Chromosomal Aberrations þ1q21 and del(17p13) Predict Survival in Patients With Recurrent Multiple Myeloma Treated With Lenalidomide and Dexamethasone

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1 Chromosomal Aberrations þ1q21 and del(17p13) Predict Survival in Patients With Recurrent Multiple Myeloma Treated With Lenalidomide and Dexamethasone Ulrike Klein, MD 1 ; Anna Jauch, PhD 2 ; Thomas Hielscher 3 ; Jens Hillengass, MD 1 ; Marc S. Raab, MD 1 ; Anja Seckinger, MD 1 ; Dirk Hose, MD 1 ; Anthony D. Ho, MD 1 ; Hartmut Goldschmidt, MD 1,4 ; and Kai Neben, MD 1 BACKGROUND: In the era of novel agents such as lenalidomide and bortezomib, risk stratification by chromosomal abnormalities may enable a more rational selection of therapeutic approaches in patients with multiple myeloma (MM). METHODS: The authors analyzed the prognostic value of deletion del(13q14), del(17p13), þ1q21, translocation t(4;14), t(11;14), and t(14;16) by fluorescence in situ hybridization (FISH) in a series of 92 patients with recurrent MM who were treated with lenalidomide and dexamethasone (len/dex) at the study center. RESULTS: Patients carrying del(13q14) or t(14;16) were found to have a shorter median time to disease progression (TTP) of 5.1 months (vs 14.4 months; P ¼.009) and 2.0 months (vs 10.5 months; P <.001), respectively. However, no effect on TTP was observed in patients harboring del(13q14) as an exclusive chromosomal aberration without the concomitant presence of t(4;14) or del(17p13). The median overall survival (OS) for patients with del(17p13) or þ1q21 was 6.7 months (P ¼.002) and 8.3 months (P <.001), respectively, whereas the median OS for patients carrying none of these abnormalities was not reached. Multivariate analysis revealed that the effects of del(17p13) and þ1q21 on OS were independent of patient age as well as the type and number of regimens administered before len/dex. CONCLUSIONS: The results of the current study suggest that the prognostic significance of t(4;14) may be ameliorated or eliminated in patients treated with len/dex, whereas the presence of del(17p13) or þ1q21 is still associated with a dismal OS. The presence of t(11;14) and del(13q14) as exclusive chromosomal aberrations indicates no impact on outcome. Because of its rarity in MM, a confirmation of the prognostic role of the t(14;16) aberration is still pending. Cancer 2011;117: VC 2010 American Cancer Society. KEYWORDS: multiple myeloma, lenalidomide, cytogenetics, overall survival. Multiple myeloma (MM) is a clonal late B-cell disorder characterized by accumulated and expanded malignant plasma cells in the bone marrow, leading to variable organ damage such as osteolytic lesions, hypercalcemia, renal insufficiency, anemia, and the production of a monoclonal protein in most of the cases. 1 Although some progress has been made in the management of patients with MM, resulting in an improvement in survival (especially in younger patients), MM remains an incurable disease. 2 The introduction of novel therapeutic agents such as thalidomide, lenalidomide, and bortezomib has improved survival. 3 However, the course of the disease demonstrates heterogeneity of widely diverging survival times ranging from months to years. For this reason, prognostic factors are needed to determine the course of the disease, define therapeutic strategies, and predict long-term outcome. Using fluorescence in situ hybridization (FISH), specific changes in interphase cells can be detected, overcoming the problematic lack of dividing cells required for conventional cytogenetics. 4 Previous studies have identified the presence of deletion del(13q14), del(17p13), and þ1q21 as well as translocation t(4;14) and t(14;16) detected by FISH as high-risk factors for a Corresponding author: Kai Neben, MD, Department of Internal Medicine V, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, Germany; Fax: (011) ; kai.neben@med.uni-heidelberg.de 1 Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; 2 Institute for Human Genetics, University of Heidelberg, Heidelberg, Germany; 3 Department of Biostatistics, German Cancer Research Center, Heidelberg, Germany; 4 National Center for Tumor Diseases, Heidelberg, Germany We thank Katrin Heimlich, Maria Dorner, and Hildegard Bethauser for technical assistance in the enrichment of CD138-positive plasma cells; Frank Muller for data management; and Fabienne McClanahan for spellchecking. DOI: /cncr.25775, Received: May 21, 2010; Revised: August 29, 2010; Accepted: October 5, 2010, Published online December 3, 2010 in Wiley Online Library (wileyonlinelibrary.com) 2136 Cancer May 15, 2011

