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PD1 expression in CD4+ and CD8+ T cells is increased after treatment in multiple myeloma patients with persistent disease. The GEM-Pembresid trial analyzed the efficacy and safety of pembrolizumab as consolidation in patients achieving at least very good partial response but with persistent measurable disease after first- or second-line treatment. Moreover, the characteristics of the immune system were investigated to identify potential biomarkers of response to pembrolizumab. One out of the 17 evaluable patients showed a decrease in the amount of M-protein, although a potential late effect of high-dose melphalan could not be ruled out. Fourteen adverse events were considered related to pembrolizumab, two of which (G3 diarrhea and G2 pneumonitis) prompted treatment discontinuation and all resolving without sequelae. Interestingly, pembrolizumab induced a decrease in the percentage of NK cells at cycle 3, due to the reduction of the circulating and adaptive subsets (0.615 vs. 0.43, p = 0.007, 1.12 vs. 0.86, p = 0.02). In the early progressors, a significantly lower expression of PD1 in CD8+ effector memory T cells (MFI 1327 vs. 926, p = 0.03) was observed. In conclusion, pembrolizumab used as consolidation monotherapy shows an acceptable toxicity profile but did not improve responses in this MM patient population. The trial was registered at clinicaltrials.gov with identifier NCT02636010 and with EUDRACT number 2015-003359-23.

Disease control at 5 years would be a desirable endpoint for elderly multiple myeloma (MM) patients, but biomarkers predicting this are not defined. Therefore, to gain further insights in this endpoint, a population of 498 newly diagnosed transplant-ineligible patients enrolled in two Spanish trials (GEM2005MAS65 and GEM2010MAS65), has been analyzed. Among the 435 patients included in this post-hoc study, 18.6% remained alive and progression free after 5 years of treatment initiation. In these patients, overall survival (OS) rate at 10 years was 60.8% as compared with 11.8% for those progressing within the first 5 years. Hemoglobin (Hb) >= 12 g/dl (OR 2.74, p = 0.001) and MGUS-like profile (OR 4.18, p = 0.005) were the two baseline variables associated with long-term disease-free survival. Upon including depth of response (and MRD), Hb >= 12 g/dl (OR 2.27) and MGUS-like signature (OR 7.48) retained their predictive value along with MRD negativity (OR 5.18). This study shows that despite the use of novel agents, the probability of disease control at 5 years is still restricted to a small fraction (18.6%) of elderly MM patients. Since this endpoint is associated with higher rates of OS, this study provides important information about diagnostic and post-treatment biomarkers helpful in predicting the likelihood of disease control at 5 years., This study was supported by the Centro de Investigacion Biomedica en Red-Area de Oncologia-del Instituto de Salud Carlos III (CIBERONC; CB16/12/00369 and CB16/12/00377), Instituto de Salud Carlos III/Subdireccion General de Investigacion Sanitaria (FIS no. PS09/01897/01370, PI12/01761, PI12/02311, PI13/01469, PI14/01867, G03/136, CD13/00340), Asociacion Espanola Contra el Cancer (GCB120981SAN) and the European Research Council (ERC) 2015 Starting Grant (MYELOMANEXT).

Background: Isatuximab is a monoclonal antibody that binds a specific epitope on the human CD38 receptor and has antitumour activity via multiple mechanisms of action. In a previous phase 1b study, around 65% of patients with relapsed and refractory multiple myeloma achieved an overall response with a combination of isatuximab with pomalidomide and low-dose dexamethasone. The aim of this study was to determine the progression-free survival benefit of isatuximab plus pomalidomide and dexamethasone compared with pomalidomide and dexamethasone in patients with relapsed and refractory multiple myeloma. Methods: We did a randomised, multicentre, open-label, phase 3 study at 102 hospitals in 24 countries in Europe, North America, and the Asia-Pacific regions. Eligible participants were adult patients with relapsed and refractory multiple myeloma who had received at least two previous lines of treatment, including lenalidomide and a proteasome inhibitor. Patients were excluded if they were refractory to previous treatment with an anti-CD38 monoclonal antibody. We randomly assigned patients (1:1) to either isatuximab 10 mg/kg plus pomalidomide 4 mg plus dexamethasone 40 mg (20 mg for patients aged ≥75 years), or pomalidomide 4 mg plus dexamethasone 40 mg. Randomisation was done using interactive response technology and stratified according to the number of previous lines of treatment (2–3 vs >3) and age (

