Phase II Study of Pomalidomide in High-Risk Relapsed and Refractory Multiple Myeloma

$Phase II Study of Pomalidomide in High-Risk Relapsed and Refractory Multiple Myeloma$

Letters to the Editor 2413 REFERENCES Table 1. Summary of the GEP70 and GEP5 models by P values from univariate analysis when GEP5 and GEP70 were considered as both 1 Shaughnessy JDJr, Zhan F, Burington BE, Huang Y, Colla S, Hanamura I et al. A validated gene expression model of high-risk multiple myeloma is defined by binary and continuous variables deregulated expression of genes mapping to chromosome 1. Blood 2007; 109: 2276–2284. Protocol Outcome Gene P in continuous P in binary 2 Decaux O, Lode L, Magrangeas F, Charbonnel C, Gouraud W, Jezequel P et al. variable predictor Cox analysis log-rank analysis Prediction of survival in multiple myeloma based on gene expression profiles TT3a OS GEP5 1.76E − 10 3.87E − 05 reveals cell cycle and chromosomal instability signatures in high-risk patients and − − hyperdiploid signatures in low-risk patients: a study of the Intergroupe Franco- GEP70 1.65E 11 2.98E 10 26 – PFS GEP5 1.14E − 05 0.001044 phone du Myelome. J Clin Oncol 2008; : 4798 4805. GEP70 7.75E − 10 2.75E − 08 3 Wu P, Walker BA, Brewer D, Gregory WM, Ashcroft J, Ross FM et al. A gene expression-based predictor for myeloma patients at high risk of developing bone 17 – TT3b OS GEP5 4.17E − 10 5.67E − 06 disease on bisphosphonate treatment. Clin Cancer Res 2011; : 6347 6355. − − 4 Kuiper R, Broyl A, de Knegt Y, van Vliet MH, van Beers EH, van der Holt B et al. Agene GEP70 2.11E 08 1.09E 06 26 – PFS GEP5 1.72E − 10 3.35E − 07 expression signature for high-risk multiple myeloma. Leukemia 2012; :2406 2413. GEP70 3.50E − 08 1.85E − 05 5 Johnson SK, Heuck CJ, Albino AP, Qu P, Zhang Q, Barlogie B et al. The use of molecular-based risk stratification and pharmacogenomics for outcome prediction and personalized therapeutic management of multiple myeloma. Int J 94 – FABP5 and TAGLN2 among a set of 24 proteins that are Hematol 2011; :321 333. associated with short OS.14 This set of 85 patients included 47 6 Subramanian A, Miller DM. Structural analysis of alpha-enolase. Mapping the functional domains involved in down-regulation of the c-myc protooncogene. who were enrolled in TT3b. The correlation of expression at J Biol Chem 2000; 275:5958–5965. both mRNA (via our GEP analyses) and protein levels supports 7 Liu RZ, Graham K, Glubrecht DD, Germain DR, Mackey JR, Godbout R. Association the biological relevance of the genes included in the GEP5 of FABP5 expression with poor survival in triple-negative breast cancer: implica- model. Work is in progress to identify agents that can effectively tion for retinoic acid therapy. Am J Pathol 2011; 178: 997–1008. target these prognostic genes. 8 Gupta S, Pramanik D, Mukherjee R, Campbell NR, Elumalai S, de Wilde RF et al. Molecular determinants of retinoic acid sensitivity in pancreatic cancer. Clin Cancer Res 2012; 18:280–289. CONFLICT OF INTEREST 9 Kang JU, Koo SH, Kwon KC, Park JW, Kim JM. Gain at chromosomal region BB has received research funding from Celgene and Millennium, is a consultant to 5p15.33, containing TERT, is the most frequent genetic event in early stages of Celgene and Millennium, and is a co-inventor on patents and patent applications non-small cell lung cancer. Cancer Genet Cytogenet 2008; 182:1–11. related to use of GEP in cancer medicine that have been licensed to Myeloma Health, 10 Zhang Y, Ye Y, Shen D, Jiang K, Zhang H, Sun W et al. Identification of transgelin-2 LLC. SZU is a consultant to Celgene, Millennium and Onyx. He has received research as a biomarker of colorectal cancer by laser capture microdissection and quan- funding from Onyx and Celgene, and speaking honoraria from Celgene. The titative proteome analysis. Cancer Sci 2010; 101: 523–529. remaining authors declare no conflict of interest. 11 Nohata N, Sone Y, Hanazawa T, Fuse M, Kikkawa N, Yoshino H et al. miR-1 as a tumor suppressive microRNA targeting TAGLN2 in head and neck squamous cell carcinoma. Oncotarget 2011; 2:29–42. ACKNOWLEDGEMENTS 12 Loor G, Zhang SJ, Zhang P, Toomey NL, Lee MY. Identification of DNA replication and Peggy Brenner, a science editor supported by the University of Arkansas for Medical cell cycle proteins that interact with PCNA. Nucleic Acids Res 1997; 25: 5041–5046. Sciences, provided editorial assistance to the authors during preparation of this 13 Nair B, van Rhee F, Shaughnessy JDJr, Anaissie E, Szymonifka J, Hoering A et al. manuscript. This manuscript was supported by a grant from the National Institutes of Superior results of Total Therapy 3 (2003-33) in gene expression profiling-defined Health (P01CA055819). low-risk multiple myeloma confirmed in subsequent trial 2006-66 with VRD maintenance. Blood 2010; 115: 4168–4173. 14 Edmondson R, Chavan S, Heuck C, Epstein J, Barlogie B. Combining proteomics and AUTHOR CONTRIBUTIONS gene expression profiling identifies proteins/genes associated with short overall BB, JE, JC and CJH conceived and planned the project; PQ, QZ, AH and JC survival in multiple myeloma. Blood (ASH Annu Meet Abstr) 2012; 120:Abstract197. conducted statistical analyses; patients were accrued by BB, FvR, SW and SZU; all authors wrote and approved the manuscript. This work is licensed under a Creative Commons Attribution- NonCommercial-ShareAlike 4.0 International License. The images or 1 2 1 1 1 1 CJ Heuck ,PQu, F van Rhee , S Waheed , SZ Usmani , J Epstein , other third party material in this article are included in the article’s Creative Commons 1 1 2 2 1 Q Zhang , R Edmondson , A Hoering , J Crowley and B Barlogie license, unless indicated otherwise in the credit line; if the material is not included under 1Myeloma Institute for Research and Therapy, Little Rock, AR, USA and the Creative Commons license, users will need to obtain permission from the license 2Cancer Research and Biostatistics, Seattle, WA, USA holder to reproduce the material. To view a copy of this license, visit http:// E-mail: [email protected] creativecommons.org/licenses/by-nc-sa/4.0/

