Until recently, MM was defined using strict clinical pathological criteria that required evidence of specific end-organ damage (CRAB) attributable to the underlying clonal plasma cell disorder. In ...the case of absence of end-organ damage, patients with clonal plasma cell proliferation were diagnosed either with monoclonal gammopathy of undetermined significance (MGUS) or with smoldering multiple myeloma (SMM). Further, on one hand there have been on-going revisions of the diagnostic criteria for MM and SMM, on the other there have also been revisions of the molecular classification of these disorders; namely, staging and risk. These revisions regarding both the diagnostic criteria and the molecular classification of these disorders are very important because recent advances in understanding these disorders have led to significant progress in the treatment of MM and SMM, in our understanding of disease biology, and in prognostic evaluation for cancer patients. The Revised International Staging System (RISS) combines elements of tumor burden (ISS) and disease biology (presence of high-risk cytogenetic abnormalities or elevated lactate dehydrogenase level) to create a unified prognostic index that helps in clinical care, comparing clinical trial data. The RISS will be of importance in the clinic in terms of counseling patients regarding prognosis, as well as in clinical trials to compare outcomes across clinical trials. The initial cytogenetic classification of SMM also has implications for prognosis as patients with t(4;14) translocation, 17p deletion, and 1q amplification have a higher risk of progression from SMM to MM. Although patients with trisomies are considered to have a better prognosis when diagnosed with MM, they have a higher risk of progression from SMM to MM compared to patients with t(11;14). It is possible that trisomic MM manifests earlier with more obvious bone disease, producing in essence a lead-time bias. Thus, the time from SMM to MM is shortened while the time from MM to death appears longer. There are several molecular subtypes of MM, associated with several unique differences in disease presentation and prognosis. For example, trisomic MM appears to respond particularly well to lenalidomide-based therapy, while t(4;14) MM requires bortezomib-based induction and maintenance for good outcome. In terms of clinical presentation, t(4;14) MM appears to have a lower propensity for bone disease at diagnosis, while t(14;16) MM is often associated with high levels of serum free light chains (FLC) and a higher risk of acute renal failure at diagnosis. Disease biology in MM is best reflected based on the molecular subtype of the disease and the presence or absence of specific cytogenetic abnormalities. The abnormalities such as t(4;14), t(14;16), t(14;20), gain(1q), del(1p), and del(17p) influence disease course, response to therapy, and prognosis in MM. In our center we evaluated the cytogenetics data at the onset of the disease, after 1st line therapy, after transplantation and during maintenance therapy to analyze any changes in the cytogenetic panel and additional anomalies and if all this is correlated with the characteristics of the disease, patient, and risk predictor. In particular, we evaluated 160 patients and analyzed the clinical evolution in patients in which monosomies 13 and/or 14 were present, currently not classifiable in prognostic terms. The significance of these monosomies was evaluated based on the various stages of the disease and the type of therapy administered.
No relevant conflicts of interest to declare.
Background: Salvage autologous stem cell transplant (sASCT) has been indicated as possible therapeutic option at first (1 st) relapse, alternative to continuous treatment with novel agent ...combinations in selected Multiple Myeloma (MM) patients (pts). Particularly, MM pts who are eligible for a transplant procedure at the time of relapse and who have prolonged progression free survival (PFS) after the 1 st ASCT - i.e. at least 36 or 18 months, respectively, with or without Lenalidomide (Len) maintenance - are those who could benefit most from sASCT. There are limited data regarding the frequency of choice for sASCT in the current therapeutic scenario and the outcome of sASCT when incorporating novel Len-based triplets KRd (Carfilzomib-Lenalidomide-Dexamethasone) and DaraRd (Daratumumab-Lenalidomide-Dexamethasone) as induction regimens before sASCT. Aims: To explore the real-life use, efficacy, and outcome of sASCT preceded by novel agent-based re-induction therapy in a population of unselected Len-sensitive MM population in the 1 st relapse. Patients