bluuebunny/crossref_metadata_2025 huggingface dataset:
RADAR Update on Thalidomide (Thal)- and Lenalidomide (Len)-Associated Venous Thromboembolism (VTE): Safety Concerns Persist for Multiple Myeloma (MM) Despite FDA Approvals in This Setting.
Authors: Bennett Charles L. , Hussain Zehra , Courtney Mark , Yarnold Paul , Raisch Dennis , McKoy June M.
Published: October 2019

BACKGROUND: At ASH 2004, we reported > 20% VTE rates with thal/dexamethasone (thal/dex) use as an off-label treatment for MM. The abstract prompted Richard Blumenthal, the Connecticut Attorney General, to file a Citizen’s Petition with the FDA in 2005 outlining six recommendations to address this safety concern. In 2006, the FDA indicated that four recommendations were approved. The AG’s request for a randomized clinical trial of aspirin, low molecular weight heparin (LMWH), and warfarin as VTE prophylaxis was denied- with the FDA indicating that preliminary data suggested that these agents are effective for prophylaxis. At ASH 2005, we reported > 20% VTE rates with len/dex treatment for MM. In response, the manufacturer pre-emptively included a “Black Box” warning describing high VTE rates when len was used off-label for MM. In 2006, len and thal received FDA approval for MM. The Research on Adverse Drug Events and Reports (RADAR) project conducted a systematic review of VTE rates when len or thal is prescribed for MM.

METHODS: Reports of VTE with thal or len treatment of MM were reviewed. Data sources included: the FDA’s MedWatch program and phase II/III clinical trial reports from 1998 to 7/2006.

RESULTS: FDA’s MedWatch program included reports of VTE occurring among 8 len- (3 on aspirin, 2 on warfarin, and 1 on MLWH) and 1076 thal-treated cancer patients. Clinical trials identified VTE rates of 15% among thal/dex treated patients and 14% among len/dex- treated MM patients (Table). Uncontrolled trials found that thal/dex-associated VTE rates were sometimes, but not always, lower with aspirin, LMWH, or warfarin (INR of 2 to 3), while little information on VTE prophylaxis is available for len-dex treated MM patients.

CONCLUSIONS: The extant data continue to support our assertion that randomized controlled trials are needed to identify appropriate VTE prophylaxis agents when MM patients receive len or thal with dex. Data on aspirin prophylaxis remain premature.

Clinical Trial VTE Results VTE rate among Thal treated MM patients (n = 2690) VTE rates among Len treated MM patients (n = 702) MM-extent of disease Untreated Relapsed/Refractory Untreated Relapsed/Refractory n/a = data not available     Thal/Dex None 96/667 (14.4%) 11/256 (4.3%) 38/278 (13.7%) 48/346 (13.9%) Warfarin (1–1.25 mg/d) 16/105 (15.2%) 8/85 (9.4%) n/a n/a Aspirin (81 mg/d) n/a n/a 9/54 (16.7%) n/a LMWH/Warfarin (INR 2–3) 0/63 (0.0%) 2/26 (7.7%) n/a n/a     Thal/Dex/Doxorubicin None 148/610 (24.3%) 47/271 (17.3%) n/a n/a Aspirin (81 mg/d) 3/45 (6.7%) n/a n/a n/a LMWH 19/211 (9.0%) n/a n/a n/a     Thal/Melphalan/Prednisone None 43/287 (15.0%) n/a n/a n/a Aspirin (81 mg/d) n/a n/a 1/24 (4.2%) n/a LMWH 2/64 (3.1%) n/a n/a n/a
Darbepoetin Alfa (DA) - Pattern of Use and Outcomes in Adult Patients with Non-Myeloid Malignancies and Chemotherapy-Induced Anemia: A French Observational Study.
Authors: Pigneux Arnaud P.M. , Ray-Coquard Isabelle L. , Dalivoust Philippe J.M. , Biostat Gaelle Chenuc , Bastie Anne M.
Published: October 2019

INTRODUCTION: DA is widely used to treat anemia in patients undergoing chemotherapy (CT) for non-myeloid malignancies. Three years after the commercialization of DA in France, a study of the pattern of DA use in daily practice was conducted in this population.

METHODS: A nationwide, retrospective observational study of DA use and patient outcomes was conducted in 239 centers between September 2004 and May 2005. Adult patients with non-myeloid malignancies, who had received DA for CT-induced anemia for at least three 3- or 4-weekly or at least five 2-weekly CT cycles (min. 9–12 weeks) were studied. Response was defined as hemoglobin (Hb) ≥ 12g/dL or a Hb increase of at least 2 g/dL from baseline to week 6/8. In addition, the proportion of patients achieving a Hb level of ≥ 11 g/dL as suggested by NCCN guidelines was assessed. Hb levels were evaluated at baseline, week 3 and week 6 (CT cycles of 21 days) or week 4 and week 8 (CT cycles of 15 or 28 days).

RESULTS: Of 2017 patients recruited, 1865 (92.5%) were evaluable at week 6 or 8. Analyses were conducted on the evaluable patient population. A total of 51% were female and the mean age was 62.5 years [range: 18–96 years]. The most common tumor types were non-myeloid hematological malignancies (25%), lung cancer (21%), breast cancer (16%) and gastrointestinal tumors (14%). A total of 37% of centers were University hospitals, 30% public hospitals, 21% private hospitals and 11% specialized cancer centers. Baseline mean Hb level was 10g/dL [range 5–16.6 g/dL]. A total of 843 patients at week 0 (45.4%) had a Hb <10g/dL. The first DA dose was administered to 40% of patients at the first CT cycle and to 60% of patients at subsequent cycles. At week 6/8, 707 patients (38%) had a Hb ≥ 12 g/dL and 1096 patients (58.8%) had a Hb ≥ 11 g/dL. During the study period, between week 0 and week 6/8, 272 pts (15.9%) received RBC transfusions.

