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Patients undergoing hematopoietic cell transplantation (HCT) experience decline in their physical activity during their transplant admission. There is limited experience with prospective monitoring of transplant recipients. We therefore measured physical activity and sleep patterns of subjects undergoing autologous and allogeneic HCT. Eighty-three patients were consented for this study. Sixty-three patients competed the study and had their physical activity prospectively assessed using the fitness-tracking device Fitbit HR. Outcomes included adherence, physical activity, readmission, hematopoietic engraftment, and 100-day survival. Sixty percent of patients (n = 37) underwent autologous HCT, and 40% (n = 26) underwent allogenic HCT. Both groups had a comparable number of steps at admission to the hospital. The number of daily steps during the study period was lower in the allogeneic group (2159 versus 3008, P = .07), as was the minimum number of steps recorded over the transplant admission (allogeneic HCT = 395 versus autologous HCT = 848, P = .01). Patients undergoing allogeneic HCT were less active on the day before discharge (1956 steps versus 3183 steps, P = .08). In multivariate analysis, physical activity was not associated with HCT-related outcomes. Patients undergoing HCT experience significant decline in their physical activity during their transplant admission that does not recover by the time of discharge. This effect can be objectively measured using fitness tracking devices.

Obesity is a common health problem in patients with multiple myeloma (MM) that has been linked to poor clinical outcomes and quality of life (QoL). We conducted a secondary analysis of the BMT CTN 0702, a randomized, controlled trial comparing outcomes of 3 treatment interventions after a single hematopoietic cell transplantation (HCT) (n = 758), to investigate the impact of visceral obesity, as measured by waist-to-hip ratio (WHR), on clinical outcomes and QoL in MM patients. A total of 549 MM patients, median age 55.5 years, were enrolled in the study. The majority of patients received triple-drug antimyeloma initial therapy before enrollment, and 29% had high-risk disease according to cytogenetic assessment. The median duration of follow-up was 6 years. There was no significant association between WHR and progression-free survival (PFS) or overall survival (OS) in MM patients undergoing HCT. Similarly, body mass index (BMI) did not significantly predict PFS or OS. Furthermore, there was no significant correlation between WHR and QoL measures. This study suggests that visceral obesity, as measured by WHR, might not have a significant impact on clinical outcomes in MM patients undergoing HCT. These findings add to the existing literature on the topic and provide valuable information for healthcare professionals and MM patients. Further studies are needed to confirm these results and to investigate other potential factors that may affect clinical outcomes and QoL in this patient population using modern imaging technologies to assess visceral obesity.

•Posttransplant maintenance with inotuzumab is safe and feasible for patients with ALL who are at high risk of relapse.•The high progression-free survival and low relapse rate for these patients at high risk is encouraging.

Pomalidomide and dexamethasone is a standard of care for patients with multiple myeloma in whom bortezomib and lenalidomide treatment has failed. KEYNOTE-183 assessed efficacy and safety of pomalidomide and dexamethasone with or without pembrolizumab in patients with relapsed or refractory multiple myeloma. Here, we present the findings of an unplanned, ad-hoc interim analysis at the request of the US Food and Drug Administration (FDA).

The introduction of CD38-targeting monoclonal antibodies (CD38 MoABs), daratumumab and isatuximab, has significantly impacted the management of patients with multiple myeloma (MM). Outcomes of patients with MM refractory to CD38 MoABs have not been described. We analyzed outcomes of 275 MM patients at 14 academic centers with disease refractory to CD38 MoABs. Median interval between MM diagnosis and refractoriness to CD38 MoAB (T0) was 50.1 months. The median overall survival (OS) from T0for the entire cohort was 8.6 [95% C.I. 7.5–9.9] months, ranging from 11.2 months for patients not simultaneously refractory to an immunomodulatory (IMiD) agent and a proteasome inhibitor (PI) to 5.6 months for “penta-refractory” patients (refractory to CD38 MoAB, 2 PIs and 2 IMiDs). At least one subsequent treatment regimen was employed after T0in 249 (90%) patients. Overall response rate to first regimen after T0was 31% with median progression-free survival (PFS) and OS of 3.4 and 9.3 months, respectively. PFS was best achieved with combinations of carfilzomib and alkylator (median 5.7 months), and daratumumab and IMiD (median 4.5 months). Patients with MM refractory to CD38 MoAB have poor prognosis and this study provides benchmark for new therapies to be tested in this population.