Supplementary Information accompanies this paper on the Leukemia website (http://www.nature.com/leu)

Phase II study of pomalidomide in high-risk relapsed and refractory multiple myeloma

Leukemia (2014) 28, 2413–2415; doi:10.1038/leu.2014.248 received ⩾ 2 prior therapies, including lenalidomide (Len) and bortezomib (Bor), and have demonstrated disease progression on or within 60 days of completion of the last line of therapy.1 Pomalidomide (Pom) is an IMiD immunomodulatory agent that There are limited data evaluating efﬁcacy of Pom in high-risk is now FDA approved for treatment of patients who have RRMM with prior exposure/refractoriness to Len and how best to

Accepted article preview online 25 August 2014; advance online publication, 16 September 2014

© 2014 Macmillan Publishers Limited Leukemia (2014) 2395 – 2424 Letters to the Editor 2414 combine it with other available multiple myeloma (MM) Table 1. Patient Characteristics therapies for this patient population. Herein, we are reporting a novel, response-adaptive, phase II clinical trial design that n/N (%) used Pom in high-risk RRMM with sequential addition of specific MM therapies. Age ⩾ 65 yr 32/71 (45%) The study was approved by the UAMS IRB. All subjects were Albumino3.5 g/dl 33/71 (46%) informed of the investigational nature of this study and gave B2M ⩾ 3.5 mg/l 41/65 (63%) written voluntary consent in accordance with institutional and B2M45.5 mg/l 20/65 (31%) CRP ⩾ 8 mg/l 31/70 (44%) federal guidelines. Patients with MM and high-risk features that o ⩾ Hb 10 g/dl 30/71 (42%) has relapsed or resistant to 1 prior MM therapy were eligible for LDH ⩾ 190 U/l 23/71 (32%) enrollment. High-risk features were defined by having high risk on 2 3 Cytogenetic abnormalities 61/71 (86%) gene expression profiling (GEP) (GEP 70 or GEP80 signatures), Hypodiploidy 35/71 (49%) elevated LDH or having abnormal metaphase cytogenetics at the Deletion 17p 6/71 (8%) time of disease relapse or progression. Patients with RRMM over t(4;14) 1/71 (1%) 18 years of age and ECOG performance status 0–2 were eligible. t(14;16) 2/71 (3%) All subjects were required to take aspirin or alternate prophylactic t(14;20) 0/71 (0%) anticoagulation while on study. GEP 70-gene high risk 14/34 (41%) Cycle #1 Pom was given at 4 mg orally on days 1–21 q 4 weeks; GEP 80-gene high risk 28/34 (82%) ⩾ 4 GEP CD-1 subgroup 2/34 (6%) in the absence of PR by the IMWG criteria after two cycles, GEP CD-2 subgroup 8/34 (24%) dexamethasone (Dex, 4–20 mg orally q week) and/or Bor 2 GEP HY subgroup 3/34 (9%) (1.3 mg/m IV days 1,4,8,11) and/or Vorinostat (Vor, 100–200 mg GEP MS subgroup 5/34 (15%) po days 1–21 q 4 weeks) could be added; in the absence of GEP PR subgroup 14/34 (41%) ⩾ PR by IMWG criteria after four cycles, cyclophosphamide Lenalidomide refractory prior to enrollment 58/71 (82%) (Cy, 300 mg/m2 q week) could be added. Bortezomib refractory prior to enrollment 64/71 (90%) The primary end point was progression free survival (PFS) at 1 year after enrollment; secondary end points included overall survival (OS) and overall response rates (ORR). Univariate and multivariate Cox proportional hazards regression models were used to identify associations between covariates and survival outcomes. OS and PFS were depicted using Kaplan–Meier curves. The overall response rate was defined as the percentage of patients achieving partial response (PR) or better, prior to off-study date. Best response was defined as the best response achieved while enrolled by using IMWG criteria.4 