Multiple myeloma (MM) remains as an incurable disease and, although allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a potentially curative approach, most patients ultimately relapse, and their treatment remains challenging. Because allo-HSCT can modify not only the biology of the disease, but also the immune system and the microenvironment, it can potentially enhance the response to rescue therapies. Information on the efficacy and safety of novel drugs in patients relapsing after allo-HSCT is lacking, however. The objectives of this study were to evaluate the efficacy and toxicity of rescue therapies in patients with MM who relapsed after allo-HSCT, as well as to compare their efficacy before and after allo-HSCT. This retrospective multicenter study included 126 consecutive patients with MM who underwent allo-HSCT between 2000 and 2013 at 8 Spanish centers. All patients engrafted. The incidence of grade II-IV acute graft-versus-host disease (GVHD) was 47%, and nonrelapse mortality within the first 100 days post-transplantation was 13%. After a median follow-up of 92 months, overall survival (OS) was 51% at 2 years and 43% at 5 years. The median progression-free survival after allo-HSCT was 7 months, whereas the median OS after relapse was 33 months. Patients relapsing in the first 6 months after transplantation had a dismal prognosis compared with those who relapsed later (median OS, 11 months versus 120 months; P < .001). The absence of chronic GVHD was associated with reduced OS after relapse (hazard ratio, 3.44; P < .001). Most patients responded to rescue therapies, including proteasome inhibitors (PIs; 62%) and immunomodulatory drugs (IMiDs; 77%), with a good toxicity profile. An in-depth evaluation, including the type and intensity of PI- and IMiD-based combinations used before and after allo-HSCT, showed that the overall response rate and duration of response after allo-HSCT were similar to those seen in the pretransplantation period. Patients with MM who relapse after allo-HSCT should be considered candidates for therapy with new drugs, which can achieve similar response rates with similar durability as seen in the pretransplantation period. This pattern does not follow the usual course of the disease outside the transplantation setting, where response rates and time to progression decreases with each consecutive line of treatment. (C) 2019 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.