Large language models (LLM) can potentially revolutionize the healthcare industry. They could reduce the burden on healthcare, increase care accessibility in areas with shortage and provide multilingual support to break down language barriers. Although, these models equipped with vast amounts of medical knowledge and the ability to understand and generate human-like text, require a proper set of feeding data (i.e., prompt engineering) for accurate diagnosis and providing reliable personalized treatment plans for patients.

BACKGROUND AND SIGNIFICANCE

Multiple myeloma (MM) is the second common hematologic malignancy characterized by the clonal proliferation of plasma cells. While the clinical outcomes of MM have been improved significantly, there remains an intriguing observation regarding the potential influence of race on disease biology and treatment response. In MM, the malignant plasma cell clone not only disrupts the local bone marrow microenvironment but also exerts a systemic impact on various physiological processes result in significant derangements in immune function, hematopoiesis, renal function, bone metabolism, and electrolyte homeostasis. Understanding the extent of this systemic impact and its potential variation between racial groups is crucial for optimizing patient care and treatment strategies. Here, we hypothesizedthat the systemic impact of the plasma cell clone does not differ significantly between African American and Caucasian patients. We employed a machine learning approach to capture the full spectrum of systemic effects comprehensively. Our novel model was trained to predict the magnitude of the plasma cell clone, as represented by serum monoclonal protein levels. By systematically comparing model performance with and without the inclusion of race as a variable, we sought to evaluate the potential influence of race on the systemic impact of the plasma cell clone.

Background:The treatment landscape for relapsed/refractory multiple myeloma (RRMM) has changed dramatically with the approval of CD38-targeted antibodies such as daratumumab. Despite this advancement in therapy, some patients still experience progression following daratumumab regimens. Clinical outcomes may be improved by more potent CD38-targeted treatment options. GEN3014 (HexaBody ®-CD38) is a next-generation human IgG1 anti-CD38 monoclonal antibody (mAb) that contains a hexamerization-enhancing mutation, E430G, that facilitates highly efficient complement-dependent cytotoxicity (CDC). In preclinical studies, GEN3014 showed robust tumor-cell killing through highly potent CDC, with increased efficiency compared with daratumumab, as well as potent antibody-dependent cellular cytotoxicity and antibody-dependent cellular phagocytosis (Hiemstra et al, eBioMedicine2023). Preliminary dose-escalation data from the first-in-human phase 1/2 trial of GEN3014 in RRMM patients showed clinical activity and a tolerable safety profile, and the recommended phase 2 dose was 16 mg/kg (NCT04824794). Based on these findings, expansion was initiated. Herein we describe the preliminary results of an expansion cohort in anti-CD38 mAb-naive RRMM patients.