2 Cytogenetic Analyses Density gradient centrifugation of bone marrow aspirates over Ficoll Hypaque (Biochrom, Berlin, Germany) was performed to separate mononuclear cells by standard protocol. CD138-positive (CD138þ) plasma cells were isolated by magnetic-activated cell sorting using anti-cd138 immunobeads and an auto-magnetic activated cell sorter separation system (Miltenyi Biotec, Bergisch Gladbach, Germany) according to the manufacturer s protocol. Purity was confirmed by the CD38 þ and CD138 þ phenotypes in flow cytometric analysis. Interphase FISH analysis was performed on CD138-purified plasma cells as previously described 18 using probes for chromosomes 1q21, 13q14.3, and 17p13 and for the translocations t(11;14)(q13;q32.3), t(4;14)(p16.3;q32.3), and t(14;16)(q32.3;q23). Hylen/dex in Patients With MM/Klein et al poor prognosis with regard to time to disease progression (TTP)andoverallsurvival(OS), 5-8 whereas t(11;14) was found to be associated with improved survival in some studies. 4,5 Because the majority of the studies analyzed the role of chromosomal aberrations in terms of conventional 6 8 or high-dose chemotherapy (HDCT) followed by autologous stem cell transplantation (ASCT), 9,10 to our knowledge only limited data are available concerning the role of novel agents in patients carrying 1 of these cytogenetic alterations. In particular, some previous studies have suggested that bortezomib and lenalidomide are able to overcome the adverse outcomes associated with t(4;14) and del(13q14), but not the presence of del(17p13) Inarecentreportofthe Intergroupe Francophone du Myelome analyzing patients with refractory and recurrent MM who were treated with lenalidomide and dexamethasone (len/dex), these results could not be entirely confirmed because patients in whom t(4;14) and del(13q14) were present had lower overall response rates (ORR) as well as a shorter median progression-free survival (PFS) and OS compared with those who did not harbor these abnormalities. 14 Inaddition,ananalysis of 100 patients treated with len/dex at the time of diagnosis revealed that this regimen was not able to overcome the poor prognosis of chromosomal aberrations, defined by the presence of hypodiploidy, del(13q14) by metaphase cytogenetics, del(17p13), immunoglobulin IgH translocations (t(4;14) or t(14;16)), and a high labeling index. 15 On the basis of these controversial data, there is a need for additional studies to assess the impact of treatment with len/dex in the context of genetic alterations, because risk stratification might have a broad implication for a refined selection and sequence of therapy approaches. The objective of the current study was to correlate the presence of recurrent chromosomal aberrations (ie, del (13q14), del(17p13) and þ1q21 as well as t(4;14), t(11;14) and t(14;16)) with clinical outcome in 92 patients treated with len/dex in the study institution. We analyzed whether genomic abnormalities confer prognostic information regarding ORR, TTP, and OS in addition to clinical variables such as age and different treatment regimens before len/ dex. Subsequently, we investigated whether the use of HDCT followed by ASCT is suitable to improve outcome in selected patients after induction therapy with len/dex. MATERIALS AND METHODS Patients We evaluated a series of 92 consecutive patients with MM from a single institution who were treated between May 2006 and May 2009 with len/dex and tested for cytogenetic abnormalities by FISH. Approval for this study was obtained from the Institutional Review Board of the University of Heidelberg. Informed consent was provided according to the Declaration of Helsinki. Lenalidomide was administered at a dose of 25 mg on days 1 to 21 of each 28-day cycle in combination with dexamethasone at a dose of 20 mg on days 1 to 4, 9 to 12, and 17 to 20. Treatment was continued until disease progression or unacceptable toxicity occurred. Twenty-seven patients were treated with len/dex as an induction therapy, followed by HDCT with melphalan at a dose of 200 mg/m 2 followed by ASCT. In the statistical analysis, patients were censored at the date of transplantation. Data concerning the best response were evaluated if a patient had completed at least 1 course of len/dex therapy. The response to treatment was assessed according to the European Group for Blood and Marrow Transplantation criteria for complete response (CR), partial response (PR), minimal response, stable disease, and progressive disease. 16 These criteria were complemented by the criteria of the International Myeloma Working Group for very good PR (VGPR) and near-cr (ncr). 17 Efficacy was measured with the calculation of the ORR, which is defined as the CR þ ncr þ VGPR þ PR rates. The ORR was assessed as the best response achieved during treatment with len/dex. The TTP was evaluated as the time from the initiation of len/dex therapy to first assessment of disease progression. OS was measured from the initiation of len/dex therapy until death from any cause, or censorship at the last follow-up visit. Follow-up data regarding OS were obtained until June Cancer May 15,

