Difficult-to-treat patients with relapsed/refractory multiple myeloma:A review of clinical trial results

Overall outcomes for multiple myeloma have improved due to the availability of new therapies, but patients with relapsed/refractory multiple myeloma harbouring certain factors continue to pose a therapeutic challenge. These challenging features include high-risk cytogenetics, renal impairment, patient characteristics such as age and frailty, and extramedullary disease. Prior refractory status and number of prior lines add further complexity to the treatment of these patients. While newer regimens are available and have suggested efficacy in these patient populations through subgroup analyses, differences in trial definitions and cut-offs make meaningful comparisons difficult. This review aims to examine the available clinical trial data for patients with high-risk cytogenetics, renal impairment, age and frailty and extramedullary disease.</p

Deregulation and Targeting of TP53 Pathway in Multiple Myeloma

Multiple Myeloma (MM) is an incurable disease characterized by a clonal evolution across the course of the diseases and multiple lines of treatment. Among genomic drivers of the disease, alterations of the tumor suppressor TP53 are associated with poor outcomes. In physiological situation, once activated by oncogenic stress or DNA damage, p53 induces either cell-cycle arrest or apoptosis depending on the cellular context. Its inactivation participates to drug resistance in MM. The frequency of TP53 alterations increases along with the progression of the disease, from 5 at diagnosis to 75% at late relapses. Multiple mechanisms of regulation lead to decreased expression of p53, such as deletion 17p, TP53 mutations, specific microRNAs overexpression, TP53 promoter methylations, and MDM2 overexpression. Several therapeutic approaches aim to target the p53 pathway, either by blocking its interaction with MDM2 or by restoring the function of the altered protein. In this review, we describe the mechanism of deregulation of TP53 in MM, its role in MM progression, and the therapeutic options to interact with the TP53 pathway

Progression-free survival as a surrogate endpoint for overall survival in patients with relapsed or refractory multiple myeloma

Objectives: The goal of the research was to assess the quantitative relationship between median progression-free survival (PFS) and median overall survival (OS) specifically among patients with relapsed/refractory multiple myeloma (RRMM) based on published randomized controlled trials (RCTs). Methods: Two bibliographic databases (PubMed and Embase, 1970–2017) were systematically searched for RCTs in RRMM that reported OS and PFS, followed by an updated search of studies published between 2010 and 2022 in 3 databases (Embase, MEDLINE, and EBM Reviews, 2010–2022). The association between median PFS and median OS was assessed using the nonparametric Spearman rank and parametric Pearson correlation coefficients. Subsequently, the quantitative relationship between PFS and OS was assessed using weighted least-squares regression adjusted for covariates including age, sex, and publication year. Study arms were weighted by the number of patients in each arm. Results: A total of 31 RCTs (56 treatment arms, 10,450 patients with RRMM) were included in the analysis. The average median PFS and median OS were 7.1 months (SD 5.5) and 28.1 months (SD 11.8), respectively. The Spearman and Pearson correlation coefficients between median PFS and median OS were 0.80 (P &lt; 0.0001) and 0.79 (P &lt; 0.0001), respectively. In individual treatment arms of RRMM trials, each 1-month increase in median PFS was associated with a 1.72-month (95% CI 1.26–2.17) increase in median OS. Conclusion: Analysis of the relationship between PFS and OS incorporating more recent studies in RRMM further substantiates the use of PFS to predict OS in RRMM.</p

Global Epigenetic Regulation of MicroRNAs in Multiple Myeloma

Epigenetic changes frequently occur during tumorigenesis and DNA hypermethylation may account for the inactivation of tumor suppressor genes in cancer cells. Studies in Multiple Myeloma (MM) have shown variable DNA methylation patterns with focal hypermethylation changes in clinically aggressive subtypes. We studied global methylation patterns in patients with relapsed/refractory MM and found that the majority of methylation peaks were located in the intronic and intragenic regions in MM samples. Therefore, we investigated the effect of methylation on miRNA regulation in MM. To date, the mechanism by which global miRNA suppression occurs in MM has not been fully described. In this study, we report hypermethylation of miRNAs in MM and perform confirmation in MM cell lines using bisulfite sequencing and methylation-specific PCR (MSP) in the presence or absence of the DNA demethylating agent 5-aza-2′-deoxycytidine. We further characterized the hypermethylation-dependent inhibition of miR-152, -10b-5p and -34c-3p which was shown to exert a putative tumor suppressive role in MM. These findings were corroborated by the demonstration that the same miRNAs were down-regulated in MM patients compared to healthy individuals, alongside enrichment of miR-152-, -10b-5p, and miR-34c-3p-predicted targets, as shown at the mRNA level in primary MM cells. Demethylation or gain of function studies of these specific miRNAs led to induction of apoptosis and inhibition of proliferation as well as down-regulation of putative oncogene targets of these miRNAs such as DNMT1, E2F3, BTRC and MYCBP. These findings provide the rationale for epigenetic therapeutic approaches in subgroups of MM