The prognosis for Multiple Myeloma (MM) patients (pts) has improved substantially over the past two decades with the success of immunomodulatory drugs (IMiDs), monoclonal antibodies, chimeric antigen receptor (CAR) T-cells and bispecific T-cell engagers (BiTEs) that broke the circulus vitiosusof tumor-induced immunosuppression to reengage the immune system. Functional blockade of the transforming growth factor-beta (TGF) signaling pathway improves the efficacy of cytotoxic and immune therapies, therefore we investigator the impact of TGF-inhibition in an steroid free regimn. Methods:We conducted a phase 1b study to determine the safety, efficacy, and maximal tolerated dose (200 mg po bid) of the potent, orally-available TGF type I receptor kinase inhibitor vactosertib in relapsed and/or refractory multiple myeloma (RRMM) pts who had received -2 lines of chemoimmunotherapy in combination with standard dosage of Pomalidomide without any corticosteroids. Results:Twenty one pts were enrolled in the phase 1b dose escalation cohort and received vactosertib plus pomalidomide as indicated (Fig. 1A). Pts' characteristics are described in Table 1The summary of grade 1-4 adverse events is shown (Table 2). A single grade 4 elevated bilirubin (5%) and a single grade 4 elevated lipase (5%) were observed as well as four grade 4 events of decreased neutrophils (19%). Four pts demonstrated a PR, two had a MR, nine had SD and four had disease progression (Fig. 1B). The median time to response for all pts and the responders eight weeks and median duration of response was ~12 weeks. The best overall response for individual pts to treatment is shown (Fig. 1C). Clinical activity was observed across all four dose levels (Table 3). To probe the tumor intrinsic anti-myeloma activity of vactosertib, we first determined the relative effect of vactosertib compared to the IMiDs pomalidomide and lenalidomide (Fig. 2A, B). The effect of vactosertib was greater than that observed with either lenalidomide or pomalidomide. MMCLs and patient CD138 +cells were then treated with vactosertib in combination with pomalidomide, and importantly, vactosertib with pomalidomide synergistically reduced myeloma viability (Fig. 3A). We next probed the systemic, tumor extrinsic effects of vactosertib by analyzing cytokines immune and tumor cells present within patient BM samples. (Fig. 4A). (Fig. 4B). Therefore, we explored the immunophenotype of CD8 +T-cells isolated from patient BM prior to and at the EOT. The relative percentage of T-cells that expressed the immunosuppressive markers programmed cell death-1 (PD-1), T-cell immunoglobulin and mucin domain-containing protein 3 (TIM3), B and T lymphocyte attenuator (BTLA), and cytotoxic T-lymphocyte associated protein 4 (CTLA-4) was reduced following treatment relative to their expression prior to treatment (Fig. 4C). Results indicated that vactosertib and pomalidomide treatment in vivoreduced PD-1, TIM3, BTLA and CTLA-4 expression on patient CD8 +T-cells. Next, CD8 +T-cells were isolated from patient peripheral blood and cultured in the presence of TGF-1, vactosertib, pomalidomide, or vactosertib plus pomalidomide (Fig. 5B). Treatment of patient CD8 +T-cells with vactosertib decreased PD-1 expression up to 40% and decreased TIM3 expression up to 65%. Pomalidomide alone did not significantly reduce PD-1, TIM3, BTLA, or LAG-3 on patient CD8 +T-cells. Vactosertib and pomalidomide also reduced TIM3 levels on CD8 +T-cells from most pts. (Fig. 5C, D). (Fig. 5 G, H). Results indicated that vactosertib or pomalidomide did not increase CD138 +cell death (Fig. 5I). Conclusion:Vactosertib combined with pomalidomide was well-tolerated at all doses, had a manageable adverse event profile and induced durable responses with 80% progression-free survival (PFS-6) at 6 months, Vactosertib reduced TGF- in patient bone marrow and suppressed PD-1 expression on CD8 +T-cells and lead to reduction of PD-L1/PD-L2 expression on CD138 +cells and enhanced autologous T-cell cytotoxicity. Taken together, our results support the safety and efficacy of vactosertib to treat RRMM and revealed that vactosertib modulates the T-cell immunophenotype and reinvigorates T-cell fitness.

Multiple Myeloma (MM) is a malignancy originating from mature plasma cells in the bone marrow, typically preceded by clinically asymptomatic precursor conditions. Early identification of the risk of progression from these precursor states, like Monoclonal Gammopathy of Undetermined Significance (MGUS) or Smoldering Myeloma, to full-blown MM is critical for improving patient outcomes. The current risk models for MM rely on limited clinical and laboratory parameters, unable to fully encompass the complex nature of the disease continuum. To overcome these challenges, developing and validating a more comprehensive risk model is imperative, incorporating a wider array of clinical, genetic, and immune-related factors. This approach will enhance predictive accuracy and clinical applicability significantly. Notably, changes in serum monoclonal protein spike (M-spike) levels can reflect dynamic fluctuations in the net clonal mass, representing the ongoing battle between the plasma cell clone and the anti-myeloma immune response within patients. However, the impact of this highly dynamic state on the risk of progression to MM remains largely unexplored. Our study aims to bridge this knowledge gap by investigating the association between the dynamic M-spike pattern and the risk of progression from a precursor clone to MM, offering valuable insights into a potential novel prognostic marker for disease advancement.