Toxicity was estimated using the National Cancer Institute Common Toxicity Criteria version 3.0. For Pom pharmacogenomic study, GEP analyses were performed on 18 patients with paired baseline and 48 h post Pom samples. In comparison with other agents, we also investigated expression changes of patients’ samples obtained prior to and 48 h after single-agent therapy with thalidomide (Thal), Len, Dex or Bor (see Supplementary file for methodology). Seventy-one patients with HRMM were enrolled between October 2011 and August 2012 (Table 1). Baseline patient Figure 1. Kaplan–Meier Estimates of OS and PFS from enrollment. characteristics included age ⩾ 65 years in 45%, cytogenetic abnormalities in 86%, GEP70 high risk in 14/34 (41%), GEP80 high risk in 28/34 (82%), extramedullary disease in 7/71 (10%) and 13%, respectively (Figure 1). An increased risk for OS was secondary plasma cell leukemia in 3/71 (4%). In total, 68/71 observed among patients with LDH ⩾ 190 U/l (HR = 4.62, patients (96%) had a prior autologous stem cell transplant (ASCT), Po0.001), C-reactive protein ⩾ 8 mg/l (HR = 2.13, P = 0.041), 30/71 (42%) had ⩾ 2 ASCT. Patients had received a median of five hemogloblino10 g/dl (HR = 3.47, Po0.001) and albumin prior lines of therapy (range 1–10). All the 71 patients (100%) were o3.5 g/dl (HR = 2.83, P = 0.005) (Supplementary Table S3). The Len exposed, 58 (82%) with Len-refractory (Len-R) MM, 64 (90%) most common toxicities were listed in Supplementary Table S4. with Bor-refractory (Bor-R) MM, and 53 (75%) with dual-refractory At the false discovery rate of 0.01 by paired significance analysis (dual-R) MM prior to enrollment. of microarrays, expression levels of 55 probesets (48 genes) Thirty-four (48%) patients received ⩾ 6 cycles of treatment, 9 fi ⩾ ⩾ signi cantly changed in response to Pom treatment (13%) received 12 cycles. Patients who received 6 cycles, had (Supplementary Table S5). Pathway analysis indicated that these addition of Dex (67%), Bor+Dex (18%), Bor+Dex+Cy (12%), Bor+ 48 genes were mostly related to cell adhesion, inflammatory and Dex+Cy+Vor (3%) (Supplementary Figure S1). As of July 2013, 45 hypersensitivity response, such as ITGB1, ITGB7, LGALS3BP patients (63%) discontinued therapy primarily due to progression or death. Twenty (28%) patients achieved ⩾ PR as best response (Lectin), GAS6, LYN, RAC1, PYCARD, CASP1, CORO1B, F11R and (1 Len-R, 2 Bor-R, 6 in dual-R), with median DoR for patients ⩾ PR DKK1, all with higher expression values observed post Pom. To of 3 months (range 0.5–21 months). Regimen(s) used for patients address the question whether these Pom-induced gene expres- ⩾ PR in each cycle until response were listed in Supplementary sion alterations were unique to Pom, we also investigated Table S1 and other characteristics of responders were presented in expression changes of purified plasma cells obtained prior to Supplementary Table S2. Fifty-eight patients (5 Len-R, 8 Bor-R, 43 and 48 h after single-agent therapy with Thal, Len, Dex or Bor. We dual-R) had ⩾ stable disease, giving an overall disease control rate found that all three IMiD class of drugs (Pom, Thal and Len) induce of 82%. The largest changes in serum M protein from baseline gene expression changes in similar directions which were not were displayed in Supplementary Figure S2. The OS and observed after Dex or Bor (Supplementary Figure S3). In addition, PFS for the whole group (n = 71) at 12 months were 63% and we checked the cereblon5 (CRBN) expression level after 48 h Pom