Inhibiting the oncogenic translation program is an effective therapeutic strategy in multiple myeloma

Published in final edited form as: Sci Transl Med. 2017 May 10; 9(389). https://doi.org/10.1126/scitranslmed.aal2668.Multiple myeloma (MM) is a frequently incurable hematological cancer in which overactivity of MYC plays a central role, notably through up-regulation of ribosome biogenesis and translation. To better understand the oncogenic program driven by MYC and investigate its potential as a therapeutic target, we screened a chemically diverse small-molecule library for anti-MM activity. The most potent hits identified were rocaglate scaffold inhibitors of translation initiation. Expression profiling of MM cells revealed reversion of the oncogenic MYC-driven transcriptional program by CMLD010509, the most promising rocaglate. Proteome-wide reversion correlated with selective depletion of short-lived proteins that are key to MM growth and survival, most notably MYC, MDM2, CCND1, MAF, and MCL-1. The efficacy of CMLD010509 in mouse models of MM confirmed the therapeutic relevance of these findings in vivo and supports the feasibility of targeting the oncogenic MYC-driven translation program in MM with rocaglates

The LIN28B/let-7 axis is a novel therapeutic pathway in Multiple Myeloma

MYC is a major oncogenic driver of Multiple Myeloma (MM) and yet almost no therapeutic agents exist that target MYC in MM. Here we report that the let-7 biogenesis inhibitor LIN28B correlates with MYC expression in MM and is associated with adverse outcome. We also demonstrate that the LIN28B/let-7 axis modulates the expression of MYC, itself a let-7 target. Further, perturbation of the axis regulates the proliferation of MM cells in vivo in a xenograft tumor model. RNA sequencing and gene set enrichment analyses of CRISPR-engineered cells further suggest that the LIN28/let-7 axis regulates MYC and cell cycle pathways in MM. We provide proof-of-principle for therapeutic regulation of MYC through let-7 with an LNA-GapmeR containing a let-7b mimic in vivo, demonstrating that high levels of let-7 expression repress tumor growth by regulating MYC expression. These findings reveal a novel mechanism of therapeutic targeting of MYC through the LIN28B/let-7 axis in MM that may impact other MYC dependent cancers as well

Carfilzomib, lenalidomide and dexamethasone followed by a second ASCT is an effective strategy in first relapse multiple myeloma: a study on behalf of the Chronic malignancies working party of the EBMT

In the setting of a first relapse of multiple myeloma (MM), a second autologous stem cell transplant (ASCT) following carfilzomib-lenalidomide-dexamethasone (KRd) is an option, although there is scarce data concerning this approach. We performed a retrospective study involving 22 EBMT-affiliated centers. Eligible MM patients had received a second-line treatment with KRd induction followed by a second ASCT between 2016 and 2018. Primary objective was to estimate progression-free survival (PFS) and overall survival (OS). Secondary objectives were to assess the response rate and identify significant variables affecting PFS and OS. Fifty-one patients were identified, with a median age of 62 years. Median PFS after ASCT was 29.5 months while 24- and 36-months OS rates were 92.1% and 84.5%, respectively. Variables affecting PFS were an interval over four years between transplants and the achievement of a very good partial response (VGPR) or better before the relapse ASCT. Our study suggests that a relapse treatment with ASCT after KRd induction is an effective strategy for patients with a lenalidomide-sensitive first relapse. Patients with at least four years of remission after a frontline ASCT and who achieved at least a VGPR after KRd induction appear to benefit the most from this approach

The Mutational Landscape of Circulating Tumor Cells in Multiple Myeloma

The development of sensitive and non-invasive ‘‘liquid biopsies’’ presents new opportunities for longitudinal monitoring of tumor dissemination and clonal evolution. The number of circulating tumor cells (CTCs) is prognostic in multiple myeloma (MM), but there is little information on their genetic features. Here, we have analyzed the genomic landscape of CTCs from 29 MM patients, including eight cases with matched/paired bone marrow (BM) tumor cells. Our results show that 100% of clonal mutations in patient BM were detected in CTCs and that 99% of clonal mutations in CTCs were present in BM MM. These include typical driver mutations in MM such as in KRAS, NRAS, or BRAF. These data suggest that BM and CTC samples have similar clonal structures, as discordances between the two were restricted to subclonal mutations. Accordingly, our results pave the way for potentially less invasive mutation screening of MM patients through characterization of CTCs

