Обоснование. Комбинация карфилзомиба, леналидомида и дексаметазона (KRd) одобрена для лечения пациентов с рецидивом и рефрактерным течением (РР) множественной миеломы (РРММ) на основе результатов исследования ASPIRE. Цель. Анализ эффективности и безопасности применения схемы KRd в условиях реальной клинической практики.
Материалы и методы. В проспективный анализ включены пациенты с ММ, получившие не менее одной линии предшествующей терапии. Критериями включения служили: рецидив/прогрессия; рефрактерность; отсутствие очень хорошей частичной ремиссии (ОХЧР) и более после 1-й линии терапии. С февраля 2016 г. использовался стандартный режим KRd (ASPIRE), с октября 2019 г. карфилзомиб применяли в дозе 56 мг/м2 в 1, 8 и 15-й дни. Трансплантация аутологичных стволовых кроветворных клеток (аутоТСКК), консолидация (KRd) и поддерживающая терапия (Rd) расценивались как одна линия терапии. Результаты и обсуждение. Проанализирована терапия 77 больных. Медиана возраста на момент диагноза – 55 (30–72) лет. У 56% (n=43) схема KRd применена во 2-й линии (группа 1), у 44% (n=34) – в 3-й и более (группа 2). У 23/43 пациентов из группы 1 произведена ранняя смена терапии из-за недостаточной эффективности (после 2–4 курсов VCD или PAD). Схема KRd послужила «мостом» к аутоТСКК у 25 (32%) больных (21 из 25 в группе 1). Еще 7 пациентам выполнен сбор аутоСКК (все из группы 1).
Общий ответ (ОО) достигнут у 80,5%, полный ответ – 33,8%, ОХЧР – 26%. Частота ОО в группе 1 составила 98% против 65,6% в группе 2; 24-месячная общая выживаемость составила 70%, выживаемость без прогрессии – 49,8%. В группе 1 24-месячная общая выживаемость составила 85,6% против 50,0% в группе 2; 24-месячная выживаемость без прогрессии – 67,8% против 25,5% (р=0,01). Заключение. Наш анализ подтвердил высокую эффективность схемы KRd в терапии РРММ в реальной практике. Ранняя коррекция терапии при недостаточной эффективности 1-й линии позволила реализовать стратегию высокодозной консолидации и аутоТСКК у большего числа больных ММ.
Ключевые слова: карфилзомиб, леналидомид, аутологичная трансплантация, реальная клиническая практика, рецидив и рефрактерное течение множественной миеломы
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Background. Carfilzomib, lenalidomide, and dexamethasone (KRd) have been approved for the treatment of relapsed and refractory multiple myeloma (RRMM) based on ASPIRE clinical trial. Aim. Analysis of efficacy and safety of KRd in routine clinical practice.
Materials and methods. The prospective analysis included patients with MM who received at least one line of previous therapy. The inclusion criteria were relapse/progression; refractoriness; lack of very good partial response (VGPR) and more after the first line of therapy. Since February 2016, we used KRd like in ASPIRE trial, since October 2019, carfilzomib has been used at a dose of 56 mg/m2 on days 1, 8 and 15. Autologous hematopoietic stem cell transplantation (autoHSCT), consolidation (KRd) and maintenance therapy (Rd) were regarded as one line of therapy. Results and discussion. We evaluated 77 patients with median age at the time of diagnosis is 55 (30–72) years. For 56% (n=43) of patients KRd was applied as the second line (group 1), for 44% (n=34) – as the third and more (group 2). In 23/43 patients from group 1, an early change in therapy was made due to insufficient effectiveness (after 2–4 courses of VCD or PAD). KRd served as a "bridge" to autoHSCT in 25 (32%) patients (21 of 25 in group 1). Another 7 patients underwent collection of autoHSC (all from group 1).
The overall response rate (ORR) was 80.5%, with 33.8% complete response (CR) and 26% VGPR. ORR in group 1 was 98% versus 65.6% in group 2; 24-month overall survival (OS) was 70%, progression free survival (PFS) – 49.8%. In group 1, 24-month OS was 85.6% versus 50.0% in group 2, 24-month PFS was 67.8% versus 25.5% (p=0.01). Conclusion. Our analysis confirmed the high efficiency of KRd in the treatment of RRMM in real-life practice. Early correction of therapy with insufficient effectiveness of the first line made it possible to implement the strategy of high-dose consolidation and autoHSCT in a larger percentage of patients with MM.