CONCLUSIONS: Despite the very short follow-up of 6/8 weeks, almost 40% of the patients achieved a Hb ≥ 12 g/dL. More importantly, the proportion of patients reaching a Hb level within the range recommended by NCCN guidelines (≥ 11 g/dL) at this short follow-up was around 60%, which is comparable to results published in other trials of DA.
Bone Mineral Density in Transfusion Independent Thalassemia Patients.
Authors: Pakbaz Zahra , Zhang Zhe , Fung Ellen , Sweeters Nancy , Singer Sylvia , Vichinsky Elliott
Published: October 2019

Low bone mineral density (BMD) is commonly seen in regularly transfused thalassemia patients; however, there have been few reports for bone mineral density assessment in transfusion independent thalassemia patients. The present report includes the results of BMD assessments in patients with transfusion independent thalassemia who were referred to the bone density clinic through 2002–2006. BMD was evaluated by dual energy x-ray absorptiometry (DXA, Hologic Delphi A). A convenience sample of 24 patients (Females=15) with transfusion independent thalassemia were measured with a mean age of 22.1 ± 13.8 years. Subjects younger than 10 yrs old (n = 7) underwent scans for Lumbar spine (LS; L1-L4) and whole body (WB), patients ages 10–20 (n = 5) were assessed for LS, WB, and non-dominant hip, and for patients older than 20 (n = 12), LS and hip scans were completed. Z-scores specific for age and gender were generated using Zemel BS et al.(J. Bone Min Res 2004) database. Z-scores less than −2.0 were considered as low bone density. Calcium intake was assessed by a brief food frequency questionnaire. Past medical history, medications, history of fractures, and family history of osteoporosis were obtained by chart review and patient interview. Data is presented as Mean ± SD. T-test was used to assess differences in continuous variables. The mean LS Z-score (n = 24) was −1.5 ± 1.0 and the mean hip Z-score (n = 17) was −0.5 ± 1.1. Mean WB Z-score (n = 10) was −2.0 ± 1.2. There was a significant (p<0.001) difference between spine and hip Z-scores. Overall 46% had a Z-score less than −2.0. Thirty-three percent of patients have spine Z-scores of less than −2.0 and 25% spine Z-scores between −2.0 and −1.0. Average spine Z-score in patients younger than 10 years old (n=7) was −1.6 ± 0.5. In WB scans, 50% of the patients had WB Z-scores worse than −2.0. None of the young patients (5–9 yrs; n = 7) consumed inadequate intake of calcium (< 2/3 of RDA age specific) while 75% of patients ages 10–20 (n = 4) years old consumed inadequate intake of calcium (dietary + supplement). Neither spine nor hip Z-score was related to patients’ gender, age, and calcium intake. Two patients reported fractures in the past and two reported family history of osteoporosis. Six patients had delayed puberty and one has hypogonadism. Seven patients have short stature. This data suggests that low bone mass is not only a problem in transfused thalassemia patients, but is also observed in non-transfused patients. The significance and pathophysiology of low bone mass should be studied further in non-transfused patient population, especially in younger children.
Impact of Chemotherapy-Induced Anemia on Economic and Quality of Life Outcomes in Adults with Cancer.
Authors: Tran Kimbach T. , Stephens Jennifer M. , Liou Sarah Y. , Botteman Marc F.
Published: October 2019

OBJECTIVES: Anemia is one of the most common hematologic adverse events experienced by cancer patients. The incidence of chemotherapy-induced anemia is as high as 100% for Grade 1 to 2 and 80% for Grade 3 to 4 anemia, although it varies depending on the cancer type and treatment regimen administered. Anemia is associated with high healthcare costs as well as decreased quality of life. The objective of this study was to review the economic and quality of life (QoL) outcomes of anemia in cancer patients.

METHODS: A systematic search of the English-language literature published between 1990 and 2006 was conducted. Additional publications and conference proceedings were retrieved from the article bibliographies and included in the review. Articles selected include prospective or retrospective studies specifically designed to examine burden of illness, direct medical costs, indirect costs, cost drivers, or quality of life outcomes associated with chemotherapy-induced anemia in adult cancer patients. All original costs were reported, with adjusted figures (to 2006 dollars) presented in parentheses using the medical care component of the consumer price index from the US Bureau of Labor Statistics.

RESULTS: Of 183 abstracts screened, 36 met selection criteria and were reviewed in detail. Fifteen and 11 studies focused on economics and QoL burden associated with anemia, respectively. The average annual cost attributable to anemia ranges from $18,418 (2006 US$ $22,775) to $69,478 ($93,454) per patient. Inpatient and outpatient services account for a significant portion of the total costs of anemia. Other key cost drivers for anemia include the cost of erythropoietic drugs, which range from approximately $210 ($239) to $1,090 ($1,288) per week, and the cost of red blood cell (RBC) transfusions, which range from $232 ($323) to $512 ($712) per unit. Patients with hematologic malignancies require almost double the number of RBC units and have higher associated costs than patients with solid tumors. Indirect costs include lost work time due to fatigue for an average of 4.2 sick/vacation days per month. In addition to raising the cost of care, anemia affects patient QoL in the following key domains: energy/fatigue, role (ability to work), social function, and leisure activities. Furthermore, some patients may report daily fatigue, overall decreasing everyday QoL.

CONCLUSIONS: Anemia is a common hematologic adverse event experienced by cancer patients, resulting in significant health care costs, indirect costs, and decrements in patient QoL. In particular, patients with hematologic malignancies incur higher anemia-associated costs compared to patients with solid tumors. The economic burden of cancer treatment-induced anemia, as well as the impact on patient QoL, should be considered when making clinical decisions regarding the optimal treatment course for patients with cancer.
Microalbuminuria among Egyptian Children and Adult with Sickle Cell Hemoglobinopathy, Single Institution Study.
Authors: Ibrahim Wafaa E. , Abdelmonem Ashraf M. , Mahmoud Nermin H. , Mostafa Waleed
Published: October 2019

Introduction: Renal failure is one of the most serious complications of sickle cell diseases; it affects 5% – 18% and leads to early death. Protienuria is highly correlated with risk for future chronic renal failure.

