Association of Minimal Residual Disease With Superior Survival Outcomes in Patients With Multiple Myeloma: A Meta-analysis

Importance: Numerous studies have evaluated the prognostic value of minimal residual disease (MRD) in patients with multiple myeloma (MM). Most studies were small and varied in terms of patient population, treatment, and MRD assessment methods. Objective: To evaluate the utility of MRD detection in patients with newly diagnosed MM. Data Sources: A Medline search was conducted for articles published in English between January 1990 and January 2016. Study Selection: Eligible studies reported MRD status and progression-free survival (PFS) or overall survival (OS) in 20 or more patients following treatment. Among 405 articles identified, 21 met the initial eligibility criteria and were included in the analysis. Data Extraction and Synthesis: Information on patient characteristics, treatment, MRD assessment, and outcomes were extracted using a standard form. Main Outcomes and Measures: The impact of MRD status on PFS and OS was assessed by pooling data from relevant trials. Data were adjusted to allow for different proportions of patients with MRD in different studies, and analyzed using the Peto method. Forest plots were created based on Cox model analysis. Other prespecified research questions were addressed qualitatively. Results: Fourteen studies (n = 1273) provided data on the impact of MRD on PFS, and 12 studies (n = 1100) on OS. Results were reported specifically in patients who had achieved conventional complete response (CR) in 5 studies for PFS (n = 574) and 6 studies for OS (n = 616). An MRD-negative status was associated with significantly better PFS overall (hazard ratio [HR], 0.41; 95% CI, 0.36-0.48; P < .001) and in studies specifically looking at CR patients (HR, 0.44; 95% CI, 0.34-0.56; P < .001). Overall survival was also favorable in MRD-negative patients overall (HR, 0.57; 95% CI, 0.46-0.71; P < .001) and in CR patients (HR, 0.47; 95% CI, 0.33-0.67; P < .001). Tests of heterogeneity found no significant differences among the studies for PFS and OS. Conclusions and Relevance: Minimal residual disease-negative status after treatment for newly diagnosed MM is associated with long-term survival. These findings provide quantitative evidence to support the integration of MRD assessment as an end point in clinical trials of MM

A DNA target-enrichment approach to detect mutations, copy number changes and immunoglobulin translocations in multiple myeloma.

Genomic lesions are not investigated during routine diagnostic workup for multiple myeloma (MM). Cytogenetic studies are performed to assess prognosis but with limited impact on therapeutic decisions. Recently, several recurrently mutated genes have been described, but their clinical value remains to be defined. Therefore, clinical-grade strategies to investigate the genomic landscape of myeloma samples are needed to integrate new and old prognostic markers. We developed a target-enrichment strategy followed by next-generation sequencing (NGS) to streamline simultaneous analysis of gene mutations, copy number changes and immunoglobulin heavy chain (IGH) translocations in MM in a high-throughput manner, and validated it in a panel of cell lines. We identified 548 likely oncogenic mutations in 182 genes. By integrating published data sets of NGS in MM, we retrieved a list of genes with significant relevance to myeloma and found that the mutational spectrum of primary samples and MM cell lines is partially overlapping. Gains and losses of chromosomes, chromosomal segments and gene loci were identified with accuracy comparable to conventional arrays, allowing identification of lesions with known prognostic significance. Furthermore, we identified IGH translocations with high positive and negative predictive value. Our approach could allow the identification of novel biomarkers with clinical relevance in myeloma

Prozone effect of serum IgE levels in a case of plasma cell leukemia

We describe a case of multiple myeloma (MM) and secondary plasma cell leukemia (PCL) secreting IgE-kappa immunoglobulin. To our knowledge, only 2 cases of IgE-producing secondary PCL have been reported in the medical literature. In our patient, the only tumor marker available for monitoring the therapeutic response to chemotherapy and allogeneic stem cell transplantation was the quantitative M component at serum protein electrophoresis (SPEP), because serum free light chains were in the normal range, Bence-Jones proteinuria was absent, and quantitative serum IgE levels provided inaccurate and erratic results, due to the prozone effect. This is a laboratory phenomenon that occurs when antigen excess interferes with antibody-based methods requiring immune complex formation for detection. It is important to recognize the presence of a prozone effect, because it can produce falsely normal results, and therefore it could lead clinicians to incorrect assessment of the response to therapy

Consensus recommendations for risk stratification in multiple myeloma: report of the International Myeloma Workshop Consensus Panel 2.

A panel of members of the 2009 International Myeloma Workshop developed guidelines for risk stratification in multiple myeloma. The purpose of risk stratification is not to decide time of therapy but to prognosticate. There is general consensus that risk stratification is applicable to newly diagnosed patients; however, some genetic abnormalities characteristic of poor outcome at diagnosis may suggest poor outcome if only detected at the time of relapse. Thus, in good-risk patients, it is necessary to evaluate for high-risk features at relapse. Although detection of any cytogenetic abnormality is considered to suggest higher-risk disease, the specific abnormalities considered as poor risk are cytogenetically detected chromosomal 13 or 13q deletion, t(4; 14) and del17p, and detection by fluorescence in situ hybridization of t(4; 14), t(14; 16), and del17p. Detection of 13q deletion by fluorescence in situ hybridization only, in absence of other abnormalities, is not considered a high-risk feature. High serum beta(2)-microglobulin level and International Staging System stages II and III, incorporating high beta(2)-microglobulin and low albumin, are considered to predict higher risk disease. There was a consensus that the high-risk features will change in the future, with introduction of other new agents or possibly new combinations. (Blood. 2011; 117(18): 4696-4700