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2. Лучинин А.С., Семочкин С.В., Минаева Н.В., и др. Эпидемиология множественной миеломы по данным анализа популяционного регистра Кировской области. Онкогематология. 2017;12(3):50-6 [Luchinin AS, Semochkin SV, Minaeva NV, et al. Epidemiology of multiple myeloma according to the Kirov Region population registers. Oncohematology. 2017;12(3):50-6 (in Russian)]. DOI:10.17650/1818-8346-2017-12-3-50-56
3. Скворцова Н.В., Поспелова Т.И., Ковынев И.Б., и др, Эпидемиология множественной миеломы в Новосибирске (Сибирский федеральный округ). Клиническая онкогематология. 2019;12(1):86-94 [Skvortsova NV, Pospelova TI, Kovynev IB, et al. Epidemiology of Multiple Myeloma in Novosibirsk (Siberian Federal District). Clinical Oncohematology. 2019;12(1):86-94 (in Russian)]. DOI:10.21320/2500-2139-2019-12-1-86-94
4. Виноградова О.Ю., Птушкин В.В., Черников М.В., и др. Эпидемиология множественной миеломы в городе Москва. Терапевтический архив. 2019;91(7):83-92 [Vinogradova OYu, Ptushkin VV, Chernikov MV, et al. Epidemiology of multiple myeloma in city Moscow. Terapevticheskii Arkhiv (Ter. Arkh). 2019;91(7):83-92 (in Russian)].
DOI:10.26442/00403660.2019.07.000305
5. Moreau P, San Miguel J, Sonneveld P, et al. Multiple myeloma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2017;28(Suppl. 4):iv52-iv61. DOI:10.1093/annonc/mdx096
6. Zou Ya, Lin M, Sheng Zh, Niu S. Bortezomib and lenalidomide as front-line therapy for multiple myeloma. Leuk Lymphoma. 2014;55(9):2024‑31. DOI:10.3109/10428194.2013.847935
7. Facon T, Dimopoulos MA, Dispenzieri A, et al. Final analysis of survival outcomes in the phase 3 FIRST trial of up-front treatment for multiple myeloma. Blood. 2018;131(3):301-10. DOI:10.1182/blood-2017-07-795047
8. Mateos MV, Dimopoulos MA, Cavo M, et al. Daratumumab plus bortezomib, melphalan, and prednisone for untreated myeloma. N Engl J Med. 2018;378(6):518-28. DOI:10.1056/NEJMoa1714678
9. Sivaraj D, Bacon W, Long GD, et al. High-dose BCNU/Melphalan conditioning regimen before autologous stem cell transplantation in newly diagnosed multiple myeloma. Bone Marrow Transplant. 2018;53(1):34‑8. DOI:10.1038/bmt.2017.208
10. Dhakal B, Szabo A, Chhabra S, et al. Autologous transplantation for newly diagnosed multiple myeloma in the era of novel agent induction a systematic review and meta-analysis. JAMA Oncol. 2018;4(3):343-50. DOI:10.1001/jamaoncol.2017.4600
11. Su B, Zhu X, Jiang Y, et al. A meta-analysis of autologous transplantation for newly diagnosed multiple myeloma in the era of novel agents. Leuk Lymphoma. 2018;60. DOI:10.1080/10428194.2018.1543874
12. Dingli D, Ailawadhi S, Bergsagel PL, et al. Therapy for relapsed multiple myeloma: guidelines from the Mayo stratification for myeloma and risk-adapted therapy. Mayo Clin Proc. 2017; 92:578-98. DOI:10.1016/j.mayocp.2017.01.003
13. Harousseau JL, Attal M. How I treat first relapse of myeloma. Blood. 2017;130:963-73. DOI:10.1182/blood-2017-03-726703