3 Table 1. Patient Characteristics of 92 Patients With Multiple Myeloma Characteristic No. of Patients Frequency Median (Range) Male gender 53 58% Monoclonal protein IgG 57 62% IgA 18 20% Bence Jones 14 15% Other 3 3% No. of regimens prior to len/dex 2 (1 10) Bortezomib-containing regimens 52 57% Thalidomide-containing regimens 32 35% Bortezomib- and thalidomide-containing regimens 20 22% HDCT followed by ASCT 74 80% Age at onset of therapy with len/dex, y 65 (29 80) No. of cycles with len/dex 3 (1 25) Ig indicates immunoglobulin; len/dex, lenalidomide/dexamethasone; HDCT, high-dose chemotherapy; ASCT, autologous stem cell transplantation. bridization was performed according to the manufacturer s instructions (Kreatech, Amsterdam, the Netherlands; and Vysis, Downers Grove, Ill). A total of 100 interphase nuclei per probe were evaluated using a DM RXA epifluorescence microscope (Leica, Wetzlar, Germany). Hybridization efficiency was validated on interphase nuclei obtained from the peripheral blood and bone marrow of a healthy donor. The thresholds for gains, deletions, and translocations were set at 10%. Statistical Analysis Estimation of the OS distribution was performed using the method of Kaplan and Meier. For comparisons of OS curves, the log-rank test was used. In addition, Cox proportional hazards regression analysis was used to evaluate the prognostic impact in a univariate model as well as in a multivariate model together with prognostically relevant clinical factors. TTP was evaluated in a competing risk analysis, with ASCT being the competing risk. TTP was analyzed fitting a subdistributional hazard regression model. 19 This model directly assesses the effect of a prognostic factor on TTP in a competing risk setting and allows for the incorporation of additional covariates. The TTP distribution was estimated using cumulative incidence rates. The prognostic value of clinical factors was assessed by their estimated hazard ratios (HR) including 95% confidence intervals. Response rates were analyzed using the Fisher exact test. P values were adjusted for multiple testing using the Bonferroni-Holm correction. The result of a test was always regarded as statistically significant when the corresponding 2-sided P was <.05. All statistical computations were performed with the statistical software environment R (version 2.9.0; R Development Core Team) using the R package cmprsk version RESULTS Patient Cohort Between May 2006 and May 2009, 212 consecutive patients with refractory or recurrent MM were treated at the study institution with a combination of len/dex. In this retrospective analysis, we included all 92 of the 212 patients who completed at least 1 cycle of len/dex and were tested for cytogenetic abnormalities by FISH. Patient characteristics are shown in Table 1. The patient group was comprised of 53 men and 39 women with a median age of 65 years at the onset of therapy with len/ dex (range, 29 years-80 years). The median number of regimens before the administration of len/dex was 2 (range, 1 regimen-10 regimens), including HDCT followed by ASCT in approximately 80% of patients. For the entire group, the median follow-up time was 12.1 months. The median TTP was 9.9 months. During the follow-up, 32 deaths occurred. The median survival time had not been reached at the time of last follow-up. Frequencies of Chromosomal Aberrations Interphase FISH analysis of CD138-enriched plasma cells revealed gains of chromosomes 1q21 (50%), as well as deletions of chromosomes 13q14 (59%) and 17p13 (16%). Furthermore, the IgH translocations t(4;14), t(11;14), and t(14;16) were observed at a frequency of 2138 Cancer May 15, 2011

4 len/dex in Patients With MM/Klein et al Table 2. Univariate Analysis of the Prognostic Impact of Chromosomal Abnormalities on TTP and OS a TTP OS Aberration No. of Patients Analyzed Incidence HR (95% CI) Log-rank P Adjusted P HR (95% CI) Log-rank P Adjusted P del(13q14) 92 59% 2.5 ( ) ( ) del(17p13) 92 16% 2.0 ( ) ( ) < t(4;14) 89 21% 1.7 ( ) ( ) t(11;14) 92 17% 0.6 ( ) ( ).4.7 t(14;16) 72 6% 5.8 ( ) <.001 < ( ).4.7 þ1q % 1.7 ( ) ( ) <.001 <.001 TTP indicates time to disease progression; OS, overall survival; HR, hazard ratio; 95% CI, 95% confidence interval; del, deletion; t, translocation. a Statistical significance level is.05. Table 3. Correlation Between Chromosomal Aberrations and Best Response Rates During Treatment With Lenalidomide and Dexamethasone a Chromosomal Aberration Chromosomal Aberration Present Response Rate PR Frequency, % Chromosomal Aberration Absent Response Rate PR Frequency, % OR (95% CI) P Adjusted P del(17p13) 5/13 patients 38 49/73 patients ( ) del(13q14) 25/50 patients 50 29/36 patients ( ) þ1q21 19/38 patients 50 29/42 patients ( ) t(4;14) 9/18 patients 50 45/67 patients ( ) t(11;14) 11/16 patients 69 43/70 patients ( ) t(14;16) 1/4 patients 25 42/65 patients ( ) PR indicates partial response; OR, odds ratio; 95% CI, 95% confidence interval; del, deletion; t, translocation. a The Fisher exact test for independence between response rates and chromosomal aberrations was used (<PR vs PR). 