Targeting MYC in multiple myeloma by interfering with the LIN28B/let-7 axis and inhibiting translation initiation

Le Myélome Multiple (MM) est une hémopathie maligne caractérisée par la prolifération de plasmocytes tumoraux médullaires. MYC occupe un rôle central dans l'oncogenèse du MM car son activation est responsable de la progression du stade précurseur de MGUS en MM symptomatique. Dans ce travail, nous rapportons que l’expression de LIN28B est corrélée à celle de MYC et est associée à un mauvais pronostic dans le MM. Nous montrons que l'axe LIN28B/let-7 module l'expression de l’ARNm de MYC, lui-même cible de let-7. De plus, la perturbation de l'axe LIN28B/let-7 induit une régulation la prolifération des lignées cellulaires de MM in vitro et in vivo. L'analyse par séquençage d’ARN de modèles de KO par utilisation de la technologie CRISPR a montré que l'axe LIN28B/let-7 régule les voies de signalisation de MYC et du cycle cellulaire dans MM. Nous avons de plus établi une preuve de principe thérapeutique de la possibilité de cibler MYC par l’emploi de LNA-GapmeR contenant une séquence analogue à let-7b. Dans un modèle de xénogreffe murin, nous montrons que des niveaux élevés d'expression de let-7, par administration de LNA-GapmeR let-7b, répriment la croissance tumorale en régulant l’expression de MYC. Ces résultats révèlent un nouveau mécanisme de ciblage thérapeutique de MYC via l'axe LIN28B/let-7 dans MM. Nous nous sommes ensuite intéressés à évaluer de nouvelles formes de biomarqueurs moléculaires dans le MM par étude des miARN contenus dans les exosomes circulants. Nous avons examiné le rôle pronostique des miARN exosomaux dans une cohorte de 156 échantillons de patients uniformément traités pour un MM au diagnostic. Après analyse du profil de miARN exosomaux par séquençage de nouvelle génération, nous avons utilisé technique de qRT-PCR pour étudier la corrélation entre le niveau d’expression de 22 miARN et la survie sans progression (SSP) et la survie globale (SG). Deux miARN, à savoir let-7b et miR-18a, étaient significativement associés à la SSP et SG en analyse univariée, et étaient statistiquement significatifs après ajustement pour le système international de stratification du risque (ISS) et les marqueurs cytogénétique en analyse multivariée. Nos résultats confirment le niveau d’expression des miARN let-7b et miR-18a au sein des exosomes circulants permettent d’améliorer la stratification du risque chez les patients atteints de MM. Enfin, pour mieux comprendre le programme oncogénique piloté par MYC, nous avons étudié l’efficacité thérapeutique d’une librairie de petites sur des lignées cellulaires avec une forte expression de MYC, dans le MM. Les résultats ont permis d’identifier les rocaglates, une famille de composés inhibant l’initiation de la traduction, comme étant les plus actifs. L’étude du profil transcriptionnel par séquençage de l’ARN de lignées cellulaires de MM traitées par CMLD010509 ou DMSO a révélé l’activation d’un programme de transcription et l’inhibition d’un programme traductionnel, caractéristique de l’inactivation de HSF1 secondaire à l’inhibition de la traduction. Le profile traductionnel était étudié par spectrométrie de masse quantitative, permettant d’identifier un ensemble de protéines, tels que MYC, MDM2, CCND1, MAF et MCL-1, spécifiquement affectées par l’inhibition de la traduction liée au composé CMLD010509 dans le MM. Nous avons confirmé l’efficacité thérapeutique des rocaglates dans plusieurs modèles murins de MM. Ces résultats démontrent la possibilité de cibler le programme de traduction oncogénique lié à MYC dans MM.MYC is a major oncogenic driver of Multiple Myeloma (MM) and yet almost no therapeutic agents exist that target MYC in MM. Here we report that the let-7 biogenesis inhibitor LIN28B correlates with MYC expression in MM and is associated with adverse outcome. We also demonstrate that the LIN28B/let-7 axis modulates the expression of MYC, itself a let-7 target. Further, perturbation of the axis regulates the proliferation of MM cells in vivo in a xenograft tumor model. RNA-sequencing and gene set enrichment analyses of CRISPR-engineered cells suggested that the LIN28/let-7 axis regulates MYC and cell cycle pathways in MM. We provide proof of principle for therapeutic regulation of MYC through let-7 with an LNA-GapmeR (locked nucleic acid-GapmeR) containing a let-7b mimic in vivo, demonstrating that high levels of let-7 expression repress tumor growth by regulating MYC expression. These findings reveal a novel mechanism of therapeutic targeting of MYC through the LIN28B/let-7 axis in MM. We next sought to establish new biomarkers in MM, enable to capture the molecular alterations of the disease. For this purpose, we examined the prognostic significance of circulating exosomal microRNAs (miRNAs) in a cohort of 156 patients with newly diagnosed MM, uniformly treated and followed. Circulating exosomal miRNAs were isolated and used to perform small RNA sequencing analysis on 10 samples and a qRT-PCR array on 156 samples. We studied the relationship between miRNA levels and patient outcomes including progression-free survival (PFS) and overall survival (OS). We identified miRNAs as the most predominant small RNAs present in exosomes isolated from the serum of MM patients and healthy controls by small RNA sequencing of circulating exosomes and used a qRT-PCR assay to measure the expression of 22 exosomal miRNAs. Two of them, namely let-7b and miR-18a, were significantly associated with both PFS and OS in the univariate analysis, and were still statistically significant after adjusting for the International Staging System (ISS), and adverse cytogenetics in the multivariate analysis. Our findings support the use of circulating exosomal let-7b and miR-18a improves the identification of patients with newly diagnosed MM with poor outcomes. Finally, to better understand the oncogenic program driven by MYC and investigate its potential as a therapeutic target, we screened a chemically diverse small molecule library for anti-MM activity in cell lines with high expression of MYC. The most potent hits identified were rocaglate-scaffold inhibitors of translation initiation. Expression profiling of MM cells revealed reversion of the oncogenic MYC-driven transcriptional program by CMLD010509, the most promising rocaglate. Proteome-wide, reversion correlated with selective depletion of short-lived proteins that are key to MM growth and survival, most notably MYC, MDM2, CCND1, MAF, and MCL-1. The efficacy of CMLD010509 in several mouse models of MM confirmed the therapeutic relevance of these findings in vivo and supports the feasibility of targeting the oncogenic MYC-driven translation program in MM with rocaglates

