Correspondence
156
Table 2
Patient
1
2
3
4
5
6d
7
8
9
10
Response to MAC treatment
Weeks of
treatment
21a
26a
64
40a
104
50
32
20
22
13a
Baseline
Response to MAC
Baseline
Response to MAC
Serum M-protein
(g/dl)
24-h Urine Mprotein (g)
Serum M-protein
change (%)
Urine M-protein
change (%)
Serum creatinine
(mg/dl)
Serum creatinine
change (%)
NAb,c
NAc
9.4
2.2
4.0
6.1
5.4
4.3
1.9
6.2
3.4
1.2
4.3
2.8
0.63
NA
NA
NA
3.8
NA
NA
NA
29
46
46
90
38
66
47
37
58
54
71
34
56
NA
NA
NA
54
NA
5.1
1.0
6.1
2.3
5.1
0.9
1.1
1.1
4.0
1.0
41
NA
69
35
59
NA
NA
NA
45
NA
a
Progression of disease.
NA ¼ not applicable.
c
Patient 1, light-chain disease; patient 2, no significant amount of M-protein in serum.
d
Normalized serum calcium by the end of first week of MAC therapy.
b
was changed to a once-weekly schedule. Delays in the
administration of MAC therapy occurred in seven patients. Delays
secondary to hematologic toxicity occurred in two patients for
ANC o500 109/l and platelets o50 109/l, attributable to
melphalan. Only one patient required transient G-CSF support for
neutropenia. Delays of only a few days occurred in five patients
whose QTc intervals were prolonged (4460 ms), attributable to
arsenic trioxide. Of note, no grade 4 adverse events were observed
and no treatment discontinuations occurred among patients on
MAC therapy. In this small series of patients treated, MAC therapy
has been shown to be an active new therapeutic regimen for
patients with refractory MM. A formal large multi-center phase 1/2
clinical trial is underway to further investigate this novel
combination for patients with relapsed or refractory MM, and
extend the promising findings of this pilot study.
Duality of interest
Dr Berenson has an ongoing financial relationship with Cell
Therapeutics, Inc., which includes research grants, honoraria,
speaker’s bureau, and consultant work only.
MJ Borad1,2
R Swift1
JR Berenson1
1
Institute for Myeloma and Bone Cancer
Research, Los Angeles, CA, USA; and
2
Department of Hematology/Oncology, Tulane
University School of Medicine, New Orleans,
LA, USA
References
1 Mathews V, Balasubramanian P, Shaji RV, George B, Chandy M,
Srivastava A. Arsenic trioxide in the treatment of newly diagnosed
acute promyelocytic leukemia: a single center experience. Am J
Hematol 2002; 70: 292–299.
2 Niu C, Yan H, Yu T, Sun HP, Liu JX, Li XS et al. Studies on treatment
of acute promyelocytic leukemia with arsenic trioxide: remission
induction, follow-up, and molecular monitoring in 11 newly
diagnosed and 47 relapsed acute promyelocytic leukemia patients.
Blood 1999; 94: 3315–3324.
3 Soignet SL, Frankel SR, Douer D, Tallman MS, Kantarjian H, Calleja
E et al. United States multicenter study of arsenic trioxide in
relapsed acute promyelocytic leukemia. J Clin Oncol 2001; 19:
3852–3860.
4 Munshi NC, Tricot G, Desikan R, Badros A, Zangari M, Toor A et al.
Clinical activity of arsenic trioxide for the treatment of multiple
myeloma. Leukemia 2002; 16: 1835–1837.
5 Hussein MA, Saleh M, Ravandi F, Mason J, Rifkin RM, Ellison R.
Phase 2 study of arsenic trioxide in patients with relapsed
or refractor multiple myeloma. Br J Haematol 2004; 125:
470–476.
6 Bahlis NJ, McCafferty-Grad J, Jordan-McMurry I, Neil J, Reis I,
Kharfan-Dabaja M et al. Feasibility and correlates of arsenic trioxide
combined with ascorbic acid-mediated depletion of intracellular
glutathione for the treatment of relapsed/refractory multiple
myeloma. Clin Cancer Res 2002; 8: 3658–3666.