21%, 17%, and 6%, respectively. Because of the retrospective nature of the current study, cytogenetic data were not available for all patients. Because of the small number of purified plasma cells in some specimens, we were not able to test the full set of probes by FISH in all patients. The exact number of probes tested is depicted in Table 2. Correlation of Chromosomal Aberrations With Response Rates The ORR (PR) for the entire group was 58.7%. The presence of del(13q14), but not del(17p13), þ1q21, t(4;14), t(11;14), and t(14;16), resulted in a significantly lower response rate of 50% compared with patients who were negative for del(13q14) (81%) (P ¼.04) (Table 3). For 25 patients carrying del(13q14) without t(4;14) or del(17p13), no effect on the ORR was observed, in comparison with patients who were negative for del(13q14) (ORR, 63.5% vs 60.9%; P ¼ not significant). Notably, none of the patients carrying del(17p13) or t(14;16) achieved a VGPR or CR as best response to len/dex, although this finding was not statistically significant because of the small number of patients with this aberration. Correlation of Chromosomal Aberrations With Patient Outcome We analyzed the prognostic impact of chromosomal aberrations on TTP and OS (Table 2). Although del(13q14) and t(14;16) demonstrated a significant impact on TTP, del(17p13) and þ1q21 were found to be of statistical significance for OS (Fig. 1). In detail, the median TTP for patients with del(13q14) or t(14;16) was 5.1 months (vs 14.4 months; P ¼.009) and 2.0 months (vs 10.5 months; P <.001), respectively. The median OS for patients with del(17p13) or þ1q21 was 6.7 months (P ¼.002) and 8.3 months (P <.001), respectively, whereas the median OS was not reached for patients without either of these abnormalities. In a multivariate analysis (Table 4), we analyzed the statistical impact of chromosomal aberrations in combination with age, different pretreatment regimens, and the duration of disease before len/dex therapy as well as the use of HDCT followed by ASCT as consolidation therapy. Translocations t(14;16) and t(11;14) were not Cancer May 15,

5 OS (P ¼.049 and P ¼.025, respectively). When del(13q14) was analyzed as an exclusive chromosomal aberration without the presence of t(4;14) or del(17p13), no effect on TTP was observed compared with patients who were negative for del(13q14). Correlation of 11q21 and t(4;14) With Other Chromosomal Aberrations Because þ1q21 but not t(4;14) was identified as a prognostic factor in the statistical analysis, we analyzed whether these chromosomal aberrations are associated with additional chromosomal changes. As shown in Table 5, both t(4;14) and þ1q21 were positively linked with the presence of del(13p14), whereas both aberrations demonstrated a negative correlation with the presence of t(11;14). In addition, there was trend toward a positive correlation between t(4;14) and þ1q21 (P ¼.08). Figure 1. Impact of deletion del(17p13), del(13q14), þ1q21, and translocation t(14;16) on the time to disease progression (TTP) and overall survival (OS) of patients treated with lenalidomide and dexamethasone is shown. (A-H) Myeloma patients were stratified by the presence or absence of each of the specific cytogenetic abnormalities demonstrating statistical significance in the univariate and multivariate analyses. included in this model because of the small number of patients carrying 1 of these chromosomal aberrations or, in the case of t(11;14), because no effect on TTP and OS was observed in the univariate analysis. The Cox proportional hazards regression analysis revealed that del(13q14) was the only chromosomal alteration with a statistically significant impact on TTP (P ¼.042), whereas del(17p13) and þ1q21 were of statistical significance for Impact of HDCT Followed by ASCT on Survival Patients who fulfilled the following criteria were offered HDCT followed by ASCT as consolidation therapy after induction therapy with len/dex: 1) age 70 years, 2) TTP >12 months after upfront ASCT, and 3) good clinical performance status (Eastern Cooperative Oncology Group [ECOG] status 0-2). Of these 27 patients, 25 received 3 courses, 1 patient received 2 courses, and 1 patient received 4 courses of