapsed and refractory MM (RRMM; Dimopoulos, Blood, 2013). In MM-003, significant PFS and OS benefits with POM + LoDEX Tx were seen in different age groups; tolerability and dose intensity were not affected by age (Weisel, Blood, 2013). STRATUS is a multicenter, single-arm, open-label, European, phase 3b trial to further evaluate safety and efficacy of POM + LoDEX in a large pt population. This analysis examines outcomes by age (≤ 65 vs. 〉 65 yrs, and ≤ 70 vs. 〉 70 yrs). Methods: Eligible pts had refractory or relapsed and refractory disease (progressive disease [PD] during or within 60 days of last line of Tx), having previous BORT and LEN failure and adequate prior alkylator therapy as defined in study protocol. Pts must have been refractory to the last prior Tx line. Pts with Eastern Cooperative Oncology Group performance status 〉 2 were excluded. Pts received 28-day cycles of POM 4 mg D1-21 + DEX 40 mg (20 mg for pts aged 〉 75 yrs) once weekly. All pts received thromboprophylaxis with low-dose aspirin, low-molecular-weight heparin, or equivalent based on clinical recommendations. Tx continued until PD or unacceptable toxicity. The primary endpoint was safety; the secondary endpoints included POM exposure, overall response rate (ORR; ≥ partial response), duration of response (DOR), PFS, and OS. Outcomes were analyzed by pt age at baseline (≤ 65 vs. 〉 65 yrs, and ≤ 70 vs. 〉 70 yrs). Results: As of March 17th, 2014, a total of 456 pts have been enrolled, and 452 had received POM + LoDEX; 48% were aged ≤ 65 yrs, 52% were 〉 65 yrs, 71% were ≤ 70 yrs, and 29% were 〉 70 yrs. Pts were heavily pretreated (median 4-5 prior Tx depending on age subgroup). Median follow-up was 6.8 mos. Younger pts (≤ 65 yrs) were more likely to have better renal function (creatinine clearance ≥ 60 mL/min; 80%) than those aged 〉 65 (49%). Median relative dose intensity was similar independent of age (range, 0.95-0.97 mg/day). The most common grade (Gr) 3-4 treatment-emergent adverse events (TEAEs) across age groups were neutropenia, anemia, thrombocytopenia, and pneumonia (Table). Gr 3-4 deep vein thrombosis (DVT) with prophylaxis was 1% in each subgroup. Discontinuations of POM due to TEAEs were low in pts aged ≤ 65 (0.9%), 〉 65 (3.0%), ≤ 70 (1.3%), and 〉 70 (3.8%) yrs. Outcomes by age are summarized in the Table. ORR was consistent for pts aged ≤ 65 (38%), 〉 65 (32%), ≤ 70 (35%), and 〉 70 (34%) yrs; DORs were 5.1, 6.8, and 5.8 mos and not estimable (NE) in these pt populations, respectively. Median PFS and median OS were similar across all age groups (PFS range, 4.0-4.9 mos, OS range, 10.6-11.5 mos). Conclusions: The data reported here further demonstrate the tolerability and efficacy of POM + LoDEX in pts with RRMM in the age subgroups analyzed (≤ 65 vs. 〉 65 yrs and ≤ 70 vs. 〉 70 yrs). Safety profiles were consistent, while dose intensity was similar across age groups. PFS, OS, and response rates were comparable with those previously reported in trials of POM + LoDEX in pts with RRMM and reinforce 4 mg POM as an appropriate starting dose irrespective of age. These data support POM + LoDEX as a standard Tx option for pts with refractory or RRMM regardless of age. Table 1. Age ≤ 65 yrs (n = 215) Age 〉 65 yrs (n = 237) Age ≤ 70 yrs (n = 319) Age 〉 70 yrs (n = 133) Grade 3-4 TEAEs, % Neutropenia Anemia Thrombocytopenia Pneumonia 38 30 22 13 41 24 16 10 38 29 21 11 44 23 15 11 Grade 3-4 EOI, % DVT/PE PN 1

Description: Renal impairment (RI) is a frequent complication of multiple myeloma (MM) and is associated with significant morbidity and risk of early death. Patients with severe RI (eGFR 90 days, p=0.14). There was no significant difference in the probability of major renal response or time to renal response for those who received VTD vs VCD, PAD or VMP, even after adjusting for need of dialysis and age. Among patients who required dialysis, 9 (56%) received a three drug combination (5 VTD, 3 VCD and one PAD); among patients who became independent of dialysis 3 received VTD, 1 PAD and 3 VD. An early death (within