Clinical features associated with COVID-19 outcome in multiple myeloma: first results from the International Myeloma Society data set

The primary cause of morbidity and mortality in patients with multiple myeloma(MM) is an infection. Therefore there is great concern about the susceptibility to the outcome of COVID-19 infected patients with MM. This retrospective study describes the baseline characteristics and outcome data of COVID-19 infection in 650 patients with plasma cell disorders, collected by the International Myeloma Society to understand the initial challenges faced by myeloma patients during COVID-19 pandemic. Analysis were performed for hospitalized MM patients. Among hospitalized patinets, the median age was 69 years, and nearly all patients(96%) had MM. Approximately 36% were recently diagnosed(2019-2020), and 54% of patients were receiving first-line therapy. Thirty-three percent of patients have died, with significant geographic variability, ranging from 27% to 57% of hospitalized patients. Univariate analysis identified age, ISS3, high-risk disease, renal disease, suboptimal myeloma control(active or progressive disease), and one or more comorbidities as risk factors for higher rates of death. Neither history of transplant, including within a year of COVID-19 diagnosis, nor other anti-MM treatments were associated with outcomes. Multivariate analysis found that only age, high-risk MM, renal disease, and suboptimal MM control remained independent predictors of adverse outcome with COVID-19 infection. The management of MM in the era of COVID-19 requires careful consideration of patient and disease-related factors to decrease the risk of acquiring COVID-19 infection, while not compromising disease control through appropriate MM treatment. This study provides initial data to develop recommendations for the management of MM patients with COVID-19 infection

A targeted sequencing approach in multiple myeloma reveals a complex landscape of genomic lesions that has implications for prognosis

Background: Next-generation sequencing (NGS) studies have shown that mul- tiple myeloma is a heterogeneous disease with a complex subclonal architecture and few recurrently mutated genes. The analysis of smaller regions of interest in the genome (\u201ctargeted studies\u201d) allows interrogation of recurrent genomic events with reduces complexity of downstream analysis at a lower price. Aims: Here, we performed the largest targeted study to date in multiple myelo- ma to analyze gene mutations, deletions and amplifications, chromosomal copy number changes and immunoglobulin heavy chain locus (IGH) translo- cations and correlate results with biological and clinical features. Methods: We used Agilent SureSelect cRNA pull down baits to target: 246 genes implicated in myeloma or cancer in general in a mixed gene discovery/confirmation effort; 2538 single nucleotide polymorphisms to detect amplifications and deletions at the single-gene and chromosome level; the IGH locus to detect translocations. We sequenced unmatched DNA from CD138- purified plasma cells from 418 patients with multiple myeloma at diagnosis, with a median follow-up of 5.3 years. We sequenced at an average depth of 337x using Hiseq2000 machines (Illumina Inc.). We applied algorithms developed in- house to call genomic events, filtering out potential artifacts and germline vari- ants. We then ranker each event on its likelihood of being \u201concogenic\u201d based on clustering, recurrence and cross-reference with the COSMIC database. Results: We identified 2270 gene mutations in 412/418 patients, and of those 688 were oncogenic. 342 patients harbored at least one oncogenic mutation. 215/246 genes showed at lease one likely somatic mutation, but only 106 showed at least one oncogenic mutation. 63% of oncogenic mutations were accounted for by the top 9 driver genes previously identified (KRAS, NRAS, TP53, FAM46C, BRAF, DIS3, TRAF3, SP140, IRF4), implying our gene discov- ery effort did not identify novel mutated genes. We included deletion of tumor suppressors, amplification of oncogenes, chromosomal copy number changes and IGH translocations for a total of 76 variables, so that 413/418 patients showed at least one informative driver genomic event, (median 4/patient). We investigated pairwise associations between events and found significant corre- lations, such as TP53 mutations and del(17p), CYLD mutations and del(16), FAM46C mutations and del(1p), SF3B1 mutations and t(11;14). Hotspots muta- tions of IRF4 lysine p.123 showed an inverse correlation with a hyperdiploid karyotype and del(16) as opposed to other missense mutations scattered along the gene, which has pathogenic implications. Survival was negatively affected by the cumulative burden of lesions in an almost linear fashion, with median survival of 10.97 and 4.07 years in patients with =7 lesions respectively, and this was independent of the nature of the genomic events. Given the het- erogeneity and complex interplay of the variables we fitted a cox-proportional hazard model to predict survival. We found that mutations in TP53, amplifications of MYC, deletions of CYLD, amp(1q), del12p13.31 and del17p13 where the only significant events, all promoting shorter survival. In particular, TP53 muta- tions and deletions, often co-occurring, had an additive effect so that carriers of both showed a dismal survival of 17 months (Figure 1).Summary/Conclusions: Due to the complex genomic landscape in MM, a discovery effort still requires large studies to derive significant associations. We conclude that a targeted sequencing approach may provide prognostic models and give insights into myeloma biology