Background: Hematopoietic stem cell transplant (SCT) is a high-intensity treatment that can cause psychological distress. Pre-transplant psychosocial screening is commonly used to assess mental health, social support, compliance, and health behaviors in HCT centers. However, the optimal standardized approach to psychosocial screening is still being defined. Some studies have shown that pre-transplant psychosocial assessments can predict overall survival (OS) after SCT, while others have found associations with non-relapse mortality (NRM) but not with OS. Single-institution reports consistently indicate that pre-HCT psychosocial assessments are associated with the length of SCT hospitalization and readmission rate.

Background:Multiple myeloma (MM) remains a highly treatable but generally incurable plasma cell dyscrasia. These plasma cells synthesize massive amounts of paraprotein relying heavily on the ubiquitin proteasome system to maintain homeostasis and are exquisitely sensitive to proteasome inhibition to avoid terminal ER stress. We postulated that increased expression of clinically relevant proteasome subunits would correlate with reduced overall survival in MM patients treated with proteasome inhibitors.

Evasion of immune destruction is a hallmark of cancer that thwarts the efficacy of immunotherapy and reduces patient benefit. The development of immunotherapies has sparked a revolution in oncology by releasing the power of the human immune system, but the identity of novel, actionable antigens exclusively presented on cancer cells remains elusive. Proteasomes are multi-subunit proteolytic complexes that selectively degrade intracellular proteins. Proteasomes play a critical in controlling myriad cellular processes including metabolism, cell cycle progression, signal transduction, protein quality control and differentiation. Importantly, proteasomes are also the source of most antigenic peptides presented to the immune system on major histocompatibility complex (MHC)-class I molecules. In this process, intracellular and viral proteins are degraded in the cytosol to 8 and 9-amino acid peptides, which are then transported into the endoplasmic reticulum, where they associate with MHC-class I molecules and are presented to the cell surface. Immune cells contain a highly specialized, cytokine-inducible proteasome variant, known as the immunoproteasome, in which the three constitutive catalytic subunits are replaced by homologous catalytic subunits. Immunoproteasomes are specially adapted for a role in MHC class I antigen processing and presentation to CD8 +T-cells. Here, we performed a high-through screen (HTS) to detect novel molecular entities that activated immuno-proteasomal catalytic activity. We identified a curated panel of molecules which not only enhanced hydrolysis of the cell-permeable substrate LLVY-R110 but also enhanced the presentation of MHC class I antigens. E.G7-Ova is a mouse lymphoma cell line derived by electroporation of EL4 cells (C57BL/6, H-2b, T lymphoma) with chicken ovalbumin ( OVA) cDNA. Proteasomes degrade OVA to generate the peptide SIINFEKL that is presented by murine MHC-class I H-2Kb molecules. E.G7-Ova cells were pretreated with compound A and co-cultured with the T-cell hybridoma B3Z that had been genetically-engineered to express a SIINFEKL-restricted t-cell receptor (TCR). Pretreatment of E.G7-Ova cells with compound A significantly increased tumor cell lysis by B3Z cells. The treatment of multiple myeloma (MM) cells with compound A also dramatically enhanced the expression of pan-MHC class I antigens. Treatment of MM cells with compound A increased the intracellular level of the proteasome activator PA28α/β, which is expressed by PSME1/2. Compound A treatment also enhanced hydrolysis of the fluorogenic peptide substrate Ac-ANW-AMC, which is selectively cleaved by the immunoproteasome β5-associated catalytic activity. Treatment of MM cells with compound A followed by mass spectrometry (MS) revealed that immunoproteasome activation modulated the relative presentation of individual antigenic peptides bound to MHC class I molecules. Pre-treatment of MM cells with compound A also significantly enhanced the anti-myeloma activity of human cytotoxic T-cells. Taken together, our results demonstrate that immunoproteasome activation has the potential to overcome immune escape and promote host immunity. In addition, our model systems now allows us to identify actionable tumor antigens on patient tumor cells as an indispensable tool for the development of cancer immunotherapies, e.g., T cell receptor (TCR)-transduced T-cells and patient-specific mRNA and peptide vaccines. Finally, immunoproteasome activators have the potential to contribute not only to cytotoxic T-cell mediated tumor lysis but also the treatment of intracellular infections and autoimmune and neurodegenerative proteinopathies characterized by the pathologic accumulation of toxic, proteinaceous aggregates.