len/dex as induction therapy. To compare the outcome of patients receiving ASCT (ASCT group; n ¼ 21) with patients who continued on to receive len/dex therapy until disease progression (no- ASCT group; n ¼ 39), we performed a landmark analysis at 6 months after the initiation of therapy with len/dex. Patients belonging to the ASCT group were predominantly male (76% vs 41%; P ¼.01) and were pretreated less frequently with bortezomib (33% vs 64%; P ¼.03) compared with patients in the no-asct group. There was no statistically significant difference noted with regard to the distribution of chromosomal aberrations between the 2 groups. As shown in Figure 2, the OS at 12 months for patients in the no-asct group was 56.5% compared with 100% for patients receiving ASCT (P ¼.006). In addition, the multivariate analysis (Table 4) indicated that patients receiving ASCT had a statistically significantly better OS (HR, 0.11; P ¼.033), independent of chromosomal abnormalities and treatment with bortezomib or thalidomide before len/dex therapy Cancer May 15, 2011

6 len/dex in Patients With MM/Klein et al DISCUSSION This retrospective study included a series of 92 patients with recurrent MM who were analyzed for genomic aberrations and treated with len/dex in the study institution. All interphase FISH experiments were performed on CD138-enriched plasma cells, which were analyzed with a comprehensive set of 6 different DNA probes specific for the most recurrent chromosomal aberrations observed in MM. The incidences of del(13q14) (59%), del(17p13) (16%), and t(4;14) (21%) were within the same range as that reported in 2 previous trials. 13,14 In addition, we analyzed the impact of þ1q21, t(11;14), and t(14;16) on outcome in patients with recurrent MM who were treated with len/dex. The ORR of 58.7% and the median TTP of 9.9 months were slightly lower when compared with the data reported in 2 previously reported phase 3 trials comparing len/dex with dexamethasone alone. 21,22 This is Table 4. Multivariate Analysis of the Prognostic Impact of Chromosomal Abnormalities and Clinical Parameters on TTP and OS According to Multivariate Cox Proportional Hazards Regression Analysis a Variable TTP OS HR P HR P del(17p13) del(13q14) t(4;14) þ1q Age >2 therapies before len/dex Bortezomib treatment before len/dex Thalidomide treatment before len/dex Duration between first MM therapy to initiation of len/dex ASCT after 3 cycles of len/dex b TTP indicates time to disease progression; OS, overall survival; HR, hazard ratio; del, deletion; t, translocation; len/dex, lenalidomide/dexamethasone; MM, multiple myeloma; ASCT, autologous stem cell transplantation. a Statistical significance level is.05. b Time-dependent variable. most likely the result of the dose reduction of dexamethasone by 50% in the current study compared with the 2 previous phase 3 studies to prevent infections and venous thromboembolism. As shown in a randomized trial by ECOG, 23 a higher dose of dexamethasone (40 mg on days 1-4, 9-12, and vs 40 mg on ays 1, 8, 15, and 22) in combination with lenalidomide (25 mg on days 1-21 in both treatment arms) was associated with an improved ORR of 79% versus 68% after 4 cycles of len/dex in newly diagnosed patients with MM. Depending on different chromosomal aberrations, the ORR varied in the current study from 25% to 69%, whereas significant results were noted only for patients carrying del(13q14) or t(14;16). Both chromosomal abnormalities demonstrated a significant impact on TTP as well. Actually, the majority of the prognostic power of del(13q14) was related to concomitant alterations of t(4;14) or del(17p13), which are frequently associated with del(13q14). In patients lacking t(4;14) and del(17p13), del(13q14) was no longer found to be of prognostic significance. This concurs with previously published data in the setting of both conventional therapy and ASCT. 5,6,8 To our knowledge to date, t(14;16) as assessed by FISH has shown to be of adverse prognosis only if conventional chemotherapy is applied. 24 For highdose therapy, a prognostic value has been demonstrated using gene expression profiling-based assessment (spiked maf expression). 25 Despite our own similar experience in a limited number of patients, a confirmation of the prognostic role of t(14;16) is still pending because of the rarity of the translocation. It is interesting to note that in the current study, þ1q21 was identified as an independent factor predicting OS in the context of treatment with len/dex in patients with recurrent MM. This is in keeping with a recent study describing amplifications of 1q and/or deletions of 1p as Table 5. Correlation of t(4;14) and þ1q21 With Other Chromosomal Aberrations t(4;14)- Negative Samples t(4;14)- Positive Samples 11q21- Negative Samples 11q21- Positive Samples No. % No. % Kendall Tau P No. % No. % Kendall Tau P del(13q14) 36/ / / / del(17p13) 12/ / / / T(4;14) 6/ / t(11;14) 16/ / / / t(14;16) 4/53 8 0/ /35 3 3/ þ1q21 28/ / t indicates translocation; del, deletion. Cancer May 15,

