A pilot study of bortezomib in Korean patients with relapsed or refractory myeloma

Recent clinical trials showed that bortezomib, a novel proteasome inhibitor, had therapeutic activity in multiple myeloma. However, there was no data about the feasibility of bortezomib in Korean patients. We performed a pilot study of bortezomib in patients with relapsed or refractory myeloma (1.3 mg/m2 twice weekly for 2 week in a 3-week cycle). Seven patients were enrolled. The median age of patients was 59 yr. All patients previously received VAD (vincristine, doxorubicin and dexamethasone) and thalidomide chemotherapy. Three patients previously received alkylator-containing chemotherapy and 4 patients, autologous stem cell transplantation. Bortezomib monotherapy resulted in 3 partial remissions (43%), 3 no changes (43%) and 1 progressive disease (14%). One patient who had no response to bortezomib monotherapy experienced partial remission after addition of dexamethasone to bortezomib. The most common serious toxicity was thrombocytopenia (grade 3/4, 10 of 20 cycles (50%)) and grade 3 peripheral neuropathy was developed in 2 of 20 cycles (10%). Drug-related adverse event led to discontinuation of bortezomib in 1 patient. There was no treatment related mortality. Overall, bortezomib seems to be effective and feasible. Conduction of larger clinical studies on Korean patients is necessary to characterize clinical efficacy and safety of bortezomib more precisely.     

STI571、三氧化二砷和Velcade对bcr/abl+-CD34+细胞增殖、凋亡的影响

目的 研究STI571、三氧化二砷(As2O3)和Velcade在单独及联合应用时对bcr/abl -CD34 细胞增殖、凋亡的影响.方法 提取慢性粒细胞白血病患者骨髓的bcr/abl -CD34 细胞,用STI571、As2O3、Velcade单独及联合处理96 h,通过CCK-8分析及流式细胞术分别检测细胞增殖、凋亡的变化,并用Hoechst33342染色及荧光显微镜技术观察凋亡细胞形态学改变.同时检测上述方案对正常骨髓CD34 细胞的抑制作用.结果 STI571、As2O3及Velcade对bcr/abl -CD34 细胞的作用呈剂量依赖性,其中在低浓度时以抑制增殖作用为主,促凋亡作用不明显.当0.25～2 μmol/L STI571分别与2.5 μmol/LAs2O3及15nmol/L Velcade联合后,抑制率和凋亡率均显著提高,呈相加或协同作用,且对正常CD34 细胞的抑制作用无进一步增强.结论 As2O3及Velcade与STI571联合能够增强对BCR/ABL -CD34 细胞的作用,具有一定临床意义.     

Aberrant nuclear factor-kappa B activity in acute myeloid Leukemia: from molecular pathogenesis to therapeutic target

The overall survival of patients with acute myeloid leukemia (AML) has not been improved significantly over the last decade. Molecularly targeted agents hold promise to change the therapeutic landscape in AML. The nuclear factor kappa B (NF-κB) controls a plethora of biological process through switching on and off its long list of target genes. In AML, constitutive NF-κB has been detected in 40% of cases and its aberrant activity enable leukemia cells to evade apoptosis and stimulate proliferation. These facts suggest that NF-κB signaling pathway plays a fundamental role in the development of AML and it represents an attractive target for the intervention of AML. This review summarizes our current knowledge of NF-κB signaling transduction including canonical and non-canonical NF-κB pathways. Then we specifically highlight what factors contribute to the aberrant activation of NF-κB activity in AML, followed by an overview of 8 important clinical trials of the first FDA approved proteasome inhibitor, Bortezomib (Velcade^®), which is a NF-κB inhibitor too, in combination with other therapeutic agents in patients with AML. Finally, this review discusses the future directions of NF-κB inhibitor in treatment of AML, especially in targeting leukemia stem cells (LSCs).     