The evasion of host immunity is a hallmark of cancer. Tumor cells develop strategies to evade host immunity and to resist currently available immunotherapies, while others present a low tumor mutation burden limiting the presence of tumor antigenicity. Proteasomes are exquisitely complex, intricately regulated protein-degrading machines that are responsible for the overwhelming majority of intracellular proteolysis in eukaryotic cells. Proteasomes are also essential for the efficient processing of intracellular proteins to generate antigenic epitopes that complex with MHC-class I molecules and are displayed on antigen-presenting cells (APCs) to activate CD8 +cytotoxic T-lymphocytes (CTLs). We hypothesized that pharmacologic activation of proteasomes would modulate the tumor immunopeptidome to increase MHC class I antigen presentation and promote CTL activity. Here, we developed a cell-based, high-throughput screen (HTS) to identify FDA-approved pharmacologics and bioactive molecules that increased proteasomal activity to promote the presentation of MHC class I antigens. The HTS revealed that the histone deacetylase 6 (HDAC6)-selective inhibitors tubastatin-A, ACY-738 and ACY-1215 increased proteasome activity in a panel of multiple myeloma (MM) cell lines. The HDAC6 inhibitors also significantly enhanced MHC-class I antigen presentation pan-MHC class-I expression in a diverse panel of cancer cell lines. Pretreatment of MM patient CD138 +tumor cells with HDAC6 inhibitors promoted the cytotoxic activity of autologous patient-derived T-cells. Mechanistic studies revealed that pharmacologic blockade or genetic ablation of HDAC6 or the HDAC6 ubiquitin-binding (BUZ) domain disrupted the association of HDAC6 with the ubiquitin-like protein HR23B, a substrate-shuttle factor that delivers ubiquitinylated cargo to proteasomes. Taken together, the results validate the HDAC6-BUZ domain as an attractive drug discovery target and demonstrate the immediate translational impact of proteasome activators to modulate the immunopeptidome and enhance antitumor immunity. Proteasome activators also represent a paradigm-shifting approach to overcome mechanisms of immune escape. FDA-approved drugs that increase proteasome activity and boost antigen presentation can now be repositioned as cancer immunotherapeutics to overcome the existing bottlenecks in drug development.

In 2000, the Institute of Medicine highlighted significant evidence supporting a positive association between higher surgical oncologic procedure volume and improved clinical outcomes. Over nearly two decades since that report, research on the volume-outcome relationship in hematologic malignancies remains somewhat unclear. Most of the research on the impact of procedural volume in Multiple Myeloma (MM) management has relied on the National Cancer Database (NCDB), which consistently indicated that MM patients treated at higher-volume facilities experienced lower mortality rates compared to those treated at lower-volume facilities. Still, the underlying reasons for this disparity have remained elusive.

Manjappa: Pfizer: Research Funding. Caimi:Amgen: Other: Advisory Board; Bayer: Other: Advisory Board; Verastem: Other: Advisory Board; Celgene: Speakers Bureau; Kite pharmaceuticals: Other: Advisory Board; ADC therapeutics: Other: Advisory Board, Research Funding. de Lima:BMS: Other: Personal Fees, advisory board; Incyte: Other: Personal Fees, advisory board; Kadmon: Other: Personal Fees, Advisory board; Celgene: Research Funding; Pfizer: Other: Personal fees, advisory board, Research Funding. Malek:Clegene: Other: Advisory board , Speakers Bureau; Janssen: Other: Advisory board, Speakers Bureau; Sanofi: Other: Advisory board; Amgen: Honoraria; Medpacto: Research Funding; Cumberland: Research Funding; Bluespark: Research Funding; Takeda: Other: Advisory board , Speakers Bureau.

Monoclonal gammopathy of undetermined significance (MGUS) is a premalignant, clonal plasma cell disorder, characterized by the presence of a monoclonal (M) protein in serum, <10% clonal plasma cells in the bone marrow, and absence of end-organ damage attributable to multiple myeloma (MM). MGUS incidence is estimated as 0.3% and 3% among those <50 years and >50 years, respectively. Although renal failure is a defining feature of MM, frequently patients (pts) with a variety of renal pathologies have less than 10% plasma cell burden in the bone marrow, therefore they cannot be categorized as MM to be eligible for an anti-myeloma therapy. However, it is clear that there is a causative relationship between MGUS and the pathologic process in kidneys in at least a subset patient and starting anti-myeloma therapy potentially can reverse or slow down the renal insult caused by MGUS. This led to the creation of the new entity and term, “monoclonal gammopathy of renal significance” (MGRS), to properly convey the nature of these relationship. Therefore, MGRS depicts a subset of MGUS and ascertains that the significance of the monoclonal gammopathy is no longer undetermined.