Leukemia (2014) 2395 – 2424 © 2014 Macmillan Publishers Limited Letters to the Editor 2415 but no significant change was found. However, interferon SZ Usmani1,2, Q Zhang1, K Stratton3,PQu3, S Yaccoby1, E Hansen3, regulatory factor 4 (IRF4), one of the downstream targets of CRBN D Steward1, S Panozzo1, N Petty1, A Hoering3, S Waheed1, previously reported to be critical for myeloma cell survival,5,6 was F Van Rhee1, J Crowley3 and B Barlogie1 downregulated post Pom treatment (P = 0.001), suggesting a 1Myeloma Institute for Research and Therapy, University of Arkansas CRBN-dependent anti-myeloma activity for POM. Interestingly, for Medical Sciences, Little Rock, AR, USA; IRF4 expression was also decreased after Dex but not Bor. The zinc 2Levine Cancer Institute/Carolinas Healthcare System, finger-containing transcription factors, Ikaros family zinc finger Charlotte, NC, USA and proteins 1 and 3 (IKZF1 and IKZF3), can be selectively bound by 3Cancer Research and Biostatistics, Seattle, WA, USA the CRBN-CRL4 ubiquitin ligase and resulted in ubiquitination and E-mail: [email protected] degradation.7,8 In myeloma cell lines, it has been reported that Len downregulates IKZF1 and IKZF3 protein levels but not their mRNA levels.7,8 In our study, we found that the mRNA level of IKZF1 was significantly upregulated in MM patients after Pom treatment (P = 0.001), which could be a response of MM cells to counter the REFERENCES IKZF1 protein degradation effect of Pom. But no significant change was found for the IKZF3 expression after Pom. Further- 1 Lacy MQ, McCurdy AR.. Pomalidomide. Blood 2013; 122:2305–2309. more, we found that the expression-based proliferation index9 2 Shaughnessy JD Jr., Zhan F, Burington BE, Huang Y, Colla S, Hanamura I et al. fi was lower (P = 0.05) after 48 h Pom, which implies the killing A validated gene expression model of high-risk multiple myeloma is de ned by 109 effect of Pom towards the malignant plasma cells (more deregulated expression of genes mapping to chromosome 1. Blood 2007; : 2276–2284. discussion of Pom pharmacogenomic study can be found in fi 3 Shaughnessy JD Jr, Qu P, Usmani S, Heuck CJ, Zhang Q, Zhou Y et al. Supplementary le). Pharmacogenomics of bortezomib test-dosing identifies hyperexpression of Pom has shown to be active in RRMM in several single- 10,11 proteasome genes, especially PSMD4, as novel high-risk feature in myeloma agent early phase clinical trials and perhaps more pronounced treated with Total Therapy 3. Blood 2011; 118: 3512–3524. 12–15 response in combination with steroids. The initial phase I 4 Durie BG, Harousseau JL, Miguel JS, Blade J, Barlogie B, Anderson K et al. 10 study demonstrated activity with two dosing schedules International uniform response criteria for multiple myeloma. Leukemia 2006; 20: (MTD = 2 mg QD and 5 mg QOD). The efficacy and safety data 1467–1473. from the single-agent phase II study showed an ORR of 63%, 5 Zhu YX, Braggio E, Shi CX, Bruins LA, Schmidt JE, Van Wier S et al. Cereblon including CR in 3 patients (5%), VGPR in 17 patients (28%), and PR expression is required for the antimyeloma activity of lenalidomide and pomali- in 18 patients (30%).12 More recently, Pom has been combined domide. Blood 2011; 118: 4771–4779. with other FDA approved and novel agents for RRMM with 6 Shaffer AL, Emre NC, Lamy L, Ngo VN, Wright G, Xiao W et al. IRF4 addiction in response rates varying from 48.5–72% (see Supplementary file for multiple myeloma. Nature 2008; 454: 226–231. references). There are limited data on the differential efficacy of Pom 7 Kronke J, Udeshi ND, Narla A, Grauman P, Hurst