硼替佐米联合地塞米松方案治疗多发性骨髓瘤分析

目的探讨硼替佐米联合地塞米松（VD）方案治疗多发性骨髓瘤（MM）的疗效及安全性。方法回顾分析我科诊断的11例MM患者的临床资料,均为初诊MM患者,采用VD方案治疗1—3个疗程,继之以长春新碱联合阿霉素和地塞米松（VAD）方案化疗1～4个疗程,达平台期后以沙利度胺加泼尼松、马法兰维持治疗。结果11例患者中位随访时间24个月,VD方案1个疗程完全缓解5例,接近完全缓解2例,部分缓解4例。主要不良反应：末梢神经麻木1例,躁动、多语2例,肺部感染加重并真菌感染2例,腹泻1例,带状疱疹2例。结论VD方案治疗初诊MM疗效肯定,安全性尚好,可作为MM的首选治疗方案。     

Bortezomib in multiple myeloma and lymphoma: a systematic review and clinical practice guideline

Questions

1. In patients with multiple myeloma, Waldenström macroglobulinemia, or lymphoma, what is the efficacy of bortezomib alone or in combination as measured by survival, quality of life, disease control (for example, time to progression), response duration, or response rate?
2. What is the toxicity associated with the use of bortezomib?
3. Which patients are more or less likely to benefit from treatment with bortezomib?

Perspectives

Evidence was selected and reviewed by two members of the Hematology Disease Site Group and by methodologists from the Program in Evidence-based Care (pebc) at Cancer Care Ontario. The practice guideline report was reviewed and approved by the Hematology Disease Site Group, which comprises hematologists, medical and radiation oncologists, and a patient representative. As part of an external review process, the report was disseminated to practitioners throughout Ontario to obtain their feedback.

Outcomes

Outcomes of interest were overall survival, quality of life, response rates and duration, and rates of adverse events.

Methodology

A systematic search was conducted of the medline, embase, HealthStar, cinahl, and Cochrane Library databases for primary articles and practice guidelines. The resulting evidence informed the development of clinical practice recommendations. Those recommendations were appraised by a sample of practitioners in Ontario and modified in response to the feedback received. The systematic review and modified recommendations were approved by a review body w theithin pebc.

Results

The literature review found one randomized controlled trial (rct)—the only published rct of bortezomib in relapsed myeloma. A number of phase ii studies were also retrieved, including a randomized phase ii study. No randomized trials were retrieved for lymphoma.The rct found bortezomib to be superior to high-dose dexamethasone for median time to progression and 1-year survival in patients with relapsed myeloma, although grade 3 adverse events were more common in the bortezomib arm. Bortezomib is recommended as the preferred treatment option in patients with myeloma relapsing within 1 year of the conclusion of initial treatment; it may also be a reasonable option in patients relapsing at least 1 year after autologous stem-cell transplantation.

Practice Guideline

This evidence-based series applies to adult patients with myeloma, Waldenström macroglobulinemia, or lymphoma of any type, stage, histology, or performance status.

Recommendations

Based on the results of a large well-conducted rct, which represents the only published randomized study in relapsed myeloma, the Hematology Disease Site Group (dsg) offers the following recommendations:

• For patients with myeloma refractory to or relapsing within 1 year of the conclusion of initial or subsequent treatment or treatments, including autologous stem-cell transplantation, and who are candidates for further chemotherapy, bortezomib is recommended as the preferred treatment option.
• Bortezomib is also a reasonable option for patients relapsing at least 1 year after autologous stem-cell transplantation. The dsg is aware that thalidomide, alkylating agents, or repeat transplantation may also be options for these patients. However, evaluation of these other options is beyond the scope of this practice guideline.
• For patients with myeloma relapsing at least 1 year after the conclusion of alkylating agent–based chemotherapy who are candidates for further chemotherapy, further treatment with alkylating agent–based chemotherapy is recommended.
• Evidence is insufficient to support the use of bortezomib in patients with non-Hodgkin lymphoma or Waldenström macroglobulinemia outside of clinical trials.

Qualifying Statements

Limited evidence supports the appropriateness of a specific time-to-relapse period as being indicative of treatment-insensitive disease. The 1-year threshold provided in the foregoing recommendations is based on the opinion of the Hematology dsg.For specific details related to the administration of bortezomib therapy, the dsg suggests that clinicians refer to the protocols used in major trials. Some of those details are provided here for informational purposes.