Aim: to estimate the prevalence of microalbuminuria among Egyptian children and adults with sickle hemoglobinopathy, and to evaluate the effect ACE inhibitor on positive cases.

Subject and method: 60 patients (mean age 13.03±9.15) with sickle hemoglobinopathy were included. Patients were divided into 3 groups: sickle cell disease (group I) constituted 20%, Sickle ß-Thalassemia (group II) 46.6% and sickle cell trait (group III) 33.4%. Informed consent was obtained from patients and/or guardians and study approval by local IRB was obtained. Microalbuminuria was measured by turbidimetric assay in 24 hour urine collection. Patients with microalbuminuria were started on a 4 weeks trial of ACE inhibitor after excluding any contraindication for the drug. Patients were closely monitored for side effects and repeat microalbuminuria assay was done at the end of the trial period. Data were coded, entered and processed using SPSS (version 11).

Results: The prevalence of microalbuminuria was 32.5% in sickle cell disease, and sickle β thalassemia while in sickle cell trait was 5 % (p=0.02). The highest level of microalbuminuria (93.3+-146.27) was observed in sickle cell disease patients followed by sickle β thalassemia (63.82+-172.38) followed by sickle cell trait(18.75+-12.86).

Compared to patients with no microalbuminuria, the group with positive microalbuminuria was significantly older (18.31±4.48 vs. 9.24± 4.96 years), had higher number of blood transfusions / year (7.08±3.55 vs. 5.11±4.05), higher mean number of hemolytic crisis (2.38±1.98 vs. 1.11±1.19), higher mean number of pain crisis (2.92±1.61 vs. 2.2±1.48), and higher mean serum creatinine (0.63±0.31 vs. 0.47±0.19) (p<0.01).

After 4 weeks trial of ACE inhibitor there was a statistically significant reduction (77.9% reduction) in number of cases with microalbuminuria as well as level of microalbuminuria (dropped from 171.91 ± 251.60 to 27.11 ± 13.99) (p= 0.005). Conclusion: Microalbuminuria is a significant problem among patients with sickle cell disease. ACE inhibitors have significant impact on improving microalbuminuria.
Patients Mobilizing Large Numbers of CD34+ Cells ("Super-Mobilizers") Have Improved Survival in Autologous Stem Cell Transplantation for Lymphoid Malignancies.
Authors: Bolwell Brian J. , Pohlman Brad , Rybicki Lisa , Kalaycio Matt , Sobecks Ronald , Dean Robert M. , Bernhard Laura , Cherni Kelly , Ferraro Christina , Bates Jenny , Brown Stacey , Sweetenham John William
Published: October 2019

We have anecdotally observed that many patients mobilized with Etoposide (VP) + filgrastim (G) collect very high numbers of CD34+ cells for autologous stem cell transplantation (ASCT). Some BMT centers have suggested that the cellular composition of an autologous graft may influence ASCT outcome. We therefore queried whether patients collecting high numbers of PBPCs (“super-mobilizers”) have a better outcome than other patients. We retrospectively reviewed 693 consecutive adult patients with Non-Hodgkin Lymphoma (NHL) or Hodgkin Lymphoma (HL) receiving an ASCT from 1/1994 through 12/2005 treated with a uniform preparative regimen of Busulfan, Cyclophosphamide and Etoposide (Bu/Cy/VP). Of these 693 patients, 350 were mobilized with VP (2 gm/m2) + G and comprised the study population. After receiving VP+G, patients were collected for a minimum of 2 days with a collection goal of 7 × 106 CD34+ cells/kg. A minimum collection of 2.0 × 106 cells was required to proceed to ASCT. Super-mobilizers were defined as collecting, and infusing, greater than 8 × 106 CD34+ cells/kg. 203 patients were super-mobilizers, while 147 collected between 2.0 and 7.95 CD34+ cells/kg. Pre-transplant performance status, LVEF, and DLCO were similar between the two groups. Super-mobilizers were slightly younger (mean 47 years old vs. 51 years old, p=0.003) and more likely to have received 2 or fewer prior chemotherapy regimens, (80% vs. 63%, p<0.001). 82% of the entire study population had NHL and 18% HL, and 83% had chemotherapy sensitive disease at the time of ASCT. The super-mobilizer group required fewer days of pheresis for mobilization (median 2 days vs. 5 days, p<0.001). The median CD34+ dose of the super-mobilizer group was 13.7 × 106/kg vs. 4.4 ×106/kg in the standard collecting group. The super-mobilizer group had a superior overall survival as shown graphically below:

Figure Figure

A multivariable analysis was performed, and revealed three variables associated with improved survival: disease status at transplant (comparing patients in remission vs. those with refractory disease, p=0.004), younger age at transplant (p=0.033), and CD34+ cell dose (>8 vs. <8, p=0.038). We conclude that patients mobilized with VP+G achieving robust CD34+ cellular mobilization have an improved outcome after ASCT. The mechanism of action of this phenomenon is conjectural; further studies are required to determine if the composition of the infused graft directly influences outcome, and, if so, what specific cellular components are important. However, collecting large numbers of CD34+ cells may be clinically beneficial (regardless of the specific mechanism of action) and may warrant a change in definition of collection end points.
Testing Standard and Genetic Markers in 220 Patients with Multiple Myeloma (MM) with Complete Data Sets: Superiority of Molecular Genetics.
Authors: Shaughnessy John D. , Haessler Jeffrey , Hanamura Ichiro , Huang Yongsheng , Stewart James P. , Zhan Fenghuang , Sawyer Jeffrey , Anaissie Elias , van Rhee Frits , Tricot Guido , Epstein Joshua , Zangari Maurizio , Pineda-Roman Mauricio , Hollmig Klaus , Crowley John , Barlogie Bart
Published: October 2019

Background: Many prognostic models have been proposed for staging patients with MM, most recently the ISS system utilizing B2M and albumin.