Ciblage de MYC par étude de l'axe LIN28B/let-7 et de l'initiation de la traduction dans le myélome multiple

MYC is a major oncogenic driver of Multiple Myeloma (MM) and yet almost no therapeutic agents exist that target MYC in MM. Here we report that the let-7 biogenesis inhibitor LIN28B correlates with MYC expression in MM and is associated with adverse outcome. We also demonstrate that the LIN28B/let-7 axis modulates the expression of MYC, itself a let-7 target. Further, perturbation of the axis regulates the proliferation of MM cells in vivo in a xenograft tumor model. RNA-sequencing and gene set enrichment analyses of CRISPR-engineered cells suggested that the LIN28/let-7 axis regulates MYC and cell cycle pathways in MM. We provide proof of principle for therapeutic regulation of MYC through let-7 with an LNA-GapmeR (locked nucleic acid-GapmeR) containing a let-7b mimic in vivo, demonstrating that high levels of let-7 expression repress tumor growth by regulating MYC expression. These findings reveal a novel mechanism of therapeutic targeting of MYC through the LIN28B/let-7 axis in MM. We next sought to establish new biomarkers in MM, enable to capture the molecular alterations of the disease. For this purpose, we examined the prognostic significance of circulating exosomal microRNAs (miRNAs) in a cohort of 156 patients with newly diagnosed MM, uniformly treated and followed. Circulating exosomal miRNAs were isolated and used to perform small RNA sequencing analysis on 10 samples and a qRT-PCR array on 156 samples. We studied the relationship between miRNA levels and patient outcomes including progression-free survival (PFS) and overall survival (OS). We identified miRNAs as the most predominant small RNAs present in exosomes isolated from the serum of MM patients and healthy controls by small RNA sequencing of circulating exosomes and used a qRT-PCR assay to measure the expression of 22 exosomal miRNAs. Two of them, namely let-7b and miR-18a, were significantly associated with both PFS and OS in the univariate analysis, and were still statistically significant after adjusting for the International Staging System (ISS), and adverse cytogenetics in the multivariate analysis. Our findings support the use of circulating exosomal let-7b and miR-18a improves the identification of patients with newly diagnosed MM with poor outcomes. Finally, to better understand the oncogenic program driven by MYC and investigate its potential as a therapeutic target, we screened a chemically diverse small molecule library for anti-MM activity in cell lines with high expression of MYC. The most potent hits identified were rocaglate-scaffold inhibitors of translation initiation. Expression profiling of MM cells revealed reversion of the oncogenic MYC-driven transcriptional program by CMLD010509, the most promising rocaglate. Proteome-wide, reversion correlated with selective depletion of short-lived proteins that are key to MM growth and survival, most notably MYC, MDM2, CCND1, MAF, and MCL-1. The efficacy of CMLD010509 in several mouse models of MM confirmed the therapeutic relevance of these findings in vivo and supports the feasibility of targeting the oncogenic MYC-driven translation program in MM with rocaglates.Le Myélome Multiple (MM) est une hémopathie maligne caractérisée par la prolifération de plasmocytes tumoraux médullaires. MYC