and methods: We planned a retrospective multicenter study, approved by local ethic committees, aimed at identifying MM Len-sensitive pts in the 1 st relapse addressed to sASCT. On a final cohort of 663 MM pts addressed in 22 Italian centers to Len-based triplets salvage therapy from 2017 to December 2022, sASCT after Len-based re-induction was the therapy of choice for 123 pts (18.6%), while the remaining 540 pts (81,4%) were addressed to continuous Len-based triplets until progression or unacceptable toxicity. The rate of pts addressed to sASCT at the time of the 1 st relapse was distributed as follows: 81 pts out of 512 pts (15.8%) received sASCT in the time window 2017-2019, 42 pts out 151 (27.8%) between 2020-2022 (p=0.001). Table 1 summarizes patients' characteristics and treatment history details. In our series 1 st ASCT was performed without Len maintenance. All pts entering the analysis received re-induction treatment before sASCT as well as continuous therapy with DaraRd or KRd according to standard schedule and doses. sASCT consisted of Melphalan 200 mg/m 2 as a conditioning regimen followed by infusion of ≥2*10 6 CD34* cells per kg body weight. The option to perform maintenance therapy following sASCT was chosen by the attending physician. The response was assessed according to IMWG criteria. Compared with pts treated with continuous Len-based triplets, those addressed to sASCT were younger (62 vs 68 years, p<0.001), with a longer time from diagnosis (3.9 vs 2.5 years, p<0.001), and they received a higher rate of prior ASCT (80.5% vs 53.8%, p<0.001). Regarding the sASCT program, KRd was the most common choice for the re-induction phase (102 pts, 82.9%), DaraRd was used in the remaining 21 pts (17.1%). The median number of cycles before sASCT was 6 (range 4-10), and maintenance after transplant was performed only in 18 pts (14.9%). sASCT was associated with an overall response rate (ORR) of 94.3% (116 pts), with 78% (96 pts) of very good partial response or better (≥VGPR), and 35.5% (43 pts) of CR. No case of transplant-related mortality was documented. After a median follow-up of 33.6 months (IQR 21.3-51.8), the median PFS of pts addressed to sASCT was 36.6 months, with 24-month PFS of 75% (95%CI 65-82%)(Figure 1). When a multivariableCox regression model was carried out including 1 st ASCT, the best response to 1 st line therapy and ≥36 months PFS after 1 st line therapy, as well as the number of re-induction KRd/DaraRd cycles as covariates, only PFS ≥36 months after 1 st-line therapy retained an independent statistically significant association with a reduced progression/death risk after sASCT (HR=0.5, 95%CI; 0.2-1.0, p=0.049). The median overall survival (OS) was not yet reached with a 2-year OS of 89% (95%CI: 81-93%). Conclusions: This study on 663 consecutive MM cases in the first relapse showed that salvage transplants retained a significant role in the current clinical management of MM, accounting for around 19% of selected salvage strategies. The incorporation of the highly active combinations KRd and DaraRd used as re-induction regimens before sASCT was associated with a significantly high rate of deep and long-lasting response, representing a possible alternative strategy to continuous therapy with Len-based triplets. The major benefit of Len-based triplets followed by sASCT was related to prolonged remission after first-line therapy.
Introduction Three TKIs, imatinib (IM), dasatinib (DAS) and nilotinib (NIL), are approved for frontline therapy in Italy. Choice of frontline TKI is based mainly on evaluation of patient's ...characteristics and clinical expectations. To avoid long term adverse events or potential drug interactions, elderly patients may start CML treatment with a frontline reduced dose of TKI (RD-TKI). Aim To analyse outcome of CP-CML patients aged over 65 years in a large and unselected cohort treated with RD-TKI. Methods We retrospectively evaluated 747 patients from 1/2012 to 12/2019 at 36 Hematology Centres participating at the “Campus CML” project. Results Clinical features for the whole cohort according to frontline TKI initial dose are reported in Table 1. Among all patients, 605 (81%) were treated with standard dose (SD) while the remaining 142 (19%) with reduced dose (RD). As to frontline TKI, 579 patients (77%) received IM and 158 (23%) a 2G-TKI (DAS n=78, 49%; NIL n=80, 51%). Of the 142 RD-TKI, 122 (85.9%) started with IM, 14 (9.9%) with DAS and 6 (4.2%) with NIL. Median RD was 100 mg for IM (range 100-300), 20 mg for DAS (range 20-50) and 250 mg for NIL (range 150-300). RD-TKI was mainly reported in IM treated patients (p=0.018), in