Patients and Methods: In the context of Total Therapy 2 (TT2) for newly diagnosed MM, we identified 220 patients in whom 4 standard prognostic factors (SPF: B2M, albumin, LDH, hemoglobin), imaging data (MRI-defined focal lesions [MRI-FL]), metaphase-derived cytogenetic abnormalities (CA), FISH-derived amp1q21 and del13q14, and gene expression profiling (GEP)-derived data are available. The baseline characteristics and clinical outcome of the 220 patients are similar to those of the entire population of 668 patients receiving TT2. The median follow-up of the 220 patients is 42mo compared to 52mo for all 668 patients. Five multivariate analysis-based prognostic models were derived, utilizing SPF only (model I), with progressive addition of CA (model II), MRI (model III), FISH (model IV) and GEP (model V).

Results: In model I, B2M, LDH and hemoglobin, but not albumin were independently significantly associated with overall survival (OS) (R2=22.5%); upon introduction of CA (model II) (p=.008), only LDH remained significant (p=.033) (R2=28.3%); addition of MRI (model III) was not significant (R2=31.1%); addition of FISH (model IV) was significant for amp1q21 (p=.003) but not for del13q13, with CA remaining significant (p=.023) (R2=38.1%); when GEP was added (model V), the 70 gene-derived model (p<.001) and FISH-based amp1q21 (p=.025) were the only significant variables associated with OS (R2=43.4%). Indeed when GEP was entered into the model first, its R2 value was 24.6%, with the addition of amp1q21 raising R2 to 31.8%, beyond which only minor contributions were made by the remaining 7 variables. With the combined use of GEP and amp1q21, 3 risk groups could be distinguished with 5-yr OS rates of 82% with GEP-low risk/no amp1q21 (n=107), 61% with GEP-low risk/amp1q21 (n=78) and 29% with GEP-high risk regardless of amp1q21 status (n=35).

Conclusion: Among an ever increasing prognostication armamentarium in MM, few studies have investigated the concurrent use of all reputedly important variables. Here, we clearly show, in a comparison of 5 prognostic models that, once molecular genetic variables were introduced, standard prognostic parameters provided little if any further contribution. Therefore, such genetic tests should be more widely performed in order to adequately evaluate the results of clinical therapeutic trials and identify robust high-risk subgroups for novel therapies with purportedly unique mechanisms of action.

Figure Figure
A Gene Expression Signature of Benign Monoclonal Gammopathy Evident in Multiple Myeloma Is Linked to Good Prognosis.
Authors: Zhan Fenghuang , Barlogie Bart , Arzoumanian Varant , Huang Yongsheng , Hollmig Klaus , Pineda-Roman Mauricio , Tricot Guido , van Rhee Frits , Zangari Maurizio , Dhodapkar Madhav , Shaughnessy John D.
Published: October 2019

Monoclonal gammopathy of undetermined significance (MGUS) can progress to multiple myeloma (MM), often through a phase of smoldering MM (SMM). We hypothesized that a molecular signature of MGUS may be detectable in a subset of patients with MM. Applying Significance Analysis of Microarrays, 52 genes, involved in important pathways related to cancer, were found to be differentially expressed between plasma cells from 22 healthy subjects, 24 strictly defined MGUS/SMM and 351 symptomatic MM (P < .001). Unsupervised hierarchical clustering of 351 MM and 44 cases of MGUS and 16 cases of MM with a MGUS history, created two major cluster branches, one containing 82% of the MGUS cases and 28% of the MM, termed MGUS-like MM (MGUS-L MM). Using the same clustering approach on an independent cohort of 213 MM revealed 27% were MGUS-L. The MGUS-L MM signature was associated with a higher prevalence of low-risk clinical and molecular features and superior survival (P < .01), despite a lower incidence of complete remission (P = .006). The MGUS-L signature was also seen in 15 of 20 patients surviving more than 10 years after autotransplant. These data reveal molecular switches associated with the development and progression of plasma cell dyscrasias.
Nifuroxazide Inhibits STAT3 Function and Shows Potent Anti-Tumor Activity Against Multiple Myeloma.
Authors: Nelson Erik A. , Hideshima Teru , Gashin Laurie , Walker Sarah R. , Lynch Rebecca A. , Chauhan Dharminder , Anderson Kenneth C. , Frank David A.
Published: October 2019