occupe un rôle central dans l'oncogenèse du MM car son activation est responsable de la progression du stade précurseur de MGUS en MM symptomatique. Dans ce travail, nous rapportons que l’expression de LIN28B est corrélée à celle de MYC et est associée à un mauvais pronostic dans le MM. Nous montrons que l'axe LIN28B/let-7 module l'expression de l’ARNm de MYC, lui-même cible de let-7. De plus, la perturbation de l'axe LIN28B/let-7 induit une régulation la prolifération des lignées cellulaires de MM in vitro et in vivo. L'analyse par séquençage d’ARN de modèles de KO par utilisation de la technologie CRISPR a montré que l'axe LIN28B/let-7 régule les voies de signalisation de MYC et du cycle cellulaire dans MM. Nous avons de plus établi une preuve de principe thérapeutique de la possibilité de cibler MYC par l’emploi de LNA-GapmeR contenant une séquence analogue à let-7b. Dans un modèle de xénogreffe murin, nous montrons que des niveaux élevés d'expression de let-7, par administration de LNA-GapmeR let-7b, répriment la croissance tumorale en régulant l’expression de MYC. Ces résultats révèlent un nouveau mécanisme de ciblage thérapeutique de MYC via l'axe LIN28B/let-7 dans MM. Nous nous sommes ensuite intéressés à évaluer de nouvelles formes de biomarqueurs moléculaires dans le MM par étude des miARN contenus dans les exosomes circulants. Nous avons examiné le rôle pronostique des miARN exosomaux dans une cohorte de 156 échantillons de patients uniformément traités pour un MM au diagnostic. Après analyse du profil de miARN exosomaux par séquençage de nouvelle génération, nous avons utilisé technique de qRT-PCR pour étudier la corrélation entre le niveau d’expression de 22 miARN et la survie sans progression (SSP) et la survie globale (SG). Deux miARN, à savoir let-7b et miR-18a, étaient significativement associés à la SSP et SG en analyse univariée, et étaient statistiquement significatifs après ajustement pour le système international de stratification du risque (ISS) et les marqueurs cytogénétique en analyse multivariée. Nos résultats confirment le niveau d’expression des miARN let-7b et miR-18a au sein des exosomes circulants permettent d’améliorer la stratification du risque chez les patients atteints de MM. Enfin, pour mieux comprendre le programme oncogénique piloté par MYC, nous avons étudié l’efficacité thérapeutique d’une librairie de petites sur des lignées cellulaires avec une forte expression de MYC, dans le MM. Les résultats ont permis d’identifier les rocaglates, une famille de composés inhibant l’initiation de la traduction, comme étant les plus actifs. L’étude du profil transcriptionnel par séquençage de l’ARN de lignées cellulaires de MM traitées par CMLD010509 ou DMSO a révélé l’activation d’un programme de transcription et l’inhibition d’un programme traductionnel, caractéristique de l’inactivation de HSF1 secondaire à l’inhibition de la traduction. Le profile traductionnel était étudié par spectrométrie de masse quantitative, permettant d’identifier un ensemble de protéines, tels que MYC, MDM2, CCND1, MAF et MCL-1, spécifiquement affectées par l’inhibition de la traduction liée au composé CMLD010509 dans le MM. Nous avons confirmé l’efficacité thérapeutique des rocaglates dans plusieurs modèles murins de MM. Ces résultats démontrent la possibilité de cibler le programme de traduction oncogénique lié à MYC dans MM