elderly (p<0.001) and in patients with comorbidities, in particular diabetes (p=0.005) and ischemic heart disease (p=0.039). Number of concomitant drugs was also significantly associated with RD-TKI (p<0.001) probably to avoid drug interactions and subsequent toxicity. In detail, among RD-TKI, 41.1% of patients was treated with more than five concomitant drugs. Sokal score did not impact on TKI starting dose. No differences emerged between SD-TKI and RD-TKI in terms of haematological or extra-haematological toxicity. TKI frontline dose was not associated with difference in resistance, nor primary neither secondary resistance. Progression to blastic phase was reported in 1.2% of the whole population, none of which in RD-TKI. At 12 months no differences were noted in terms of achievement of major molecular response (MMR), obtained in 22.4% of SD-TKI treated patients and in 19% of RD-TKI treated patients. RD-TKI had inferior probability of deep molecular response (DMR) achievement (p=0.003), reported in 12.6% of patients. No differences were reported in 12-months cumulative rate of permanent discontinuation for any cause and for primary resistance between SD-TKI and RD-TKI as reported in Figure 1. Conclusions RD-TKI was a frontline treatment strategy used mainly in frail elderly patients, with more comorbidities and concomitant therapies. RD-TKI did not impact on primary resistance leading to TKI switch. While no differences were reported in the rate of MMR, the rate of 12-months DMR achievement was inferior in RD-TKI, but this result need to be confirmed with longer follow-up.
Introduction Median age at diagnosis in patients with Chronic Myeloid Leukemia (CML) is about 60 years: only few data are available in younger subjects at present. Aim To analyze initial features, ...choice of frontline Tyrosine-Kinase Inhibitor (TKI) and early adverse events leading to permanent TKI discontinuation in the first 12 months from TKI start in newly diagnosed subjects aged ≤ 40 years in a large and unselected real-life cohort of CML patients. Methods We retrospectively evaluated 1963 patients newly diagnosed from 1/2012 to 12/2019 at 38 Hematology Centers in Italy participating at the “Campus CML” project: according to age at diagnosis, 302 were ≤ 40 years Younger Patients (YP), 900 were > 45 < 65 years Intermediate Aged Patients (IAP) and 761 were ≥ 65 years Elderly Patients (EP). Results Clinical features, frontline TKI and causes of early TKI discontinuation according to age at diagnosis are reported in the Table 1. As to baseline clinical features, YP had significantly higher WBC count, lower Hb levels and higher rate of spleen enlargement: moreover, as expected, low-risk Sokal score was more common and rate of concomitant diseases/number of concomitant drugs lower in YP. As to frontline TKI, 96 YP (31.1%) received imatinib (IM) and 206 (68.9%) a 2G-TKI dasatinib (DAS) n=60, 19.9%; nilotinib (NIL) n=144, 47.6%: choice of 2G-TKI as frontline treatment was significantly more common in YP compared to both IAP and EP (p < 0.001). Causes of permanent frontline TKI discontinuation during the first 12 months of treatment according to age at diagnosis are reported in the Table 1: among YP, 45 (14.9%) discontinued frontline TKI treatment due to hematologic toxicity (5 cases, 1.6%), extra-hematologic toxicity (11 cases, 3.7%), primary resistance (24 cases, 8.0%), secondary resistance (2 cases, 0.6%) or evolution in blastic phase (BP) (3 cases, 1.0%). Cumulative incidence of permanent discontinuation at 12 months was 14.6% (95%CI 10.7 - 18.5) in YP compared to 16.9% (95%CI 14.3 - 19.2) in IAP (p=0.388) and 24.0% (95%CI 20.9 - 27.1) in EP (p < 0.001) (Figure 1): considering only permanent TKI discontinuation due to treatment resistance (primary resistance + secondary resistance + evolution in BP), no difference was observed according to age at diagnosis 9.6% (95%CI 6.3 - 12.9) in YP versus 10.2% (95%CI 8.2 - 12.2) in IAP versus 11.8% (95%CI 9.6 - 14.0) in EP, p=0.589. Conclusions Our data highlight the following peculiar clinical features at baseline and during the first year of treatment in YP with CML compared with IAP and EP: a delayed diagnosis, outlined by higher WBC count and rate of spleen enlargement; an expected choice of 2G-TKI as frontline treatment in the real-life, even if about one third of them was still treated with IM; a lower incidence of early frontline TKI permanent discontinuation compared to EP but not IAP, mainly due to toxic causes and not related to resistance. Data on early molecular response and further evaluations at 24 and 36 months are warranted to complete present analysis.