Single-agent thalidomide for treatment of first relapse following high-dose
chemotherapy in patients with multiple myeloma
Leukemia (2005) 19, 156–159. doi:10.1038/sj.leu.2403564
Published online 28 October 2004
Correspondence: Dr R Fenk, Department of Hematology, Oncology
and Clinical Immunology, University of Duesseldorf, Moorenstr. 5,
Duesseldorf 40225, Germany; Fax: þ 49 211 8118853;
E-mail: [email protected]
Received 26 August 2004; accepted 17 September 2004; Published
online 28 October 2004;
Leukemia
TO THE EDITOR
The use of thalidomide has improved the treatment of patients
with multiple myeloma (MM). Thalidomide has shown to have
therapeutic activity as a single agent in patients with relapsed
and/or refractory MM.1,2 Thalidomide monotherapy can induce
remissions in about one-third of relapsing or refractory
patients1,2,4–8 and combinations of thalidomide with dexamethasone and/or chemotherapy can further improve response
Correspondence
rates in these patients.1–3 Abnormal cytogenetics, high plasma
cell labeling index, IgA isotype, high levels of LDH or beta2microglobulin as well as low hemoglobulin, platelet count or
albumin have been identified in different studies as adverse
prognostic factors for outcome after treatment with thalidomide
in patients with relapsed or refractory MM.4–8 Apart from results
of patients with advanced and heavily pretreated disease,
studies have shown efficiency of thalidomide treatment in
untreated patients.1,2 Currently, data of an early patient
population, who are neither untreated nor heavily pretreated,
are very limited. Several groups have studied patients with
relapsed or refractory MM,1,2,4–8 but the patient populations
were widely heterogeneous including patients with first relapse
and patients with later relapse after more than 5 years of prior
therapy. Patients with relapse off treatment, primary refractory
disease and refractory relapse were mixed as well as patients
with prior high-dose chemotherapy (HDT) and patients who had
received only conventional chemotherapy. Thus, it is very
difficult to define the role of thalidomide for the individual
patient.
The objective of our study was to assess treatment response
and prognosis of a well-defined patient population. Therefore,
we performed a single center retrospective analysis including
patients with the following characteristics: (1) patients who
received front-line HDT, (2) patients who were not refractory
to front-line therapy but obtained at least a minimal response
and (3) patients who received thalidomide as a single agent
at first, untreated relapse. We show that this early patient
group has a favorable outcome in comparison to results of
mixed patient groups with advanced myeloma. Further, we
provide prognostic factors for this group of patients, identifying a
subgroup of patients with bad risk and need for a more
aggressive salvage therapy. This will help to optimize the
clinical use of thalidomide in patients with MM relapsing
after HDT.
The objectives of our study were to determine response rate,
progression-free survival (PFS) and overall survival (OS) and to
identify relevant prognostic factors for this group of patients.
Treatment response and duration of remissions were assessed
according to the EBMT criteria. For the evaluation of prognostic
parameters, the following data have been examined: age (no
older than 65 years vs older than 65 years), gender (male vs
female), immunoglobulin isotype (no IgA isotype vs IgA isotype),
results from conventional cytogenetic banding analysis of bone
marrow samples obtained prior to thalidomide therapy (normal
vs abnormal), results from laboratory tests obtained at the time
of relapse including level of serum beta2-microglobulin (p2.5
vs 42.5 mg/dl), serum LDH (p0.8 normal limit vs
40.8 normal limit), serum CRP (p6 vs 46 mg/l), serum
albumin level (p40 vs 440 g/l), platelet count (4100 109/l vs
p100 109/l), hemoglobulin (410 mg/l vs p10 mg/dl) and
serum creatinine (normal vs abnormal). Further, thalidomide
dosage within the first 3 months (more than 200 mg daily vs
200 mg daily or less), HDT conditioning regimen (idarubicine/
melphalan/cyclophosphamide vs melphalan), response to HDT
(complete remission (CR) þ near-complete remission (nCR) vs
partial remission (PR) þ minimal response (MR)), duration of
remission after HDT (412 vs o12 months) and application of
interferon (INF) maintenance therapy after HDT (yes vs no) were
included.