Activation of the transcription factor STAT3 is essential for the pathogenesis of many cancers, including multiple myeloma. While normal cells can tolerate a reduction in STAT3 function, tumors often require constitutive STAT3 signaling for survival. Thus, identifying drugs that inhibit STAT3 activity may provide new therapeutic agents useful for cancer treatment. We have developed a high throughput cell-based screen to identify drugs that inhibit STAT3-dependent transcriptional activity. To assure the specificity of these drugs for STAT3 function, we performed a counter screen assessing NF-kappaB-dependent transcriptional activity. To bypass the difficulties inherent in the development of novel small molecules for clinical use, we analyzed a library of 1120 drugs that are either FDA approved, or are otherwise known to be safe in humans. From this screen, we identified nifuroxazide, a drug used to treat dehydration associated with diarrheal illness, as a potent inhibitor of STAT3 transcriptional activity. By contrast, nifuroxazide has no effect on NF-kappaB-dependent transcription. Myeloma cells containing constitutive STAT3 activation show decreased STAT3 tyrosine phosphorylation when incubated with 10 uM nifuroxazide. In addition, expression of STAT3 target genes necessary for myeloma survival, including bcl-x, mcl-1, and cyclin D1, is markedly reduced by 10 uM nifuroxazide. To determine whether these effects of nifuroxazide on STAT3 signaling alter cell viability, we utilized U266 myeloma cells, which depend on STAT3 activation for survival. U266 viability is inhibited by nifuroxazide at an EC50 of approximately 3 uM. Notably, RPMI 8226 myeloma cells, which do not contain activated STAT3, are not affected by comparable concentrations of nifuroxazide. In addition, this dose has no effect on normal peripheral blood mononuclear cells. Given that myeloma cells receive survival signals from bone marrow stromal cells, we determined if nifuroxazide affects myeloma survival in stromal cell co-cultures. Nifuroxazide is effective at reducing U266 viability in the presence of bone marrow stromal cells at an EC50 of approximately 3 uM. Thus, screening for compounds that inhibit STAT3 transcriptional activity is useful in identifying potential drugs for myeloma therapy. Through this approach, we have identified a novel STAT3 inhibitory function for nifuroxazide. Nifuroxazide inhibits STAT3 mediated survival of myeloma cells and may be useful, either alone or in combination with other drugs, for the treatment of patients with multiple myeloma.
HGF Inhibits BMP-Induced Osteoblastogenesis: Implications for the Bone Disease in Multiple Myeloma.
Authors: Standal Therese , Abildgaard Niels , Fagerli Unn-Merete , Stordal Berit , Hjertner Oyvind , Borset Magne , Sundan Anders
Published: October 2019

Multiple myeloma is a hematological malignancy characterized by accumulation of malignant plasma cells in the bone marrow. Most patients develop osteolytic lesions, caused by an uncoupling of bone formation from bone resorption. In patients with osteolytic lesions the osteoblasts are fewer and less active. HGF (Hepatocyte Growth Factor) is produced by the malignant plasma cells and is found at high concentrations in the bone marrow of most patients with multiple myeloma. In this study we show that HGF inhibited BMP-induced expression of alkaline phosphatase and mineralization in human mesenchymal stem cells (MSC) and the murine myoid cell line C2C12. Furthermore, the expression of the osteoblast-specific transcription factors Runx2 and Osterix was reduced by HGF treatment. HGF inhibited BMP-induced differentiation of MSC partly by keeping the cells in a proliferative, undifferentiated state. The in vitro data was supported by the observation of a negative correlation between HGF and a marker of osteoblast activity, bone specific alkaline phosphatase (rho=−0,45, p=0,008), in sera from 34 myeloma patients. These observations suggest that HGF inhibits bone formation in multiple myeloma.
SB431542, a TGF-Beta Receptor Kinase Inhibitor, Restores Bone Formation Which Ameliorates Myeloma-Induced Microenvironment.
Authors: Takeuchi Kyoko , Abe Masahiro , Oda Asuka , Amou Hiroe , Hiasa Masahiro , Asano Jin , Kitazoe Kenichi , Hashimoto Toshihiro , Ozaki Shuji , Kido Shinsuke , Inoue Daisuke , Matsumoto Toshio
Published: October 2019

Multiple myeloma (MM) cells stimulate bone resorption and concomitantly suppress bone formation, leading to devastating bone destruction. TGF-beta, a potent inhibitor for terminal osteoblasts (OB) maturation and mineralization, is abundantly produced and released from bone tissues through enhanced bone resorption, and activated by osteoclasts (OC)-derived acids and MMPs in MM bone lesions. In the present study we investigated the impact of TGF-beta inhibition on induction of bone formation in MM as well as the effects of matured OB on MM growth. TGF-beta completely suppressed BMP-2-induced mineralized nodule formation by OB cultured in osteogenic media supplemented with beta-glycerophosphate and vitamin C. SB431542, an inhibitor of TGF-beta type I receptor kinase, potently suppressed induction of Smad6 by TGF-beta, which inhibits BMP-2 signaling. SB431542 along with BMP-2 abolished such TGF-beta actions and enhanced mineralized nodule formation more than BMP-2 alone. Notably, addition of SB431542 antagonized the inhibitory effects of conditioned media from MM cell lines (RPMI8226 and U266) and bone marrow plasma from patients with MM, resulting in restoration of the BMP-induced mineralized nodule formation. Furthermore, MC3T3-E1 cells matured by BMP-2 enough to exhibit mineralized nodules suppressed the proliferation of 5TGM1 MM cells in sharp contrast to stromal cells as well as untreated or TGF-beta-treated undifferentiated MC3T3-E1 cells that promote MM cell growth and survival. Interestingly, 5TGM1 MM cell growth was also potently suppressed by MC3T3-E1 cells cultured with BMP-2 in the absence of beta-glycerophosphate to achieve OB maturation without formation of mineralized nodules, suggesting a responsible role for OB-derived non-mineralized factors associated with terminal differentiation of OB. In addition, the induction of OB maturation down-regulated the production by OB of IL-6 and up-regulated osteoprotegerin, an inhibitor for osteoclastogenesis. Taken together, blockade of TGF-beta actions release OB from the differentiational arrest in MM bone disease and thus can be a good therapeutic maneuver restoring bone formation as well as suppressing osteoclastogenesis to ameliorate bone destruction and at the same time suppressing MM expansion by disrupting the MM-induced microenvironment which can be called as MM niche.
Defective Adhesion, Migration and Homing Are Associated with Altered Rho GTPase Activity in Cells from Fanconi Anemia Patients.
Authors: Zhang Xiaoling , Shang Xun , Wang Lei , Guo Fukun , Zheng Yi , Pang Qishen
Published: October 2019