7 Figure 2. Landmark analysis at 6 months after the initiation of therapy with lenalidomide and dexamethasone (len/dex) is shown. This analysis compared patients who maintained stable disease while receiving len/dex until disease progression (no autologous stem cell transplantation [no-asct] group; n ¼ 39) with patients who received high-dose chemotherapy followed by ASCT as consolidation therapy after 3 cycles of treatment with len/dex (ASCT group; n ¼ 21). OS indicates overall survival. predictors of poor outcome in the context of HDCT. 7 In addition, Shaughnessy et al 26 investigated the gene expression profile of 532 newly diagnosed patients with MM and identified a 70-gene subset to be an independent predictor of outcome endpoints in a multivariate analysis. It is interesting to note that approximately 30% of genes included in the 70-gene predictor mapped to chromosome 1, suggesting that deregulated expression of genes on chromosome 1 is of great importance for the clinical course of the disease in individual patients. In agreement with previous studies, patients in whom del(17p13) was present were found to have a shorter OS compared with patients without this chromosomal abnormality. 13,14,27 When the prognostic value of all chromosomal abnormalities was analyzed in a multivariate model, þ1q21 and del(17p13) were found to be associated with a dismal OS. However, the presence of 1 of these aberrations had no statistically significant impact on ORR and TTP, suggesting that novel agents such as lenalidomide should be administered early in the course of disease because neither conventional chemotherapy nor HDCT followed by ASCT have been demonstrated to improve the ORR, PFS, and OS for patients with highrisk disease. 5 8,10 In the current study, neither age nor type and number of regimens administered before len/dex was found to have a statistically significant impact on TTP and OS in the multivariate analysis. This in contrast to Wang et al, who demonstrated that the ORR and TTP were superior in thalidomide-naive versus thalidomideexposed patients before the administration of len/dex. 28 In addition, it has been shown that the ORR, TTP, and OS were significantly prolonged for patients treated with len/dex with 1 prior therapy, compared with patients who were pretreated with a higher number of previous regimens. 29 In the current study, we did not differentiate between exposure (eg, as part of the induction therapy) and refractoriness (eg, maintenance with thalidomide until disease progression) to thalidomide-containing and bortezomib-containing regimens before len/dex, because the numbers would be too small for statistical analysis. Because the greatest percentage of patients in the current study developed their first recurrence after HDCT followed by ASCT, the majority might still be responsive to treatment with thalidomide, lenalidomide, or bortezomib. In the current study, the prognostic role of t(4;14) was analyzed in the context of treatment with len/dex. The results of the current study and 1 previous study 13 indicated that t(4;14) demonstrates no statistical significance in terms of TTP and OS, suggesting that the prognostic significance of t(4;14) may be ameliorated or eliminated in patients treated with len/dex. Because we analyzed the role of len/dex therapy in patients with recurrent MM (80% of patients developed disease recurrence after ASCT), we cannot exclude a negative selection of patients presenting with t(4;14). In the context of ASCT, the French study group demonstrated that patients with t(4;14) and b 2 -microglobulin levels 4 mg/l had outcomes resembling those of patients lacking the translocation but with b 2 -microglobulin levels >4 mg/l. 7 Because bortezomib-containing first-line therapies were not available in the study institution before 2004, it can be speculated that some of these patients with t(4;14) and b 2 - microglobulin levels 4 mg/l demonstrated long-lasting remissions to bortezomib-containing first-line therapies. Therefore, some of these good high-risk patients might not have been included in the current study, suggesting that the prognostic role of t(4;14) should also be analyzed in patients with newly diagnosed MM who are treated with len/dex. Because of the retrospective nature of the current study, International Staging System (ISS) data at the time of the initiation of first chemotherapy were available for 67 patients only (73%). Therefore, we could not simply add ISS data to the multivariate model because the number of events would be too small to obtain reliable 2142 Cancer May 15, 2011