14. Sonneveld P, Broijl A. Treatment of relapsed and refractory multiple myeloma. Haematologica. 2016;101:396-406. DOI:10.3324/haematol.2015.129189
15. Kumar SK, Therneau TM, Gertz MA, et al. Clinical course of patients with relapsed multiple myeloma. Mayo Clin Proc. 2004;79:867-74. DOI:10.4065/79.7.867
16. Durie BG, Moreau P, Sonneveld P, et al. Regional differences in the treatment approaches for relapsed multiple myeloma: an IMF study. J Clin Oncol. 2012;30:8095. DOI:10.1200/JCO.2012.30.15_SUPPL.8095
17. Siegel DS, Dimopoulos MA, Ludwig H, et al. Improvement in overall survival with carfilzomib, lenalidomide, and dexamethasone in patients with relapsed or refractory multiple myeloma. J Clin Oncol. 2018;36:728-34. DOI:10.1200/JCO.2017.76.5032
18. Stewart AK, Rajkumar SV, Dimopoulos MA, et al. Carfilzomib, lenalidomide, and dexamethasone for relapsed multiple myeloma. New Engl J Med. 2015;372:142-52. DOI:10.1056/NEJMoa1411321
19. Durie BG, Harousseau JL, Miguel JS, et al. International uniform response criteria for multiple myeloma. Leukemia. 2006;20(9):1467-73. DOI:10.1038/sj.leu.2404284
20. Cancer Therapy Evaluation Program CTCAE, version 4.03. Available at: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_30. Accessed: 14.06.2010.
21. Dimopoulos MA, Wang M, Maisnar V, et al. Response and progression-free survival according to planned treatment duration in patients with relapsed multiple myeloma treated with carfilzomib, lenalidomide and dexamethasone (KRd) versus lenalidomide and dexamethasone (Rd) in the phase III ASPIRE study. J Hematology Oncology. 2018;11:49. DOI:10.1186/s13045-018-0583-7
22. Dimopoulos MA, Moreau P, Palumbo A, et al. Carfilzomib and dexamethasone versus bortezomib and dexamethasone for patients with relapsed or refractory multiple myeloma (ENDEAVOR): a randomised, phase 3, open-label, multicentre study. Lancet Oncol. 2016;17(1):27-38. DOI:10.1016/S1470-2045(15)00464-7
23. Jasielec JK, Kubicki T, Raje N, et al. Carfilzomib, lenalidomide, and dexamethasone plus transplant in newly diagnosed multiple myeloma, Blood. 2020;136:2513-23. DOI:10.1182/blood.2020007522
24. Jakubowiak AJ, Dytfeld D, Griffith Kent A, et al. A phase 1/2 study of carfilzomib in combination with lenalidomide and low-dose dexamethasone as a frontline treatment for multiple myeloma. Blood. 2012;120. DOI:10.1182/blood-2012-04-422683
25. Facon T, Lee JH, Moreau P, et al. Randomized phase 3 study of carfilzomib with melphalan-prednisone for transplant-ineligible, NDMM patients. Blood. 2019;133(18):1953-63. DOI:10.1182/blood-2018-09-874396
26. Kumar S, Jacobus SJ, Cohen AD, et al. Carfilzomib, lenalidomide, and dexamethasone (KRd) versus bortezomib, lenalidomide, and dexamethasone (VRd) for initial therapy of newly diagnosed multiple myeloma (NDMM): Results of ENDURANCE (E1A11) phase III trial [abstract]. J Clin Oncol. 2020;38(18). Abstract LBA3.