SN, McConkey M et al. in RRMM patients based on biologic features of the disease at the Lenalidomide causes selective degradation of IKZF1 and IKZF3 in multiple time of relapse. In the present phase II trial, a response-adaptive myeloma cells. Science 2014; 343:301–305. strategy was used to treat RRMM with high-risk features. Pom 8 Lu G, Middleton RE, Sun H, Naniong M, Ott CJ, Mitsiades CS et al. The myeloma drug lenalidomide promotes the cereblon-dependent destruction of Ikaros demonstrates good anti-myeloma activity in a heavily pretreated, 343 – high-risk RRMM in combination with other anti-myeloma drugs. proteins. Science 2014; :305 309. We also performed pharmacogenomic analyses utilizing global 9 Zhan F, Huang Y, Colla S, Stewart JP, Hanamura I, Gupta S et al. The molecular classification of multiple myeloma. Blood 2006; 108:2020–2028. GEP in a subset of subjects, showing that Pom has a unique CRBN- 10 Schey SA, Fields P, Bartlett JB, Clarke IA, Ashan G, Knight RD et al. Phase I study of mediated mechanism of action. Given the activity in patients with an immunomodulatory thalidomide analog, CC-4047, in relapsed or refractory poor prognostic features, further studies are needed to evaluate multiple myeloma. J Clin Oncol 2004; 22: 3269–3276. Pom in combination with other novel agents in front line setting 11 Richardson PG, Siegel D, Baz R, Kelley SL, Munshi NC, Laubach J et al. Phase 1 for high-risk MM, perhaps in a response-adaptive schema. study of pomalidomide MTD, safety, and efficacy in patients with refractory multiple myeloma who have received lenalidomide and bortezomib. Blood 2013; 121: 1961–1967. CONFLICT OF INTEREST 12 Lacy MQ, Hayman SR, Gertz MA, Short KD, Dispenzieri A, Kumar S et al. SZU is a consultant to Celgene, Millennium, Onyx and Sanofi. He has received Pomalidomide (CC4047) plus low dose dexamethasone (Pom/dex) is active and research funding from ArrayBioPharma, Celgene, Onyx, Janssen, Pharmacyclics, and well tolerated in lenalidomide refractory multiple myeloma (MM). Leukemia 2010; speaking honoraria from Celgene, Millennium and Onyx. BB has received research 24: 1934–1939. funding from Celgene and Novartis. He is a consultant to Celgene and Genzyme and 13 San Miguel J, Weisel K, Moreau P, Lacy M, Song K, Delforge M et al. Pomalidomide has received speaking honoraria from Celgene and Millennium. BB is a co-inventor on plus low-dose dexamethasone versus high-dose dexamethasone patents and patent applications related to use of GEP in cancer medicine. alone for patients with relapsed and refractory multiple myeloma (MM-003): a randomised, open-label, phase 3 trial. Lancet Oncol 2013; 14: 1055–1066. ACKNOWLEDGEMENTS 14 Richardson PG, Siegel DS, Vij R, Hofmeister CC, Baz R, Jagannath S et al. Clinical trial and translational GEP studies were supported by Celgene Corporation. Pomalidomide alone or in combination with low-dose dexamethasone in relapsed and refractory multiple myeloma: a randomized phase 2 study. Blood 2014; 123: 1826–1832. AUTHOR CONTRIBUTIONS 15 Leleu X, Attal M, Arnulf B, Moreau P, Traulle C, Marit G et al. Pomalidomide plus Designed study and wrote the manuscript: SZU, QZ; analyzed the data: SZU, BB, KS, low-dose dexamethasone is active and well tolerated in bortezomib and EH, AH, JC, QZ, PQ, SY, NP; contributed patients: SZU, BB, FVR; reviewed manuscript: lenalidomide-refractory multiple myeloma: Intergroupe Francophone du SZU, BB, KS, QZ, EH, AH, SW, NP, DS, SP, FVR, JC, BB. Myelome 2009-02. Blood 2013; 121: 1968–1975.

Supplementary Information accompanies this paper on the Leukemia website (http://www.nature.com/leu)