A total of 32 patients were included in this study. All patients
had stage III disease, 31% had abnormal creatinine levels, 72%
had IgG, 16% IgA and 12% other, nonsecretory isotype or light
chain disease. The median age at the beginning of thalidomide
treatment was 55 years (range: 33–67).The median beta2-
157
microglobulin level was 2.7 mg/dl (range: 1.5–32.6), median
LDH was 151 U/l (range: 97–234), median CRP was 5 mg/l
(range: 3–33), median serum albumin was 4.4 g/l (range: 3.7–
5.2), median platelet count was 167 109/l (range: 20–326),
median hemoglobulin was 12 mg/dl (range: 7.3–14.7) and
median creatinine was 1.0 mg/dl (range: 0.7–2.2). At the
beginning of thalidomide therapy, cytogenetic conventional
banding analysis was performed in 29 of 32 patients and
showed an abnormal karyotype in 37% of patients. Prior therapy
consisted of front-line HDT with or without INF maintenance
therapy. The median time from diagnosis of stage III disease to
HDT was 4 months (range: 3–13). Prior HDT conditioning
regimen consisted either of idarubicin 42 mg/m2, melphalan
200 mg/m2 and cyclophosphamide 120 mg/kg (HD-IMC, n ¼ 9)
or melphalan 200 mg/m2 (HD-M, n ¼ 23). INF alfa maintenance
therapy was started after hematological reconstitution with a
dosage of 1–4.5 million U in 22 patients and seven patients
received no maintenance therapy after HDT. Response rates
after HDT were as follows: 25% achieved a CR or an nCR, 69%
a PR and 6% an MR. Duration of response lasted longer than 12
months in 69% of patients. The median PFS and OS after HDT
was 22.0 (range 3.0–59.0) and 75.9 (range: 7.0–89.0) months,
respectively.
At the time of relapse after HDT, all patients received salvage
therapy with thalidomide as a single agent. Daily doses were
individually escalated based on tolerance, ranging from 100 to
400 mg. Treatment was begun with 100 mg and dose escalations
or reductions of thalidomide by 100 mg/day were scheduled at
weekly intervals. The maximum-tolerated dosage was 400 mg
and the median-tolerated dosage for maintenance therapy was
200 mg.
Overall response rate (XMR) in our study was 78%. Of 32
patients, 59% (95% CI 41–80%) achieved a PR and 19% (95%
CI 7–40%) an MR. No patient achieved a CR, but one patient
achieved an nCR. Six patients (19% (95% CI 7–40%)) had SD
with no disease progression within at least 3 months after the
start of thalidomide treatment. One patient was primary
refractory to thalidomide. After a median follow-up of
24 months (range: 3–64), the median PFS after start of
treatment with thalidomide was 23.4 months (range: 2.1–40.4)
and the median survival was 41.3 months (range: 3–64)
(Figure 1).
According to univariate analysis (Kaplan–Meier estimates, log
rank), predictive factors for a superior PFS after thalidomide
treatment were normal cytogenetics (P ¼ 0.08), CRP level
p6 mg/l (P ¼ 0.02), platelet count 4100 109/l (P ¼ 0.0002),
hemoglobulin 410 mg/l (P ¼ 0.005) and duration of remission
after the previous HDT lasting more than 12 months (P ¼ 0.02).
On multivariate analysis (Cox’s regression, including factors
with log rank Po0.1 in unifactor analysis), normal cytogenetics
(relative risk (RR) 6.5, P ¼ 0.01), CRP lower than 6 mg/l (RR 7.0,
P ¼ 0.01) and duration of remission after HDT of more than 12
months (RR 4.5, P ¼ 0.05) were associated with a better
outcome. Prognostic factors that significantly predicted superior
OS in univariate analysis were serum albumin level (P ¼ 0.01),
hemoglobulin (P ¼ 0.0002) and duration of remission after HDT
(P ¼ 0.001). Duration of remission after HDT was the only
predictive factor for OS in a multivariate analysis (RR 5.5,
P ¼ 0.01). Thus, patients with long-lasting remissions after HDT
also had sustained remissions during thalidomide treatment,
whereas patients with early relapse within 12 months after HDT
also had short-lasting remissions with thalidomide therapy.