27. Gay F, Cerrato C, Petrucci MT. et al. Efficacy of carfilzomib lenalidomide dexamethasone (KRd) with or without transplantation in newly diagnosed myeloma according to risk status: results from the FORTE trial. J Clin Oncol. 2019;37. DOI:10.1200/JCO.2019.37.15_suppl.8002
28. Takamatsu H, Yoroidaka T, Fujisawa M, et al. Comparison of minimal residual disease detection in multiple myeloma by SRL 8-color single-tube and EuroFlow 8-color 2-tube multiparameter flow cytometry. Int J Hematol. 2019;109(4):377-81. DOI:10.1007/s12185-019-02615-z
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1. Malignant neoplasms in Russia in 2017 (morbidity and mortality). Ed. by AD Kaprin, VV Starinsky, GV Petrova. Moscow: Herzen Moscow State Medical Research Institute – branch of the Federal State Budgetary Institution "NMIC of Radiology" of the Ministry of Health of Russia, 2018 (in Russian)
2. Luchinin AS, Semochkin SV, Minaeva NV, et al. Epidemiology of multiple myeloma according to the Kirov Region population registers. Oncohematology. 2017;12(3):50-6 (in Russian) DOI:10.17650/1818-8346-2017-12-3-50-56
3. Skvortsova NV, Pospelova TI, Kovynev IB, et al. Epidemiology of Multiple Myeloma in Novosibirsk (Siberian Federal District). Clinical Oncohematology. 2019;12(1):86-94 (in Russian) DOI:10.21320/2500-2139-2019-12-1-86-94
4. Vinogradova OYu, Ptushkin VV, Chernikov MV, et al. Epidemiology of multiple myeloma in city Moscow. Terapevticheskii Arkhiv (Ter. Arkh). 2019;91(7):83-92 (in Russian) DOI:10.26442/00403660.2019.07.000305
5. Moreau P, San Miguel J, Sonneveld P, et al. Multiple myeloma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2017;28(Suppl. 4):iv52-iv61. DOI:10.1093/annonc/mdx096
6. Zou Ya, Lin M, Sheng Zh, Niu S. Bortezomib and lenalidomide as front-line therapy for multiple myeloma. Leuk Lymphoma. 2014;55(9):2024‑31. DOI:10.3109/10428194.2013.847935
7. Facon T, Dimopoulos MA, Dispenzieri A, et al. Final analysis of survival outcomes in the phase 3 FIRST trial of up-front treatment for multiple myeloma. Blood. 2018;131(3):301-10. DOI:10.1182/blood-2017-07-795047
8. Mateos MV, Dimopoulos MA, Cavo M, et al. Daratumumab plus bortezomib, melphalan, and prednisone for untreated myeloma. N Engl J Med. 2018;378(6):518-28. DOI:10.1056/NEJMoa1714678
9. Sivaraj D, Bacon W, Long GD, et al. High-dose BCNU/Melphalan conditioning regimen before autologous stem cell transplantation in newly diagnosed multiple myeloma. Bone Marrow Transplant. 2018;53(1):34‑8. DOI:10.1038/bmt.2017.208
10. Dhakal B, Szabo A, Chhabra S, et al. Autologous transplantation for newly diagnosed multiple myeloma in the era of novel agent induction a systematic review and meta-analysis. JAMA Oncol. 2018;4(3):343-50. DOI:10.1001/jamaoncol.2017.4600
11. Su B, Zhu X, Jiang Y, et al. A meta-analysis of autologous transplantation for newly diagnosed multiple myeloma in the era of novel agents. Leuk Lymphoma. 2018;60. DOI:10.1080/10428194.2018.1543874
12. Dingli D, Ailawadhi S, Bergsagel PL, et al. Therapy for relapsed multiple myeloma: guidelines from the Mayo stratification for myeloma and risk-adapted therapy. Mayo Clin Proc. 2017; 92:578-98. DOI:10.1016/j.mayocp.2017.01.003
13. Harousseau JL, Attal M. How I treat first relapse of myeloma. Blood. 2017;130:963-73. DOI:10.1182/blood-2017-03-726703
14. Sonneveld P, Broijl A. Treatment of relapsed and refractory multiple myeloma. Haematologica. 2016;101:396-406. DOI:10.3324/haematol.2015.129189
15. Kumar SK, Therneau TM, Gertz MA, et al. Clinical course of patients with relapsed multiple myeloma. Mayo Clin Proc. 2004;79:867-74. DOI:10.4065/79.7.867
16. Durie BG, Moreau P, Sonneveld P, et al. Regional differences in the treatment approaches for relapsed multiple myeloma: an IMF study. J Clin Oncol. 2012;30:8095. DOI:10.1200/JCO.2012.30.15_SUPPL.8095
17. Siegel DS, Dimopoulos MA, Ludwig H, et al. Improvement in overall survival with carfilzomib, lenalidomide, and dexamethasone in patients with relapsed or refractory multiple myeloma. J Clin Oncol. 2018;36:728-34. DOI:10.1200/JCO.2017.76.5032
18. Stewart AK, Rajkumar SV, Dimopoulos MA, et al. Carfilzomib, lenalidomide, and dexamethasone for relapsed multiple myeloma. New Engl J Med. 2015;372:142-52. DOI:10.1056/NEJMoa1411321
19. Durie BG, Harousseau JL, Miguel JS, et al. International uniform response criteria for multiple myeloma. Leukemia. 2006;20(9):1467-73. DOI:10.1038/sj.leu.2404284
20. Cancer Therapy Evaluation Program CTCAE, version 4.03. Available at: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_30. Accessed: 14.06.2010.
