Lenalidomide plus Dexamethasone for High-Risk Smoldering Multiple Myeloma

Hospital Universitario de Salamanca, Instituto de Biología Molecular y Celular del Cáncer, Universidad de Salamanca-Consejo Superior de Investigaciones Científicas, Salamanca, Spain.
New England Journal of Medicine (Impact Factor: 55.87). 08/2013; 369(5):438-47. DOI: 10.1056/NEJMoa1300439
Source: PubMed


For patients with smoldering multiple myeloma, the standard of care is observation until symptoms develop. However, this approach does not identify high-risk patients who may benefit from early intervention.
In this randomized, open-label, phase 3 trial, we randomly assigned 119 patients with high-risk smoldering myeloma to treatment or observation. Patients in the treatment group received an induction regimen (lenalidomide at a dose of 25 mg per day on days 1 to 21, plus dexamethasone at a dose of 20 mg per day on days 1 to 4 and days 12 to 15, at 4-week intervals for nine cycles), followed by a maintenance regimen (lenalidomide at a dose of 10 mg per day on days 1 to 21 of each 28-day cycle for 2 years). The primary end point was time to progression to symptomatic disease. Secondary end points were response rate, overall survival, and safety.
After a median follow-up of 40 months, the median time to progression was significantly longer in the treatment group than in the observation group (median not reached vs. 21 months; hazard ratio for progression, 0.18; 95% confidence interval [CI], 0.09 to 0.32; P<0.001). The 3-year survival rate was also higher in the treatment group (94% vs. 80%; hazard ratio for death, 0.31; 95% CI, 0.10 to 0.91; P=0.03). A partial response or better was achieved in 79% of patients in the treatment group after the induction phase and in 90% during the maintenance phase. Toxic effects were mainly grade 2 or lower.
Early treatment for patients with high-risk smoldering myeloma delays progression to active disease and increases overall survival. (Funded by Celgene; number, NCT00480363.).

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    • "The risk of progression to symptomatic myeloma for patients with SMM is about 8% per year after diagnosis (Kastritis et al, 2013). The 2013 landmark study (Mateos et al, 2013) demonstrated a potential benefit of early therapy for high risk SMM patients and evidence suggests that MRI can be used as a prognostic biomarker (Moulopoulos et al, 1995, 2005; Mariette et al, 1999). The Southwestern Oncology Group S0120 study reported that detection of multiple focal lesions on MRI conferred an increased risk of progression (Dhodapkar et al, 2015) and an abnormal signal on MRI has been shown to be associated with very high risk of SMM progression and with development of lytic bone lesions (Kastritis et al, 2013). "
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    ABSTRACT: The recent consensus statement from the International Myeloma Working Group has introduced the role of whole body (WB) magnetic resonance imaging (MRI) into the management pathway for patients with multiple myeloma. The speed, coverage and high sensitivity of WB diffusion weighted (DW)-MRI and the unique capability to quantify both burden of disease and response to treatment has led to increasing implementation at leading centres worldwide for imaging malignant marrow disease, both primary and metastatic. WB DW-MRI is likely to have a significant impact on management decisions and pathways for patients with multiple myeloma. This review will introduce the basic principles of DW-MRI, present current evidence for patients with myeloma and will discuss practicalities and exciting future applications. © 2015 The Authors. British Journal of Haematology published by John Wiley & Sons Ltd.
    Preview · Article · May 2015 · British Journal of Haematology
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    • "Only the Mateos trial [21], among all trials included here, showed that mortality was significantly lower in the early treatment arm compared to that of the deferred treatment arm (7% versus 21%; OR = 0.28, 95%CI = 0.09 to 0.93). Interestingly, although all the patients included in all the trials we analyzed had SMM, the patients in the Mateos trial included a large number of high risk SMM. "
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    ABSTRACT: Purpose Whether patients with smoldering multiple myeloma (SMM) needed to receive early interventional treatment remains controversial. Herein, we conducted a meta-analysis comparing the efficacy and safety of early treatment over deferred treatment for patients with SMM. Methods MEDLINE and Cochrane Library were searched to May 2014 for randomized controlled trials (RCTs) that assessed the effect of early treatment over deferred treatment. Primary outcome measure was mortality, and secondary outcome measures were progression, response rate, and adverse events. Results Overall, 5 trials including 449 patients were identified. There was a markedly reduced risk of disease progression with early treatment (Odds Ratio [OR] = 0.13, 95% confidence interval [CI] = 0.07 to 0.24). There were no significant differences in mortality and response rate (OR = 0.85, 95% CI = 0.45 to 1.60, and OR = 0.63, 95% CI = 0.32 to 1.23, respectively). More patients in the early treatment arm experienced gastrointestinal toxicities (OR = 10.02, 95%CI = 4.32 to 23.23), constipation (OR = 8.58, 95%CI = 3.20 to 23.00) and fatigue or asthenia (OR = 2.72, 95%CI = 1.30 to 5.67). No significant differences were seen with the development of acute leukemia (OR = 2.80, 95%CI = 0.42 to 18.81), hematologic cancer (OR = 2.07, 95%CI = 0.43 to 10.01), second primary tumors (OR = 3.45, 95%CI = 0.81 to 14.68), nor vertebral compression (OR = 0.18, 95%CI = 0.02 to 1.59). Conclusions Early treatment delayed disease progression but increased the risk of gastrointestinal toxicities, constipation and fatigue or asthenia. The differences on vertebral compression, acute leukemia, hematological cancer and second primary tumors were not statistically significant. Based on the current evidence, early treatment didn’t significantly affect mortality and response rate. However, further much larger trials were needed to provide more evidence.
    Full-text · Article · Oct 2014 · PLoS ONE
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    ABSTRACT: Smoldering multiple myeloma (SMM) is an asymptomatic plasma cell disorder characterized by the presence of one or both features of serum M-protein ≥ 30 g/L and bone marrow plasma cell infiltration ≥ 10 %. However, myeloma-related symptomatology is absent from this condition. The risk of progression to active MM is not uniform, and several markers are useful for identifying SMM patients at high risk of progression to active MM. These include the size of the M-protein and the infiltration in the bone marrow, the serum-free light-chain ratio, the presence of immunoparesis and percentage of plasma cell with aberrant phenotype by flow cytometry, or the presence of focal lesions in magnetic resonance imaging. Overall, the presence of these factors identifies patients who have a 50 % probability of progression at 2 years, and the forthcoming challenge will be to identify ultra-high-risk patients who have an 80 % risk of progression at 2 years. The current standard of care is not to treat until progression to symptomatic disease occurs. Several trials of melphalan, thalidomide and bisphosphonates have been conducted in the overall SMM patient population to examine the delay in time to progression (TTP) to symptomatic disease, but these have shown no significant benefit. However, a randomized trial that focused on high-risk SMM patients allocated to receive early treatment with lenalidomide plus dexamethasone versus observation did report a significant benefit with respect to TTP and overall survival. In summary, high-risk SMM patients should be targetted for early treatment, and more so efforts should be made to identify the ultra-high-risk subgroup within the high-risk SMM patient population which may be considered as early MM and thereby candidates for receiving therapy before they develop myeloma-related symptomatology.
    No preview · Article · Aug 2013 · Current Hematologic Malignancy Reports
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