Caimi: Amgen: Other: Advisory Board; Kite Pharma: Other: Advisory Board; ADC Therapeutics: Other: Advisory Board, Research Funding; Celgene: Speakers Bureau; Verastem: Other: Advisory Board; Bayer: Other: Advisory Board. de Lima:Incyte: Other: Personal Fees, advisory board; BMS: Other: Personal Fees, advisory board; Kadmon: Other: Personal Fees, Advisory board; Pfizer: Other: Personal fees, advisory board, Research Funding; Celgene: Research Funding. Malek:Takeda: Other: Advisory board , Speakers Bureau; Sanofi: Other: Advisory board; Amgen: Honoraria; Medpacto: Research Funding; Clegene: Other: Advisory board , Speakers Bureau; Janssen: Other: Advisory board, Speakers Bureau; Bluespark: Research Funding; Cumberland: Research Funding.

Background

Multiple Myeloma (MM) is a cancer of terminally-differentiated plasma cells residing in the bone marrow. Myeloma cells frequently secrete monoclonal proteins that can be used to assess tumor volume and patient response to therapy. Monoclonal proteins are measured by gel electrophoresis and subsequent immunofixation of the observed M-spike for protein typing. However, this a time-consuming process that may take up to 3-5 days that delays physician-patient decision-making, determining response to treatment and can be a significant psychological stressor for patients. Hence, there is an unmet need to develop a more rapid, point-of-care method to determine M-spike levels. Gamma gap is the difference between total serum protein and albumin and includes a variety metabolic proteins, i.e., transferrin, as well as immunologic proteins, e.g., non-involved immunoglobulins, in addition to the M-spike. Since estimation of the non-M-spike portion of the gamma gap cannot be achieved on routine patient care, the gamma gap cannot serve as an accurate surrogate for M-spike protein levels. Here, we hypothesized that an artificial intelligence (AI) algorithm utilizing readily available clinical and laboratory data along with previous and same-day lab variables can accurately predict M-spike levels without the need for serum electrophoresis.

Reduced-intensity conditioning (RIC) regimens frequently provide insufficient disease control in patients with high-risk hematologic malignancies undergoing allogeneic hematopoietic stem cell transplantation (HSCT). We evaluated intensification of fludarabine/busulfan (Flu/Bu) RIC with targeted marrow irradiation (TMI) in a dose escalation with expansion phase I clinical trial. TMI doses were delivered at 1.5 Gy in twice daily fractions on days -10 through -7 (dose levels: 3 Gy, 4.5 Gy, and 6 Gy), Flu (30 mg/m2for 5 days) and Bu (area under the curve, 4800 µM*minute for 2 days). Eligible patients were age ≥18 years with high-risk hematologic malignancy and compromised organ function ineligible for myeloablative transplantation (n = 26). The median patient age was 64 years (range, 25 to 76 years). Nineteen patients (73%) had active or measurable residual disease at transplantation. One-year disease-free survival and overall survival were 55% (95% confidence interval [CI], 34% to 76%) and 65% (95% CI, 46% to 85%), respectively. Day +100 and 1 year transplantation-related mortality were 4% (95% CI, 0.6% to 27%) and 8.5% (95% CI, 2% to 32%), respectively. The 1-year cumulative incidence of relapse was 43% (95% CI, 27% to 69%). Rates of grade II-IV and III-IV acute GVHD rates were 57% (95% CI, 39% to 84%) and 22% (95% CI, 9% to 53%), respectively. Whole blood immune profiling demonstrated enrichment of central/transitional memory-like T cells with higher TMI doses, which correlated with improved survival compared with control samples from patients undergoing allogeneic HSCT. Intensification of a Flu/Bu RIC regimen with TMI is feasible with a low incidence of transplantation-related mortality in medically frail patients with advanced malignancies. The recommended phase 2 TMI dose is 6 Gy.