A prior remission after HDT lasting more than 12 months vs less
than 12 months was associated with a median PFS and OS of 28
vs 6 (P ¼ 0.02) and 48 vs 18 months (Po0.01), respectively
Leukemia
Correspondence
158
Proportion of patients (%)
a
b
100
90
80
Response
70
60
OS
50
40
30
20
TTP
0
PR
59
MR
19
SD
19
PD
3
Total
10
%
CR
78
10 20 30 40 50 60
Months
c
d
Proportion of patients (%)
100
100
90
80
90
OS
70
60
50
40
80
>12
50
40
<12
30
TTP
30
20
10
>12
70
60
20
p=0.001
10 20 30 40 50 60
Months
<12
10
10
20
30
Months
p=0.02
40
Figure 1
(a) Kaplan–Meier estimates of OS and TTP of all patients,
(b) response rates of all patients, and probabilities of OS (c) and TTP (d)
according to duration of remission of prior HDT lasting 412 (F) or
o12 (- - -) months.
(Figure 1). No single parameter was predictive for response to
treatment with thalidomide.
The response rate (XPR) in our study population was 59%,
which is superior to published studies with single-agent
thalidomide and heavily pretreated patients where responses
could be observed in about one-third of patients.1,2,4–8 The
median PFS in our patient population was 23 months, which is
comparable to studies with untreated patients and superior to
results from studies with single-agent thalidomide and patients
with advanced myeloma, where PFS normally ranges between 6
and 13 months.1,2,4–8 This finding suggests a higher efficiency
of thalidomide therapy when used early during the disease.
Our results show that for patients with first untreated
relapse after HDT, single-agent thalidomide provides sufficient
disease control without the need for more toxic combination
therapies. This is in contrast to patients who suffer from
relapse at a more advanced phase of their disease or who
have refractory disease where inferior responses were observed
with single-agent thalidomide.1,2,4–8 These patients need a
more toxic combination therapy of thalidomide with dexamethasone and chemotherapy, which is associated with higher
toxicity.1–3
Even though thalidomide has been shown to be very effective
in our study population, we could identify a subgroup of patients
with a high risk of relapse. An important finding of this study was
that patients who relapsed within the first year after HDT had an
inferior outcome in comparison to patients who had remissions
lasting more than 12 months. This finding was consistent with
both PFS and OS and could be confirmed by multivariate
analysis. Interestingly, the duration of remission after HDT but
not the quality of response after HDT was associated with
Leukemia
outcome. Achievement of a CR or an nCR after HDT was not of
prognostic relevance for the outcome of thalidomide salvage
therapy. Instead, the duration of remission, irrespective of
achievement of a CR, PR or an MR, had a prognostic impact.
This suggests the existence of two faces of MM with a different
biological behavior. Some patients with a ‘malignant myeloma’
subtype achieve responses that actually can be as pronounced
as a CR, but the response lasts for only a short period of time. For
these patients, response to therapy is not durable either after
chemotherapy or after treatment with immunomodulatory drugs
such as thalidomide. As a consequence, these patients should be
treated with more aggressive combination therapies. Other
patients achieve responses that may be only minor, but of long
duration. In these patients, long-term impairment of myeloma
cell growth can be achieved either by chemotherapy or
immunomodulatory drugs. These patients are candidates for
less toxic monotherapies.
In addition to the duration of prior remission, we have
confirmed cytogenetics and CRP level as other important
independent prognostic parameters.4 Other factors, like low
hemoglobulin, low platelet count or low serum albumin,5,6
were confirmed in our study as adverse prognostic factors by
univariate analysis. Interestingly, the cumulative dose of
thalidomide within the first 3 months of treatment was not
predictive for response or outcome in our study. Some authors
have suggested before that there is no dose–response relationship with thalidomide,9,10 which is in contrast to others4–6 who
showed that patients with a cumulative dosage of more than 32
or 42 g had a superior outcome. Patients in our study received a
maximum of 32 g thalidomide within the first 3 months, and a
cutoff level of 18 g was used for analysis. This lower dosage may
be the cause that we did not find statistically differences in our
study. Advanced age was not a bad prognostic factor in our
patient population as has been shown by Mileshkin et al.8 One
reason for this may be that older patients in a mixed
study population of patients with advanced disease may have
received more intensive treatment than younger patients.