21. Dimopoulos MA, Wang M, Maisnar V, et al. Response and progression-free survival according to planned treatment duration in patients with relapsed multiple myeloma treated with carfilzomib, lenalidomide and dexamethasone (KRd) versus lenalidomide and dexamethasone (Rd) in the phase III ASPIRE study. J Hematology Oncology. 2018;11:49. DOI:10.1186/s13045-018-0583-7
22. Dimopoulos MA, Moreau P, Palumbo A, et al. Carfilzomib and dexamethasone versus bortezomib and dexamethasone for patients with relapsed or refractory multiple myeloma (ENDEAVOR): a randomised, phase 3, open-label, multicentre study. Lancet Oncol. 2016;17(1):27-38. DOI:10.1016/S1470-2045(15)00464-7
23. Jasielec JK, Kubicki T, Raje N, et al. Carfilzomib, lenalidomide, and dexamethasone plus transplant in newly diagnosed multiple myeloma, Blood. 2020;136:2513-23. DOI:10.1182/blood.2020007522
24. Jakubowiak AJ, Dytfeld D, Griffith Kent A, et al. A phase 1/2 study of carfilzomib in combination with lenalidomide and low-dose dexamethasone as a frontline treatment for multiple myeloma. Blood. 2012;120. DOI:10.1182/blood-2012-04-422683
25. Facon T, Lee JH, Moreau P, et al. Randomized phase 3 study of carfilzomib with melphalan-prednisone for transplant-ineligible, NDMM patients. Blood. 2019;133(18):1953-63. DOI:10.1182/blood-2018-09-874396
26. Kumar S, Jacobus SJ, Cohen AD, et al. Carfilzomib, lenalidomide, and dexamethasone (KRd) versus bortezomib, lenalidomide, and dexamethasone (VRd) for initial therapy of newly diagnosed multiple myeloma (NDMM): Results of ENDURANCE (E1A11) phase III trial [abstract]. J Clin Oncol. 2020;38(18). Abstract LBA3.
27. Gay F, Cerrato C, Petrucci MT. et al. Efficacy of carfilzomib lenalidomide dexamethasone (KRd) with or without transplantation in newly diagnosed myeloma according to risk status: results from the FORTE trial. J Clin Oncol. 2019;37. DOI:10.1200/JCO.2019.37.15_suppl.8002
28. Takamatsu H, Yoroidaka T, Fujisawa M, et al. Comparison of minimal residual disease detection in multiple myeloma by SRL 8-color single-tube and EuroFlow 8-color 2-tube multiparameter flow cytometry. Int J Hematol. 2019;109(4):377-81. DOI:10.1007/s12185-019-02615-z
1 ГБУЗ «Городская клиническая больница им. С.П. Боткина» Департамента здравоохранения г. Москвы, Москва, Россия;
2 ФГБУ «Национальный медицинский исследовательский центр гематологии» Минздрава России, Москва, Россия;
3 ГБУ «Научно-исследовательский институт организации здравоохранения и медицинского менеджмента» Департамента здравоохранения г. Москвы, Москва, Россия
*vera_ger@mail.ru
________________________________________________
Vera A. Zherebtsova*1, Vladimir I. Vorobyev1, Eduard G. Gemdzhian2, Margarita A. Ulyanova1, Mikhail V. Chernikov3, Valentina L. Ivanova1, Olga Yu. Vinogradova1, Vadim V. Ptushkin1
1 Botkin City Clinical Hospital, Moscow, Russia;
2 National Research Center for Hematology, Moscow, Russia;
3 Research Institute of Health Organization and Medical Management, Moscow, Russia
*vera_ger@mail.ru