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804 Phase II Trial of the Combination of Ixazomib, Lenalidomide, and Dexamethasone in High-Risk Smoldering Multiple Myeloma

Program: Oral and Poster Abstracts
Type: Oral
Session: 653. Myeloma: Therapy, excluding Transplantation: Novel Proteasome Inhibitors
Hematology Disease Topics & Pathways:
multiple myeloma, Diseases, Adult, smoldering myeloma, Therapies, Plasma Cell Disorders, Study Population, Lymphoid Malignancies, Clinically relevant
Monday, December 3, 2018: 4:00 PM
Room 6F (San Diego Convention Center)

Mark Bustoros, MD1,2,3, Chia-jen Liu, MD2,3,4*, Kaitlen Reyes, NP2,3,4*, Kalvis Hornburg, BA2,3,4*, Kathleen Guimond, RN3,4*, Rachel Styles4*, Alexandra Savell, BS4*, Brianna Berrios, BS4*, Diane Warren4*, Henry Dumke, BS4*, Bradley Rivotto, BS4*, Patrick Henrick, BS4*, Emily Scranton, NP4*, Houry Leblebjian, PharmD4,5*, Kirsten Meid, MPH6*, Robert L. Schlossman, MD2, Nikhil Munshi, MD4,7, Jacob Laubach, MD2,8, Kenneth C. Anderson, MD2,4,9,10, Paul Richardson2,4,10 and Irene M. Ghobrial, MD2,3,4

1Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
2Harvard Medical School, Boston
3The Center for Prevention of Progression of Blood Cancers, Dana-Farber Cancer Institute, Boston, MA
4Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
5Department of Clinical Pharmacy, Dana-Farber Cancer Institute, Boston, MA
6Bing Center for Waldenstrom's Macroglobulinemia, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA
7Jerome Lipper Multiple Myeloma Center, LeBow Institute for Myeloma Therapeutics, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
8Dept. of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
9The LeBow Institute for Myeloma Therapeutics, Dana-Farber Cancer Institute, Boston, MA
10Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Boston, MA

Background. This study aimed to determine the progression-free survival and response rate using early therapeutic intervention in patients with high-risk smoldering multiple myeloma (SMM) using the combination of ixazomib, lenalidomide, and dexamethasone.

Methods. Patients enrolled on study met eligibility for high-risk SMM based on the newly defined criteria proposed by Rajkumar et al., Blood 2014. The treatment plan was designed to be administered on an outpatient basis where patients receive 9 cycles of induction therapy of ixazomib (4mg) at days 1, 8, and 15, in combination with lenalidomide (25mg) at days 1-21 and Dexamethasone at days 1, 8, 15, and 22. This induction phase is followed by ixazomib (4mg) and lenalidomide (15mg) maintenance for another 15 cycles. A treatment cycle is defined as 28 consecutive days, and therapy is administered for a total of 24 cycles total. Bone marrow samples from all patients were obtained before starting therapy for baseline assessment, whole exome sequencing (WES), and RNA sequencing of plasma and bone marrow microenvironment cells. Moreover, blood samples were obtained at screening and before each cycle to isolate cell-free DNA (cfDNA) and circulating tumor cells (CTCs). Stem cell collection is planned for all eligible patients.

Results. In total, 26 of the planned 56 patients were enrolled in this study from February 2017 to April 2018. The median age of the patients enrolled was 63 years (range, 41 to 73) with 12 males (46.2%). Interphase fluorescence in situ hybridization (iFISH) was successful in 18 patients. High-risk cytogenetics (defined as the presence of t(4;14), 17p deletion, and 1q gain) were found in 11 patients (61.1%). The median number of cycles completed was 8 cycles (3–15). The most common toxicities were fatigue (69.6%), followed by rash (56.5%), and neutropenia (56.5%). The most common grade 3 adverse events were hypophosphatemia (13%), leukopenia (13%), and neutropenia (8.7%). One patient had grade 4 neutropenia during treatment. Additionally, grade 4 hyperglycemia occurred in another patient. As of this abstract date, the overall response rate (partial response or better) in participants who had at least 3 cycles of treatment was 89% (23/26), with 5 Complete Responses (CR, 19.2%), 9 very good partial responses (VGPR, 34.6%), 9 partial responses (34.6%), and 3 Minimal Responses (MR, 11.5%). None of the patients have shown progression to overt MM to date. Correlative studies including WES of plasma cells and single-cell RNA sequencing of the bone microenvironment cells are ongoing to identify the genomic and transcriptomic predictors for the differential response to therapy as well as for disease evolution. Furthermore, we are analyzing the cfDNA and CTCs of the patients at different time points to investigate their use in monitoring minimal residual disease and disease progression.

Conclusion. The combination of ixazomib, lenalidomide, and dexamethasone is an effective and well-tolerated intervention in high-risk smoldering myeloma. The high response rate, convenient schedule with minimal toxicity observed to date are promising in this patient population at high risk of progression to symptomatic disease. Further studies and longer follow up for disease progression are warranted.

Disclosures: Bustoros: Dava Oncology: Honoraria. Munshi: OncoPep: Other: Board of director. Anderson: C4 Therapeutics: Equity Ownership; Celgene: Consultancy; Bristol Myers Squibb: Consultancy; Takeda Millennium: Consultancy; Gilead: Membership on an entity's Board of Directors or advisory committees; Oncopep: Equity Ownership. Richardson: Karyopharm: Other: Advisory Committee Member; Amgen: Other: Advisory Committee Member; Janssen: Other: Advisory Committee Member; Takeda: Other: Advisory Committee Member, Research Funding; BMS: Other: Advisory Committee Member, Research Funding; Celgene: Other: Advisory Committee Member, Research Funding; Oncopeptides: Other: Advisory Committee Member; Jazz Pharmaceuticals: Other: Advisory Committee Member, Research Funding. Ghobrial: Celgene: Consultancy; Takeda: Consultancy; Janssen: Consultancy; BMS: Consultancy.

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