Moreover, the older patients in that study mostly received
conventional chemotherapy and were not considered candidates for HDT.
In conclusion, we show that patients with first relapse from
remission after front-line HDT are candidates for single-agent
thalidomide therapy. Two-thirds of this early patient group
achieve durable remissions. Patients with early relapse after
HDT, abnormal cytogenetics and high CRP level do not benefit
from thalidomide monotherapy and should be treated with more
aggressive combination therapies or novel agents.
Acknowledgements
This work was supported by Leukämie Liga e.V.
R Fenk1
B Hoyer1
U Steidl1,2
M Kondakci1
T Graef1
R Heuk1
L Ruf1
C Strupp1
F Neumann1
U-P Rohr1
B Hildebrandt3
R Haas1
G Kobbe1
1
Department of Hematology, Oncology and
Clinical, Immunology, University of Duesseldorf,
Germany;
2
Hematology/Oncology Division, Harvard
Institutes of Medicine, Boston, USA; and
3
Department of Human Genetics and
Anthropology, University of Duesseldorf,
Germany
Correspondence
159
References
1 Dimopoulos MA, Anagnostopoulos A, Weber D. Treatment of
plasma cell dyscrasias with thalidomide and its derivates. J Clin
Oncol 2003; 21: 4444–4454.
2 Cavenagh JD, Oakervee H. UK Myeloma Forum and the BCSH
Haematology/Oncology Task Forces. Thalidomide in multiple
myeloma: current status and future prospects. Br J Haematol
2003; 120: 18–26.
3 Kropff MH, Lang N, Bisping G, Domine N, Innig G, Hentrich M
et al. Hyperfractionated cyclophosphamide in combination with
pulsed dexamethasone and thalidomide (HyperCDT) in primary
refractory or relapsed multiple myeloma. Br J Haematol 2003; 122:
607–616.
4 Barlogie B, Desikan R, Eddlemon P, Spencer T, Zeldis J, Munshi N
et al. Extended survival in advanced and refractory multiple
myeloma after single-agent thalidomide: identification of
prognostic factors in a phase 2 study of 169 patients. Blood
2001; 98: 492–494.
5 Yakoub-Agha I, Attal M, Dumontet C, Delannoy V, Moreau P,
Berthou C et al. Thalidomide in patients with advanced multiple
6
7
8
9
10
myeloma: a study of 83 patients – report of the Intergroupe
Francophone du Myelome (IFM). Hematol J 2002; 3: 185–192.
Neben K, Moehler T, Benner A, Kraemer A, Egerer G, Ho AD et al.
Dose-dependent effect of thalidomide on overall survival in
relapsed multiple myeloma. Clin Cancer Res 2002; 8: 3377–3382.
Kumar S, Gertz MA, Dispenzieri A, Lacy MQ, Geyer SM, Iturria NL
et al. Response rate, durability of response, and survival after
thalidomide therapy for relapsed multiple myeloma. Mayo Clin
Proc 2003; 78: 34–39.
Mileshkin L, Biagi JJ, Mitchell P, Underhill C, Grigg A, Bell R et al.
Multicenter phase 2 trial of thalidomide in relapsed/refractory
multiple myeloma: adverse prognostic impact of advanced age.
Blood 2003; 102: 69–77.
Schey SA, Cavenagh J, Johnson R, Child JA, Oakervee H, Jones
RW. An UK myeloma forum phase II study of thalidomide: long
term follow-up and recommendations for treatment. Leukemia Res
2003; 27: 909–914.
Palumbo A, Bertola A, Falco P, Rosato R, Cavallo F, Giaccone L
et al. Efficacy of low-dose thalidomide and dexamethasone as
first salvage regimen in multiple myeloma. Hematol J 2004; 5:
318–324.