Fanconi anemia (FA) is a genetic disorder characterized by bone marrow failure and predisposition to malignancy. One of the potential therapeutic options for patients with FA is collection of autologous multipotent hematopoietic progenitors prior to the development of severe pancytopenia for autologous transplantation and gene therapy. However, poor engraftment of FA hematopoietic cells represents a major obstacle for effective transplantation. Our current study attempted to investigate the mechanism underlying defective engraftment of FA bone marrow (BM) cells. Using BM cells from patients carrying mutations in the FA complementation group A (FA-A), we demonstrate that SDF (Stromal cell-derived factor)-1alpha – and integrin-mediated migration and adhesion, respectively, is defective in FA primary BM cells compared to those from normal donors (more than 2-fold decrease in both migration and adhesion compared to normal BM cells). Complementation of the FA-A defect by retrovirus gene transfer of FANCA gene almost completely restores the ability of the BM cells to migrate towards the chemokine SDF-1alpha. Similar results are obtained with primary fibroblast cells derived from a FA-A patient, which show 3-fold and 35% decrease in adhesion and migration, respectively, compared to FANCA-corrected cells. Furthermore, when transplanted into immunodeficient Nod/scid recipient mice, the FA-A BM cells exhibited significantly impaired homing function whereas normal cells were efficiently homed in the bone marrow. A significant decrease in the activity of the Rho GTPase Cdc42 in FA-A cells is found associated with the patient cell defective functions. Taken together, these data suggest that the FA proteins play a role in the regulation of cell adhesion and migration in addition to maintaining genomic stability, influencing homing and engraftment, possibly via the small GTPase signaling pathway. These findings may have implications in development of strategies for restoring engraftment function of FA hematopoietic cells.
Multicenter Phase II Trial of Patients with Refractory or Recurrent Multiple Myeloma with Oral Treatment of Thalidomide Combined with Oral Cyclophosphamide, Idarubicin and Dexamethasone.
Authors: Schmidt-Wolf Ingo G.H. , Moehler Thomas , Goldschmidt Hartmut , Geer Thomas , Kleinschmidt Rolf , Gaska Tobias , Janssens Uwe , Schubert Joerg , Brueck Patrick , Clemens Michael R. , Bair Wolfgang , Seipelt Gernot , Schleuning Michael , Hahn-Ast Corinna , Herz Susanne , von Lilienfeld-Toal Marie , Naumann Ralph , Gorschlueter Marcus , Glasmacher Axel
Published: October 2019

Introduction and rationale: The aim of our study is to evaluate the role of thalidomide in combination with oral CID therapy in order to replace the central venous line necessary for continuous infusion of chemotherapy and to avoid hospitalization.

Patients and methods: Patients with refractory or recurrent myeloma were included into this trial. Concerning inclusion criteria, 9 patients had progressive disease after standard chemotherapy, 12 no change after standard chemotherapy, 6 recurrent disease after standard therapy and 21 recurrence after high dose chemotherapy. At start of the treatment patients were in stages IIA (15 patients), IIB (1) and IIIA (34). Idarubicin was given in capsules at 8–10 mg/m2/day for days 1–4, 40 mg dexamethasone were given on days 1–4 and 15–18, cyclophosphamide at 200 mg/m2/d d1–4 and thalidomide 100mg daily with scheduled increase to 400mg. Treatment cycles were repeated every 28 days. 3–8 cycles were applied. Supportive therapy consisted of PEG-filgrastim, cotrimoxazol, dalteparin and ibandronate. In addition, patients were randomized between thalidomide and thalidomide / idarubicin maintenance treatment.

Results: At this interim analysis, 64 patients have been entered into the ongoing trial; 8 patients had to be excluded. Of the 56 included patients, 50 patients have been documented so far and are evaluable for toxicity. In total, 182 cycles have been applied. Median cycle number was 3 (1–8). There was one death during treatment due to progressive myeloma at cycle 1. The median age was 62 years (interquartile range 57–67). The following toxicities were observed: FUO (2 patients), pneumonia (4), pulmonary embolism (1), exsiccosis after diarrhea (1), constipation (1), sepsis (1), severe nausea (2), syncope (1), collaps after bleeding (1) and mucositis grade 4 (1). Hematologic toxicity was reported in 34% of the patients, mainly in cycles 1 and 2. Concerning response to treatment 39 patients are evaluable so far. Of these 30 (77%) achieved a PR or MR according to EBMT criteria, 4 patients a stable disease and 2 patients a PD. Three patients were not evaluable and scorded as failures.

Conclusions: T-CID is feasible and seems to be highly effective in relapsed or refractory myeloma patients. Toxicity seems to be acceptable and mainly hematologic and infectiologic. The remission rate of 77% is encouraging. The trial is still ongoing. At the meeting a follow-up of the trial will be presented. Further information can be obtained at www.myelom.net.
Use of Free Light Measurements in Clinical Trials of Novel Agents in Multiple Myeloma.
Authors: Mazumder Amitabha , Jagannath Sundar
Published: October 2019

