The combination of thalidomide, cyclophosphamide and ...

The Hematology Journal (2002) 3, 43 ± 48 ã 2002 The European Haematology Association All rights reserved 1466 ± 4680/02 $25.00 www.nature.com/thj

The combination of thalidomide, cyclophosphamide and dexamethasone (ThaCyDex) is feasible and can be an option for relapsed/refractory multiple myeloma RamoÂn GarcõÂ a-Sanz1, Maria Isabel GonzaÂlez-Fraile1, Magdalena Sierra1, Carlos LoÂpez1, Marcos GonzaÂlez1 and JesuÂs Fernando San Miguel*,1 1

Servicio de HematologõÂa, Hospital Universitario de Salamanca y Centro de InvestigacioÂn del CaÂncer de Salamanca, Spain

Introduction: Thalidomide has recently proven to be a useful drug for treatment of refractory and relapsed multiple myeloma patients, up to 35% of whom achieve remission. However, little is known about the potential additive or synergistic eect upon its association with other drugs with proven ecacy in MM. Material and methods: The present pilot study was designed to evaluate the toxicity and response rate of the association of thalidomide, cyclophosphamide and dexamethasone (ThaCyDex) in 22 refractory or relapsed MM patients. The protocol scheduled the administration of thalidomide at escalating doses (200 to 800 mg/day), daily oral cyclophosphamide (CTX) (50 mg/day) and pulsed dexamethasone (40 mg/day, four days every three weeks). Results: Adverse eects were moderate (grade 42) with only two patients in whom treatment was withdrawn due to neuropathy and severe somnolence. Infections were recorded in six patients, four requiring hospitalization for intravenous antibiotic therapy. No cases of thrombocytopenia grade 52 were noted. Other side eects included grade 42 constipation (29%), somnolence (35%) or dizziness (12%). In addition, one case of meralgia paresthetica and one with a deep venous thrombosis were noted. Two cases displayed hyperglycemia and myopathy attributed to dexamethasone, which was solved upon changing to prednisone. With a median follow-up of 12 months, 17 patients were evaluable for response; 13 (77%) responded to the therapy, including nine cases (53%) with a 450% M-component reduction (two of them with a complete remission). Only two responders have already progressed, with a projected event free survival of 51% at 12 months. Seven patients have died due to disease progression (n=5), sudden death (n=1) and infection (n=1). Conclusion: This study shows that ThaCyDex is a feasible and promising therapeutic approach for patients with relapsed/refractory MM. The Hematology Journal (2002) 3, 43 ± 48. DOI: 10.1038/sj/thj/6200150 Keywords:

multiple myeloma; thalidomide; cyclophosphamide; dexamethasone

Introduction Multiple myeloma (MM) accounts for approximately 1% of all human cancers and 10% of all hematological malignancies.1 The current therapeutic approaches, especially the use of high-dose therapies with autologous or allogeneic stem cell rescue, together with an eective supportive therapy, have led to an improvement in disease outcome.2 ± 4 However, the disease currently remains incurable and eventually all patients relapse. In addition, options for salvage therapy in this *Correspondence: JF San Miguel, Department of Hematology, University Hospital of Salamanca, Paseo de San Vicente, 58-182, Salamanca, 37007, Spain; Tel: +34 923 291384; Fax: +34 923 294624; E-mail: [email protected] Received 6 August 2001; accepted 26 October 2001

group of patients are very limited.2,5 This has stimulated the search for new active drugs and therapeutic strategies.6 ± 13 Thalidomide (N-phthaloylglutamimide) is a glutamic acid derivative that has demonstrated activity in a series of advanced relapsed/refractory MM patients, including patients relapsing after high-dose therapy.14 A recent update of this series has con®rmed the initial results with a 37% response rate,15 a ®gure similar to that obtained by several other groups.16 ± 18 Since thalidomide is a non-cytostatic agent without bone marrow toxicity, it seems reasonable to use it in combination with other agents in an attempt to increase the response rate. Moreover, thalidomide has been reported to restore the sensitivity of myeloma cells to other drugs and to