Description: Light chain (AL) amyloidosis is characterized by the extracellular deposition of clonal light chain-derived amyloid fibrils in various tissues. Kidneys and heart are most commonly affected; clinically non detectable deposits in other tissues may also result in significant dysfunction. Amyloid deposits within the wall of the arteries or direct toxicity of light chains may cause arterial dysfunction in patients with AL amyloidosis, with cardiovascular consequences. Endothelial dysfunction, subclinical atherosclerosis of the carotid arteries and stiffening of the arterial tree are commonly found as deleterious vascular phenotypes and are considered surrogate markers of cardiovascular disease and outcome. Matrix metalloproteases, advanced glycation products, endothelial dysfunction and neuroendocrine signaling are implicated in arterial dysfunction and are affected in AL amyloidosis. However, arterial involvement in AL has not been evaluated thoroughly. In order to evaluate vascular dysfunction in patients with AL amyloidosis we evaluated non-invasively acquired markers which may be indicative of vascular involvement: hemodynamic [reflected waves and aortic blood pressures (BP)], functional [flow-mediated dilatation and carotid-femoral pulse wave velocity (PWV)] and structural [intima-media thickness (IMT) and the presence of plaques in the carotid arteries] markers of vascular damage were measured. Ninety-one (91) consecutive newly diagnosed patients with systemic AL were prospectively studied and compared to 91 controls matched 1:1 for traditional risk factors of cardiovascular disease (age, gender, smoking, hypertension, hyperlipidemia, diabetes) and for the presence of coronary artery disease. The median age of patients with AL was 65 years (range 40-83), 56% were males, 77% had renal and 57% cardiac involvement. Median NTproBNP was 1420 pg/ml, 25%, 49% & 26% were Mayo stage 1, 2 & 3 respectively, median eGFR was 66 ml/min/1.73 m2and median involved FLC (iFLC) level was 189 mg/L. First we compared indices of vascular damage between AL patients and matched controls: arterial stiffness (PWV: 10.4±3.0 vs 8.6±3.7 m/sec, p=0.002) and arterial wall thickness in the internal carotid artery (IMT: 0.76±0.21 vs 0.68±0.21 mm, p=0.017) were significantly higher in AL patients. Thus, subclinical vascular damage, independent from traditional factors of vascular dysfunction, is present in patients with AL. Peripheral systolic and diastolic blood pressure and aortic systolic, diastolic and pulse pressure (p≤0.001) and reflected waves (augmentation index (AI), p=0.045) were significantly lower in AL patients than in controls. After adjustment for NTproBNP levels, as a marker of cardiac dysfunction, the differences in blood pressures (systolic, diastolic and pulse pressure) remained significant (p≤0.008 for all). Thus, despite increased arterial stiffness, dysfunctional vasculature results in paradoxically lower systolic and diastolic blood pressure, a hallmark of AL amyloidosis, independently from the degree of cardiac dysfunction. We then examined possible associations of markers of AL with the indices of vascular dysfunction, after adjustment for risk factors of cardiovascular disease. The level of iFLCs was an independent determinant of lower peripheral systolic (p=0.021) and aortic systolic (p=0.009) and pulse pressure (p=0.013), hsTnT (p=0.016) and NTproBNP (p=0.001) levels were independent determinants of arterial stiffness (PWV). In a multivariate model mean blood pressure and NTproBNP were the only determinants of PWV. NTproBNP also correlated with the presence of plaques in the internal carotid arteries (p=0.006) independently of other risk factors of vascular disease. Thus, markers of cardiac dysfunction and the load of FLCs were associated with vascular dysfunction. Our results suggest vascular involvement in patients with AL amyloidosis, reflected at low aortic blood pressures, increased arterial stiffness and wall thickness in the internal carotid arteries. The association of the amount of light chains with aortic blood pressure suggests a role of the toxic light chain. The observed association of arterial stiffness with markers of heart involvement is indicative of a parallel process of heart and vascular injury in AL amyloidosis. Further research, to assess the clinical utility of markers of vascular damage in AL amyloidosis is needed. Disclosures No relevant conflicts of interest to declare.

Description: Lytic bone involvement in primary systemic (AL) amyloidosis is uncommon. To-date, there is no systematic study of bone metabolism in patients with AL amyloidosis. For this reason, we evaluated prospectively 102 patients with previously untreated AL amyloidosis who were diagnosed between January 2000 and June 2008 in the Plasma Cell Dyscrasias Unit of the Department of Clinical Therapeutics (Athens, Greece). All patients had histologically confirmed AL amyloidosis, while the definition of organ involvement, hematological and organ response and progression were based on consensus criteria. The levels of the following bone remodeling indices were measured before the administration of any kind of therapy: i) osteoclast regulators: soluble receptor activator of nuclear factor-kappaB ligand (sRANKL), osteoprotegerin (OPG), chemokine C-C motif ligand 3 (CCL-3, previously known as MIP-1alpha) and osteopontin; ii) bone resorption markers: C- and N- telopeptide of type-1 collagen (CTX and NTX, respectively) and tartrate resistant acid phosphatase type-5b; iii) bone formation markers: bone-alkaline phosphatase and osteocalcin. The results were compared with those of 35 age- and gender-matched healthy controls, 40 patients with monoclonal gammopathy of undetermined significance (MGUS) and 35 newly diagnosed, untreated patients with symptomatic multiple myeloma (MM). The median age of AL patient was 65 years (range: 39-80 years); 43% were males; 60% had heart involvement, 73% renal involvement, 11% liver involvement and 40% had peripheral/autonomous nerve system involvement; 67% of patients had two or more organs involved; 16% had a baseline serum creatinine 〉2 mg/dl. The median serum albumin was 3.2 g/dl, the median serum β2-microglobulin was 1.8 mg/L and the median 24h urine protein was 3350 mg/24h. Median NT-proBNP was 1954 pg/ml; 26%, 41% and 33% of patients were Mayo stage -1, -2 and -3, respectively. None of AL patients had lytic bone lesions in plain radiography or other features suggestive of MM, such as hypercalcemia, significant anemia unrelated to renal impairment or predominant Bence-Jones proteinuria. Bone resorption (assessed by CTX or NTX) in AL-patients was increased (p