The free light assay has been reported to be valuable in monitoring patients with non-secretory multiple myeloma (MM). Furthermore, because of its short half-life, it may be useful even in patients who produce intact M-proteins. Recently, FLC has also been included in a revised response criteria for MM (BGM Durie et al International uniform response criteria for multiple myeloma. Leukemia, 7/20/06, online, 1–7,2006). We decided to study the applicability of the measurement of free light chains (FLC) in patients who were treated on clinical trials at our center with novel agents such as bortezomib and lenalidomide. We followed 21 patients with non- or hyposecretory MM with FLC measurements. These patients did not have measurable intact M-proteins and had only small amount of urine total protein (UTP) or Bence-Jones protein (BJP) present (< 0.3 mg/24hours). In 7 patients on bortezomib trials and 6 patients on lenalidomide trials, the involved FLC decreased by > 50% without the ability to detect any change in the UTP or BJP. The disease response seen was confirmed by bone marrow exams when available. Conversely, in 3 patients on each of the 2 agents, there was progression (> 25% increase) in the involved FLC without measurable increase in the small amount of UTP or BJP present, confirmed by either bone marrow or skeletal progression. Thus, in these patients, the FLC provided the only convenient means of monitoring. In 14 and 12 patients on bortezomib and lenalidomide respectively who had measurable UTP and BJP or serum M-proteins, there was a > 50% decrease in the FLC upto 8 weeks before any significant changes were seen in the urine protein measures or in serum M-proteins. Furthermore, the decrease continued after the UTP and BJP had reached a low possibly threshold level. In fact, 1 complete response on bortezomib was seen, confirmed by bone marrow studies, even with residual UTP (possibly due to bisphosphonate effect). Conversely, in 11 and 10 patients on bortezomib and lenalidomide respectively with measurable UTP and BJP or serum M, the increase in the involved FLC preceded progression in the parameters by upto 6 weeks. Thus, in these patients, the FLC provided an early warning system for their response or lack thereof. With respect to the criteria included in the reference cited above, the difference between the FLC was less meaningful in those patients with renal insufficiency, since both are significantly elevated in this state. The ratio however was the least meaningful since it was either 0 or infinite for a long time period depending upon which FLC was involved. Thus, FLC measurements are useful for monitoring patients who might not otherwise be eligible or benefit from clinical trials of novel agents. It can also serve as a early harbinger of response or progression. However, the limitations of the assay with respect to ratios and differences need to noted.
Efficient Expansion of Lymphocytes in a Culture System with Solid Phase Anti-CD3 and Anti-CD28 Monoclonal Antibodies.
Authors: Soeda Atsuko , Kondo Atsushi , Makiyama Hiroaki , Morita Yuriko , Takahashi Noriko , Yagita Hideo , Takaue Yoichi , Heike Yuji
Published: October 2019

[Background] In vitro cell expansion in culture with solid phase anti-CD3-mab (aCD3mab) is a standard method for lymphocyte proliferation and activation. However, clinical trials using activated lymphocytes with this system provided only minimal efficacy. Recently, aCD3mab/aCD28mab-coated micro-bead (aAPC) was developed as a novel tool to efficiently expand lymphocytes, and has been used in several clinical trials. This study was designed to evaluate the effects of solid phase aCD3mab/aCD28mab on the proliferation and activation of lymphocytes to compare the results with culture using aAPC.

[Methods and Results] Parameters to evaluate the efficacy of culture system included magnitude of cell proliferation, killing activity against K562 and various surface markers of cultured cells. Peripheral blood was obtained from healthy volunteers after an informed consent was obtained, and mononuclear cells (PBMNc) were separated by lymphosepal system. Firstly, we cultured PBMNc in system with solid phase aCD3mab/aCD28mab coated to a culture plate (Culture A) or with solid phase aCD3mab coated to a culture plate plus soluble form aCD28mab (Culture B) to seek an optimal condition in the solid phase for lymphocyte proliferation (Figures 1). The results showed that the optimal ratio of aCD3mab:aCD28mab for Culture A is 3:7 to yield fold-expansion of lymphocytes of 12–13, while this in Culture B with the same amount of monoclonal antibodies was 10 (n=6). There was no difference in the expression CD3, CD4 or CD8, and killing activity between expanded cells in Culture A and Culture B. Then, we compared optimized solid phase Culture A with liquid phase culture with aAPC (Culture C). As a result, cell proliferation in Culture A was 1.3–5.6 times higher and the killing activity was 1.1–1.8 times higher than Culture C (Figure 2). In Culture A, the cell expression of CD45RO and GITR was higher and that of CD161 was lower compared to Culture C (Figures 3). Solid phase culture system with aCD3mab/aCD28mab is efficient and easily applicable for the expansion of lymphocytes, however more detail characterization of the expanded cells, especially Treg function and in vivo survival, are necessary.

Figure 1. Figure 1. Figure 2. Figure 2. Figure 3. Figure 3.
Human Mesenchymal Stem Cell Therapy: Platelet Lysate Supports Efficient Preclinical Expansion.
Authors: Schallmoser Katharina , Malischnik Christina , Rohde Eva , Reinisch Andreas , Guelly Christian , Lanzer Gerhard , Linkesch Werner , Strunk Dirk
Published: October 2019

Coinfusion of hematopoietic stem cells with multipotent mesenchymal stromal/stem cells (MSC) to facilitate engraftment and immunomodulatory treatment of graft versus host disease (GvHD) are the two foremost applications of MSC therapy in hematology and oncology. Translation of promising experimental results into clinical applications has been mainly hampered by the strict dependence of MSC propagation from fetal bovine serum (FBS)-derived factors.

We analyzed the capacity of different preparations of human platelet lysates (HPL) to replace FBS for clinical scale MSC production with cytomic, proteomic and genomic technology.

Using a previously established two-step good manufacturing practice procedure for MSC propagation, we found that HPL can fully replace FBS as a growth factor supplement for clinical scale MSC preparation. HPL was reproducibly more efficient than FBS and supported the outgrowth of >400 million MSC from <0.4 million primary MSC (derived from <2mL bone marrow aspiration within 10 days ex vivo) within only 2 additional weeks of culture. Although morphologically distinct, HPL-MSC and FBS-MSC did not differ regarding their CD13+/29+/73+/90+/105+/146+/34−/45−/133−/HLA-AB+ immunophenotype. Multiplex analyses allowed delineating a distinct cytokine and growth factor profile. Whole transcriptome microarray analyses revealed a differential regulation of >300 genes after only one cycle of human as compared to bovine growth factor stimulation. Allogeneic HPL-MSC infusion in an intent to treat refractory GvHD was feasible and without infusion-related side effects in one patient. This new FBS-free two-step procedure for clinical scale MSC propagation will largely facilitate rational clinical testing of MSC based therapies. Replacing FBS with HPL excludes bovine prion, viral and zoonose contamination of the stem cell product. Based on this protocol a clinical trial for the treatment of steroid-refractory GvHD with HPL-MSC has been initiated.
New Cytogenetic Abnormalities Are Frequent in AML and MDS Relapsing after Allogeneic Hematopoietic Cell Transplantation (HCT).
Authors: Pollyea Daniel A. , Artz Andrew S. , Stock Wendy , Daugherty Christopher , Godley Lucy , Odenike Olatoyosi M. , Rich Elizabeth , Smith Sonali M. , Zimmerman Todd , Zhang Yanming , Huo Dezheng , Larson Richard , Van Besien Koen
Published: October 2019