Introduction Treatment of chronic phase (CP) chronic myeloid leukemia (CML) with tyrosine kinase inhibitors (TKIs) proved to be almost equally effective in young and elderly patients. Three TKIs, ...imatinib (IM), dasatinib (DAS) and nilotinib (NIL), are approved for frontline therapy in Italy. Choice of frontline TKI is based on a combined evaluation of patient's characteristics and expectations, with age usually playing a prominent role. However, to date, few data are available on patterns of TKI selection in very elderly patients.
Aim To analyse the use of frontline TKI therapy in a large and unselected cohort of very elderly CP-CML patients
Methods We retrospectively evaluated 332 patients aged ≥75 year diagnosed from 1/2012 to 12/2019 at 36 Hematology Centres participating at the “Campus CML” project.
Results Clinical features at diagnosis for the whole cohort and according to frontline TKI are reported in Table 1. As to frontline TKI, 285 patients (85.8%) received IM and 47 (14.2%) a 2G-TKI (DAS n=28, 59.5%; NIL n=19, 40.5%). Of the 285 IM-treated patients, 192 (67.3%) started with standard dose (400 mg/day) and 93 (32.7%) with a reduced dose (300 mg/day n=64, 22.5%; <300 mg/day n=29, 10.2%). Among the 47 patients starting a 2G-TKIs, 35 (74.4%) received standard dose and 12 (25.6%) a reduced dose (NIL <600 mg/day n=3; DAS 80 mg/day n=4 and 50 mg/day n=5). There were no differences between patients treated with imatinib or 2G-TKI (Table 1); only a previous cerebrovascular event was reported in a significantly higher rate of IM-treated patients. It is however evident that the distinct toxicity profiles of NIL and DAS had an impact on TKI choice as, for example, no patient with diabetes or ischemic heart disease received NIL.
Following widespread introduction of generic IM in Italy in early 2018, patients were divided in 2 groups: among 238 patients diagnosed from 2012 to 2017, 198 (83.1%) received IM and 40 (16.9%) a 2G-TKI, while patients diagnosed in 2018-2019 were treated with IM in 87/94 (92.5%) cases and with a 2G-TKI in 7 (7.5%) cases only (p=0.028).
Conclusions IM remains the frontline drug of choice in very elderly CML patients, and this trend seems to increase after the introduction of the generic formulation. However, 2G-TKI are used in a small but sizeable group of patients, without a clear correlation with baseline CML features, thus probably reflecting a physician's evaluation of patient's fitness and/or expectation. Efficacy and safety of initial reduced TKIs doses in the setting of very elderly patients warrant further analyses.
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Latagliata: Novartis: Honoraria; BMS Cellgene: Honoraria; Pfizer: Honoraria. Bonifacio: Novartis: Honoraria; Pfizer: Honoraria; Amgen: Honoraria; Bristol Myers Squibb: Honoraria. Elena: CELGENE: Other: funding for meeting participation; PFIZER: Membership on an entity's Board of Directors or advisory committees; NOVARTIS: Membership on an entity's Board of Directors or advisory committees; GILEAD: Membership on an entity's Board of Directors or advisory committees. Iurlo: Novartis: Speakers Bureau; Incyte: Speakers Bureau; Pfizer: Speakers Bureau; Bristol Myers Squibb: Speakers Bureau. Sportoletti: AstraZeneca: Consultancy, Honoraria; Janssen: Consultancy, Honoraria; AbbVie: Consultancy, Honoraria. Stagno: Pfizer: Consultancy, Honoraria, Other: Support for attending meetings and/or travel; InCyte: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Other: Support for attending meetings and/or travel, Research Funding. Abruzzese: Pfizer: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Incyte: Consultancy, Honoraria; Bristol Myers Squibb: Consultancy, Honoraria. Breccia: Bristol Myers Squibb/Celgene: Honoraria; Incyte: Honoraria; Abbvie: Honoraria; Pfizer: Honoraria; Novartis: Honoraria.
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