Dosage

Bortezomib 1.3,g/m² is given as a rapid intravenous bolus over 3–5 seconds on days 1, 4, 8, and 11 of a 21-day cycle; a minimum of 72 hours between doses is required to allow for recovery of normal proteasome function. Vital signs should be checked before and after each dose. A complete blood count is recommended before each dose, with blood chemistries (including electrolyte and creatinine levels) monitored at a minimum on days 1 and 8 of each cycle. The dose of bortezomib should be reduced or held immediately upon development of painful neuropathy, as described in the product monograph; dose modification may also be required for peripheral sensory neuropathy without pain or for other toxicities. Most toxicities are reversible if dose modification guidelines are followed.

Response to Treatment

Responses are usually apparent by 6 weeks (2 cycles). For patients achieving complete remission (determined by negative electrophoresis and immunofixation), bortezomib should be given for 2 additional cycles beyond the date of confirmed complete remission. In patients with progressive disease after 2 cycles or stable disease after 4 cycles, dexamethasone added to the bortezomib regimen (20 mg by mouth the day of and the day after each bortezomib dose) may produce an objective response. Bortezomib (with or without dexamethasone) should be continued in patients showing benefit from therapy (excluding those in complete remission) unless disease progression or significant toxicity is observed. Therapy should be discontinued in patients who do not respond to bortezomib alone if disease progression is seen within 2 cycles of the addition of dexamethasone.The Hematology dsg recognizes that thalidomide is an active agent in multiple myeloma patients who have relapsed after autologous stem-cell transplantation or who are refractory to alkylating agent–based chemotherapy. To date, no reported rcts have evaluated thalidomide in this role, and specifically, no trials have compared thalidomide with bortezomib. Given these limitations, the members of the Hematology dsg regard thalidomide or bortezomib as therapy alternatives to dexamethasone.     

万珂提高多发性骨髓瘤干细胞采集的临床研究

目的 研究以万珂为主化学疗法方案提高多发性骨髓瘤初发患者自体外周血造血干细胞采集的作用.方法 回顾性分析2006年1月-2010年11月4例初发多发性骨髓瘤患者在万珂治疗后自体外周血造血干细胞采集的临床资料.疗效判定依据国际骨髓瘤工作组2006年疗效判断标准.结果 经过万珂为主化学疗法方案治疗3～6个疗程(平均4个疗程...     

Velcade影响K562细胞基因表达谱的分子机制

目的 应用生物信息学方法探索Velcade影响K562细胞基因表达谱的分子机制.方法 提取并扩增Velcade处理组和溶剂对照组的K562细胞RNA,与22KAgilent Human 1A基因芯片杂交,用Agilent Feature Extraction软件采集扫描数据,再以GeneSifter,GATHER等基因芯片数据分析工具,对差异表达基因进行基因本体分类、KEGG通路分析、蛋白互作网络分析和文献挖掘.结果 获得228个差异表达基因,其中上调84个,下调144个.下调糜酶1基因幅度最大.对数比值达10.80倍,干扰素α-21基因也下调2.31倍.本体分类显示,衰老过程、白细胞活动等过程显著增强:KEGG通路分析显示,JAK-STAT信号通路,自然杀伤细胞介导的细胞毒作用和抗原处理与提呈等通路受显著影响;蛋白互作网络揭示泛素依赖的蛋白质降解通路、抗原提呈和免疫反应、JAK-STAT信号通路等处于网络中重要位置;文献挖掘显示差异表达基因与白血病、细胞凋亡、细胞周期、蛋白酶体、抑制剂、衰老和IκB等关键词高度关联.结论 Velcade可能通过抑制NF-κB和JAK-STAT等促进细胞存活的信号通路,增强细胞毒作用,诱导肿瘤细胞凋亡;Velcade还可能参与抗原加工与提呈、免疫反应、炎症反应等过程;糜酶1基因可能是Velcade发挥抗肿瘤作用的关键靶标.     

在多发性骨髓瘤中IL-8基因多态性及硼替佐米的干预效果

目的 探讨多发性骨髓瘤(MM)中IL-8基因多态性及硼替佐米(万珂)的干预效果.方法 在多种细胞株中找到3个细胞株分别含有IL-8启动子区-251位的三个基因多态性,加入万珂后检测分析各细胞株生存率,并测定各细胞株IL-8水平以及IL-8 mRNA表达水平.结果 基因型为A/A的纯合子细胞株IL-8表达量最高,对万珂最敏感,T/T细胞株IL-8表达量最低对万珂最不敏感.结论 MM中IL-8基因存在多态性,且与万珂干预治疗有关.