There are limited data regarding the incidence or prognostic value of cytogenetic abnormalities in pts with leukemic relapse after allogeneic hematopoietic cell transplantation (HCT). Between 2002 and 2005, 70 consecutive pts with high risk AML or MDS were transplanted with a reduced intensity preparative regimen of fludarabine 30 mg/m2/day IV (150 mg/m2 total), alemtuzumab SC 20 mg/day IV (100 mg total) D-7 to D-3, and melphalan 140 mg/m2 IV D-2, with tacrolimus given for post-transplantation immunosuppression. Twenty-five pts relapsed or progressed; 21 had AML, 3 had MDS and 1 had mast cell leukemia.

Twenty-two pts had cytogenetic analysis available prior to HCT and at relapse. Cytogenetic abnormalities were present in 12/22 (55%) pts prior to HCT. The median OS was 184 days (95% CI: 81 – 300) after relapse. Four pts with cytogenetic abnormalities prior to HCT reverted to a normal karyotype at relapse. Ten pts had no changes in their cytogenetics from HCT to relapse; they either remained normal or retained the same abnormality. Eight pts developed a new clonal abnormality at relapse, and had a median OS of 106 days (95% CI: 30 – 322). There was a non-significant trend toward inferior OS among pts with new abnormalities compared to the other groups (HR = 1.74, 95% CI 0.69 – 4.44, P = 0.24). The higher than previously reported rate of clonal evolution (8/22, 36%) may be due to the high prevalence of refractory disease at HCT in this cohort, more refined cytogenetic analysis, or regimen related factors (e.g. reduced intensity conditioning). The same clonal abnormality with or without new changes occurred in 7/22 pts. Thus, minimal residual disease monitoring in the subset of pts harboring pre-HCT karyotypic derangements may be a viable strategy for early detection and intervention. Our data suggest that clonal evolution at relapse of AML and MDS after HCT is relatively frequent, and in this small series, a trend toward worse outcomes exists for pts who develop new cytogenetic abnormalities. Larger studies are warranted to more completely characterize the prognostic value of cytogenetics and karyotypic evolution at relapse after HCT.

Cytogenetic abnormalities for AML/MDS relapsing after HCT (N = 22) Pre HCT* Relapse *History of cytogenetic abnormality any time before HCT **Clonal evolution in 8/22 (36%) No 10 (45%) No 7 (32%) Yes (New)** 3 (14%) Yes 12 (55%) No 4 (18%) Yes (Same) 3 (14%) Yes (New)** 5 (27%)
Expression of Proteinase Inhibitor-9 in Primary AML Blasts and Its Regulation by Interferon-γ: A Potential Immune Escape Mechanism after Allogeneic Stem Cell Transplantation.
Authors: Hoves Sabine , Kolbeck Alexandra , Mondal Krishna , Andreesen Reinhard , Mackensen Andreas
Published: October 2019

It is well established, that the curative potential of allogeneic peripheral blood stem cell transplantation (allo PBSCT) is due to immunocompetent donor T cells inducing potent anti-neoplastic effects against host tumor cells. This reaction, which is termed graft-versus-leukemia (GVL) effect, is clinically effective against a number of different hematologic malignancies such as myeloid and lymphoid leukemias. Despite great efforts of allo PBSCT in treatment of CML, the 5-year survival rate of AML patients after allo PBSCT is only about 30% due to relapsing disease. The recurrent disease is inefficiently controlled by the immune system, due most likely to the various immune escape mechanisms described for AML blasts including upregulation of anti-apoptotic molecules. Since cytotoxic T lymphocytes (CTL) and natural killer cells are the cells responsible for eliminating leukemic blasts, the most important effector molecule is Granzyme B (GrB). Misdirected GrB is quenched by its specific physiological inhibitor Protease Inhibitor-9 (PI-9) leading to inactivation of GrB. PI-9 expression by tumour cells can be used to escape immune surveillance and its presence has been shown for different tumors e.g. melanoma, colon carcinoma and lymphoma. Despite other regulators, interferon-γ (IFN-γ) has been shown to upregulate PI-9 expression in hepatocytes. Here, we wanted to investigate the expression of PI-9 in primary AML blasts and its regulation by IFN-γ. Using CD34+ positive magnetic selection, we isolated primary blasts with a purity of >90% from 20 AML patients with different FAB subtypes. For detection of PI-9 expression by Western Blotting, whole cell lysates were made from freshly purified blasts and after 24 h +/− 200 IU/ml IFN-γ. In some patients, PI-9 expression was confirmed by FACS analysis with an anti- PI-9 specific monoclonal antibody. Here we describe for the first time, that PI-9 is constitutively expressed in 16/20 (80%) of AML blasts. Treatment of AML blasts with IFN-γ could upregulate PI-9 expression in a dose-dependent manner (2–2,000 IU/ml) and strong expression of PI-9 was detectable in 6/18 patients within 4–5 h after IFN-γ exposure. Of note, a mild upregulation of PI-9 upon 24 h incubation w/o IFN-γ could be detected in 4/18 (22%) patients. We conclude, that cytokines such as IFN-γ which are secreted during the cytokine storm of acute graft-versus-host disease can contribute to the development of immune escape mechanisms in AML blasts.