Oral Presentation [CO-130] Introducción: Los estudios de secuenciación masiva (NGS) han permitido profundizar en el conocimiento de las gammapatías monoclonales tales como el mieloma múltiple (MM) y la macroglobulinemia de Waldesntröm’s (WM). Desafortunadamente, la baja incidencia de la amiloidosis de cadenas ligeras (AL) y la baja carga tumoral que presenta, a menudo enmascarada por un fondo policlonal de células plasmáticas (PC), explica la poca información que hay sobre la biología de la célula tumoral. Por ello, se desconoce si la AL presenta alguna mutación común como ocurre en la WM, si existen mutaciones recurrentes, y si estas podrían coincidir con las observadas en MM. Por lo tanto, el objetivo de este trabajo es realizar una secuenciación de exoma (WES) en una serie de pacientes con AL y comparar su perfil mutacional con el de MM. Métodos: En este estudio se incluyeron 28 pacientes con AL. Se realizó un WES, incluyendo las regiones reguladoras UTR (SureSelect Human All Exon V6 + UTRs (Agilent)) en 56 muestras pareadas sorteadas de células plasmáticas patológicas y sangre periférica como muestra control. Cada muestra tumoral fue capturada por triplicado y secuenciada en la plataforma NextSeq 500 (Illumina). Para el análisis de variantes somáticas se utilizaron los programas Strelka y ANNOVAR. . Las firmas mutacionales se analizaron con el software DeconstructSigs. Para comparar el perfil mutacional de AL con MM se utilizó la base de datos MMRF CoMMpass con 895 pacientes. Además, se han determinado los reordenamientos de los genes de las inmunoglobulinas (Igs) mediante NGS. Resultados: La cobertura media de secuenciación para las muestras de control y tumor fue de 64x y 186x, respectivamente. Se detectaron un total de 1983 SNV y 133 INDEL con una media de 71 (20-281) SNV y 5 (0-25) INDEL por paciente. Al comparar con MM (media 66 SNV y 2.5 INDEL) se observó una carga mutacional similar. Los únicos genes mutados tanto en AL como en MM fueron MUC16 (recurrencia 17% y 8%, respectivamente) e IGLL5 (recurrencia 17%, en ambas), siendo además los genes más frecuentemente mutados en AL Las firmas mutacionales más frecuentes que se identificaron fueron la 1 (desaminación espontánea de citosinas metiladas en sitios CpG), la 3 (fallo en la reparación de la ruptura de la doble cadena de ADN mediante recombinación homóloga), y la 9 (transveriones T> G en trinucleótidos ApTpN y TpTpN), identificadas en el 96%, 54% y 46% de los pacientes, respectivamente. Respecto al repertorio de los genes de las Igs, se observó que el 26% de los pacientes con AL presentan más de un clon, siendo esta heterogeneidad clonal similar a la encontrada en MM (23%). El gen IGHV3-30 fue identificado con mayor frecuencia tanto en AL como en MM, 10% y 12% de recurrencia, respectivamente. Conclusiones: Este es el primer estudio de WES en una serie de pacientes con AL. Los resultados muestran que no hay una mutación común driver en esta enfermedad, que podrían estar implicados múltiples procesos mutacionales, y que los genes descritos más frecuentemente mutados en AL y MM no coinciden. En conjunto, estos resultados suponen un avance en el entendimiento de la patogénesis de la AL.

Purpose: The aim of the International Myeloma Working Group was to develop practical recommendations for the diagnosis and management of multiple myeloma–related renal impairment (RI). Methods: Recommendations were based on published data through December 2015, and were developed using the system developed by the Grading of Recommendation, Assessment, Development, and Evaluation Working Group. Recommendations: All patients with myeloma at diagnosis and at disease assessment should have serum creatinine, estimated glomerular filtration rate, and electrolytes measurements as well as free light chain, if available, and urine electrophoresis of a sample from a 24-hour urine collection (grade A). The Chronic Kidney Disease Epidemiology Collaboration, preferably, or the Modification of Diet in Renal Disease formula should be used for the evaluation of estimated glomerular filtration rate in patients with stabilized serum creatinine (grade A). International Myeloma Working Group criteria for renal reversibility should be used (grade B). For the management of RI in patients with multiple myeloma, high fluid intake is indicated along with antimyeloma therapy (grade B). The use of high-cutoff hemodialysis membranes in combination with antimyeloma therapy can be considered (grade B). Bortezomib-based regimens remain the cornerstone of the management of myeloma-related RI (grade A). High-dose dexamethasone should be administered at least for the first month of therapy (grade B). Thalidomide is effective in patients with myeloma with RI, and no dose modifications are needed (grade B). Lenalidomide is effective and safe, mainly in patients with mild to moderate RI (grade B); for patients with severe RI or on dialysis, lena-lidomide should be given with close monitoring for hematologic toxicity (grade B) with dose reduction as needed. High-dose therapy with autologous stem cell transplantation (with melphalan 100 mg/m2 to 140 mg/m2) is feasible in patients with RI (grade C). Carfilzomib can be safely administered to patients with creatinine clearance > 15 mL/min, whereas ixazomib in combination with lenalidomide and dex-amethasone can be safely administered to patients with creatinine clearance > 30 mL/min (grade A). © 2016 by American Society of Clinical Oncology.