8 len/dex in Patients With MM/Klein et al estimates for the entire set of covariates. Instead, we investigated only the chromosomal aberrations found to have an independent prognostic effect and adjusted their effect for ISS. The independent effect of del(17p13) and þ1q21 on OS was retained after accounting for ISS. For TTP, the effect of del(13q14) was no longer found to be significant in this subgroup analysis (P ¼.054). However, comparing the effect of del(13q14) alone (HR, 1.84) with the effect of del(13q14) adjusted by ISS (HR, 1.89) in this subset of patients revealed that the larger P value is a result of the reduced sample size and, consequently, a loss of power rather than the correction for ISS. A subgroup of patients with recurrent MM who presented in good clinical condition with an age 70 years and who demonstrated a response to upfront HDCT followed by ASCT (TTP, >12 months) were offered the option to receive another HDCT and ASCT as consolidation therapy after induction with 3 cycles of len/dex at the time of disease recurrence. In principle, patients with recurrent MM can be offered the possibility of an autologous transplantation because the results of previous studies indicated 1) the feasibility of the procedure; 2) the high antimyeloma activity, although generally transient, of HDCT; and 3) that, even in a poor-risk population, up to 25% of the patients achieving a CR remained in this CR many years beyond ASCT. 30 In the current study, selected patients receiving ASCT after 3 cycles of induction therapy with len/dex had an excellent OS rate of 100% at 1 year. These encouraging data prompted us to initiate a phase 3 trial in patients with recurrent MM who were eligible for transplant (European Clinical Trials Database [EudraCT] no ), analyzing the role of ASCT after induction with 3 cycles of len/dex compared with treatment with len/dex until disease progression. In conclusion, the results of the current study add new findings to the prognostic value of high-risk cytogenetic abnormalities in patients with recurrent MM who are treated with len/dex. These data are limited by the retrospective nature of this analysis and the low frequency of some analyzed chromosomal aberrations, indicating that there is a need for further evaluation in larger patient cohorts, ideally implemented in prospective studies. Increasing evidence suggests that the impact of prognostic factors, notably t(4;14), t(14;16), and del(17p13), depend on the treatment schedule, especially in terms of the additional use of bortezomib or lenalidomide. For example, t(4;14) has been associated with more aggressive disease at baseline. In a series of patients treated with conventional chemotherapy or HDCT, this translocation was found to indicate those patients with adverse effects on survival. 6,8 In keeping with the findings of recent reports, the results of the current study emphasize that the prognostic significance of t(4;14) may be ameliorated or eliminated in patients treated with lenalidomide-based or bortezomibbased combinations. 12,13,31 Hence, we support the concept of the early use of novel agents such as lenalidomide and bortezomib in MM patients with high-risk disease. 32 CONFLICT OF INTEREST DISCLOSURES Supported in part by grants from the Dietmar-Hopp Foundation, Germany; the University of Heidelberg, Germany; the National Center for Tumor Diseases, Heidelberg, Germany; and the Tumorzentrum Heidelberg/Mannheim, Germany. Drs. Neben and Goldschmidt have received honoraria and research funding from and are members of an advisory committee for Celgene and Janssen-Cilag. REFERENCES 1. Raab MS, Podar K, Breitkreutz I, Richardson PG, Anderson KC. Multiple myeloma. Lancet. 2009;374: Ludwig H, Durie BG, Bolejack V, et al. Myeloma in patients younger than age 50 years presents with more favorable features and shows better survival: an analysis of 10,549 patients from the International Myeloma Working Group. Blood. 2008;111: Kumar SK, Rajkumar SV, Dispenzieri A, et al. Improved survival in multiple myeloma and the impact of novel therapies. Blood. 2008;111: Fonseca R, Bergsagel PL, Drach J, et al. International Myeloma Working Group molecular classification of multiple myeloma: spotlight review. Leukemia. 2009;23: Fonseca R, Blood EA, Oken MM, et al. Myeloma and the t(11;14)(q13;q32): evidence for a biologically defined unique subset of patients. Blood. 2002;99: Chiecchio L, Protheroe RK, Ibrahim AH, et al. Deletion of chromosome 13 detected by conventional cytogenetics is a critical prognostic factor in myeloma. Leukemia. 2006; 20: Avet-Loiseau H, Attal M, Moreau P, et al. Genetic abnormalities and survival in multiple myeloma: the experience of the Intergroupe Francophone du Myelome. Blood. 