Raji revisited: cytogenetics of the original Burkitt’s lymphoma cell line
Leukemia (2005) 19, 159–161. doi:10.1038/sj.leu.2403534
Published online 30 September 2004
TO THE EDITOR
Raji is the first continuous human cell line of hematopoietic
origin1 and was derived 40 years ago from a Nigerian patient
with Burkitt’s lymphoma (BL).2 Cell lines of BL origin were soon
thereafter found to harbor the Epstein–Barr virus (EBV), leading
to the discovery and isolation of this virus.3 Subsequent studies
revealed specific chromosome translocations, involving the
heavy- or light-chain immunoglobulin gene loci on chromosome 14 or 2, and the c-myc oncogene locus on chromosome 8,
in biopsies and cell lines of BL origin (for a review, see Klein4).
BL-derived cell lines provide a convenient and renewable
source of material for genetic analysis, and they have been used
in a broad variety of investigations, as reported in Leukemia5
and elsewhere; however, classical G-banding techniques have
failed to produce a complete picture of chromosomal abnormalities in these cells. In view of the wide interest in these cell
lines (more than 2500 publications in the MedLine database on
Raji alone since Pulvertaft’s seminal report2), we set out to
resolve the definitive cytogenetic profile of the Raji cell line.
We thus performed molecular cytogenetic characterization of
Raji cells using a combination of spectral karyotyping (SKY),
array comparative genomic hybridization (CGH), and fluorescence in situ hybridization (FISH) techniques. Cells were
obtained from the tissue culture collection of the Microbiology
and Tumor Biology Center (MTC) at Karolinska Institutet. SKY
results are based on 45 metaphases, prepared according to
standard cytogenetic procedures. We identified two main
populations with a similar pattern of anomalies: a hyperdiploid
(2n þ ) stemline and a hypertetraploid (4n þ ) mainline. These
Correspondence: Dr B Fadeel, Division of Molecular Toxicology,
Institute of Environmental Medicine, Karolinska Institutet, Nobels väg
13, 171 77 Stockholm, Sweden; Fax þ 46 8 33 73 27;
E-mail: [email protected]
Received 17 August 2004; accepted 24 August 2004; Published
online 30 September 2004
populations shared five structural aberrations, including the
t(8;14) translocation (Figure 1a depicts representative spectral
images), and one numerical chromosomal aberration (Table 1).
In addition, a derivative chromosome, containing material from
chromosomes 16 and 17, was specific to the 4n þ population,
and was seen in 28 out of 31 cells. In the remaining three
metaphases (the sideline), a marker containing only material from
chromosome 16 was observed (Table 1). Interphase FISH using a
probe against the centromere of chromosome 8 confirmed the
ploidy structure of the Raji cell line (data not shown).
To map more precisely the breakpoints of translocations
revealed by SKY and screen for additional gains and losses, we
performed CGH using microarrays containing 2600 genomic
human bacterial artificial chromosome (BAC) clones with a
resolution of approximately 1 Mb. Hybridization and data
analysis were performed as described previously.6 Several copy
number changes that were in concordance with the SKY results
were identified (data not shown). In addition, we observed a
more complex behavior of chromosome 8, resulting in the gain
of region 8q11.21-8q22 and the loss of region 8pter-8p11.1.
To solve the complex aberrations involving chromosome 8, we
performed three-color FISH. Using a combination of probes, we
were able to identify two translocations on der(8): a metacentric
derivative with duplication of region 8q11.21-8q22, and
deletion of region 8pter–8p11.1 involved in translocations with
chromosomes 12 and 14 (Figure 1b).
The combined results of SKY, CGH, and FISH analyses of Raji
cells are shown in Table 1. The origins and breakpoints of all
complex rearrangements previously unidentified in G-banding
studies have thus been resolved. Interestingly, the gain of
chromosome 7 or parts thereof and translocations involving 4q
were also frequently mapped in other cell lines established from BL
(Karpova et al, manuscript in preparation). Moreover, a comparison of the spectral karyotype of Raji with previously published
karyotypes based on G-banding techniques revealed that a limited
number of major aberrations were acquired since the original
deposition of this cell line (Table 1). The Raji genome thus appears
to have remained relatively stable despite decades of continuous
cultivation. Macville et al7 arrived at a similar conclusion following
the examination of the cervical carcinoma-derived cell line, HeLa.
Leukemia