2007; 109: Drach J, Ackermann J, Fritz E, et al. Presence of a p53 gene deletion in patients with multiple myeloma predicts for short survival after conventional-dose chemotherapy. Blood. 1998;92: Chang H, Qi X, Jiang A, Xu W, Young T, Reece D. 1p21 deletions are strongly associated with 1q21 gains and are an independent adverse prognostic factor for the outcome of high-dose chemotherapy in patients with multiple myeloma. Bone Marrow Transplant. 2010;45: Neben K, Jauch A, Bertsch U, et al. Combining information regarding chromosomal aberrations t(4;14) and del(17p13) with the International Staging System classification allows stratification of myeloma patients undergoing Cancer May 15,

9 autologous stem cell transplantation. Haematologica. 2010; 95: Jagannath S, Richardson PG, Sonneveld P, et al. Bortezomib appears to overcome the poor prognosis conferred by chromosome 13 deletion in phase 2 and 3 trials. Leukemia. 2007;21: Avet-Loiseau H, Leleu X, Roussel M, et al. Bortezomib plus dexamethasone induction improves outcome of patients with t(4;14) myeloma but not outcome of patients with del(17p). J Clin Oncol. 2010;28: Reece D, Song KW, Fu T, et al. Influence of cytogenetics in patients with relapsed or refractory multiple myeloma treated with lenalidomide plus dexamethasone: adverse effect of deletion 17p13. Blood. 2009;114: Avet-Loiseau H, Soulier J, Fermand JP, et al. Impact of high-risk cytogenetics and prior therapy on outcomes in patients with advanced relapsed or refractory multiple myeloma treated with lenalidomide plus dexamethasone. Leukemia. 2010;24: Kapoor P, Kumar S, Fonseca R, et al. Impact of risk stratification on outcome among patients with multiple myeloma receiving initial therapy with lenalidomide and dexamethasone. Blood. 2009;114: Blade J, Samson D, Reece D, et al. Criteria for evaluating disease response and progression in patients with multiple myeloma treated by high-dose therapy and haemopoietic stem cell transplantation. Myeloma Subcommittee of the EBMT. European Group for Blood and Marrow Transplant. Br J Haematol. 1998;102: Durie BG, Harousseau JL, Miguel JS, et al. International uniform response criteria for multiple myeloma. Leukemia. 2006;20: Cremer FW, Bila J, Buck I, et al. Delineation of distinct subgroups of multiple myeloma and a model for clonal evolution based on interphase cytogenetics. Genes Chromosomes Cancer. 2005;44: Fine JP, Gray RJ. A proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc. 1999;94: R Development Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; Available at: accessed August 15, Dimopoulos M, Spencer A, Attal M, et al. Lenalidomide plus dexamethasone for relapsed or refractory multiple myeloma. N Engl J Med. 2007;357: Weber DM, Chen C, Niesvizky R, et al. Lenalidomide plus dexamethasone for relapsed multiple myeloma in North America. N Engl J Med. 2007;357: Rajkumar SV, Jacobus S, Callander NS, et al. Lenalidomide plus high-dose dexamethasone versus lenalidomide plus lowdose dexamethasone as initial therapy for newly diagnosed multiple myeloma: an open-label randomised controlled trial. Lancet Oncol. 2010;11: Fonseca R, Blood E, Rue M, et al. Clinical and biologic implications of recurrent genomic aberrations in myeloma. Blood. 2003;101: Zhan F, Huang Y, Colla S, et al. The molecular classification of multiple myeloma. Blood. 2006;108: Shaughnessy JD Jr, Zhan F, Burington BE, et al. A validated gene expression model of high-risk multiple myeloma is defined by deregulated expression of genes mapping to chromosome 1. Blood. 2007;109: Knop S, Gerecke C, Liebisch P, et al. Lenalidomide, adriamycin, and dexamethasone (RAD) in patients with relapsed and refractory multiple myeloma: a report from the German Myeloma Study Group DSMM (Deutsche Studiengruppe Multiples Myelom). Blood. 2009;113: Wang M, Dimopoulos MA, Chen C, et al. Lenalidomide plus dexamethasone is more effective than dexamethasone alone in patients with relapsed or refractory multiple myeloma regardless of prior thalidomide exposure. Blood. 2008;112: Stadtmauer EA, Weber DM, Niesvizky R, et al. Lenalidomide in combination with dexamethasone at first relapse in comparison with its use as later salvage therapy in relapsed or refractory multiple myeloma. Eur J Haematol. 2009;82: Blade J, Rosinol L, Cibeira MT, Rovira M, Carreras E. Hematopoietic stem cell transplantation for multiple myeloma beyond Blood. 2010;115: San Miguel JF, Schlag R, Khuageva NK, et al. Bortezomib plus melphalan and prednisone for initial treatment of multiple myeloma. N Engl J Med. 2008;359: Ludwig H, Beksac M, Blade J, et al. Current multiple myeloma treatment strategies with novel agents: a European perspective. Oncologist. 2010;15: Cancer May 15, 2011