ThaCyDex for relapsed/refractory MM R Garcia-Sanz et al

44

enhance the anti-myeloma activity of dexamethasone.19 Cyclophosphamide and dexamethasone have been widely used in MM and the combination of these two drugs has recently proven to be a useful approach for relapsed/refractory patients.20 ± 22 In addition, preliminary data have shown that the combination with thalidomide and other drugs leads to a response rate of 40 to 70%.23 ± 25 We have carried out a pilot study to analyse the toxicity and ecacy for the oral association between thalidomide, cyclophosphamide and dexamethasone (ThaCyDex) as salvage therapy for patients with relapsing/refractory multiple myeloma.

accommodate patient symptoms. In case of favorable response, it was maintained inde®nitely. Cyclophosphamide (Genoxal#, Prasfarma, Barcelona, Spain) was administered orally at the dosage of 50 mg/ day. In case of neutropenia, dose was reduced in order to maintain the granulocyte count 51.0×109/l. In case of response, it was maintained for one year.

Patients and methods

Dexamethasone (Fortecortin#, Merck, Darmstadt, Germany) was given orally at the dose of 40 mg/day, for four days, every three weeks. If important secondary side eects appeared, the dosage was reduced to 20 mg/day, four days every three weeks or substituted by oral prednisone at a dose of 25 mg/48 h. In case of response, it was maintained inde®nitely.

Patients

Evaluation

Between April 2000 and December 2000, 22 consecutive eligible patients from a single institution, with relapsed/ refractory MM, were included in the study after written informed consent. Diagnosis of MM was made according to standard de®nitions. Criteria for inclusion also required a life expectancy higher than one month and absence of an irreversible organic deterioration. In addition, the minimum free-treatment period had to be at least one month. Exclusion criteria were: (1) existence of a myelodysplastic syndrome or other neoplastic disease dierent to MM; (2) presence of clinical neurologic abnormalities; (3) history of paralytic ileus; (4) presence of clinical liver dysfunction, uncontrolled infection, uncontrolled hypercalcemia or pregnancy; (5) presence of unrecoverable cytopenias (50.5 granulocytes×109/l, 530 platelets×109/l); and (6) presence of uncontrollable mellitus diabetes. In addition, all patients younger than 70 years old ®tting the criteria for autologous or allogeneic transplant rescue were excluded from this protocol. At inclusion, patients were distinguished into three groups: (1) relapse, if they had responded to initial therapy and have progressed after a plateau phase, (2) primary refractory, if they have progressed during the initial therapy, and (3) secondary refractory, if they had relapsed after an initial response progressing during the salvage therapy.

The pretreatment evaluation included complete blood counts, biochemical tests for renal and liver functions, electrophoresis of serum and urine, b2microglobulin, and C-reactive protein. Bone marrow aspirates were obtained to determine the percentage of plasma cells in bone marrow by both morphology and ¯ow cytometry, as previously described.26 In addition, samples were analysed to determine cytogenetic abnormalities both by conventional cytogenetics27 or ¯uorescence in situ hybridization.28 The proliferative activity of plasma cells was assessed by ¯ow cytometry according to the double staining with propidium iodide and the CD38/ CD138 method.29 Follow-up studies included the estimation of the monoclonal component in serum or urine every two weeks for the ®rst two months, and subsequently by monthly determinations. The bone marrow examination was scheduled six months after the beginning of treatment.

Therapeutic protocol

Assessment of response

The therapeutic protocol included the oral administration of three dierent drugs.

Response was evaluated according to the criteria used by the Spanish PETHEMA group.30 A partial response (PR) was de®ned as (1) a reduction of 50% or more of the M-component, (2) an improvement in performance status by at least two grades according to the ECOG scale or up to grade 0; and (3) a decrease of over 50% in the measured cross-sectional area of plasmacytomas measured by TAC. Furthermore, the size and number of lytic bone lesions should not have increased, and correction of hypercalcemia (511.0 mg/dl), anemia (49 mg/dl), and hypoalbuminemia (43.5 g/dl) should also have occurred. If no detectable M-component was

Thalidomide (Thalomid1) was supplied in 100-mg capsules by GruÈnenthal (Aachen, Germany) and was administered nightly at an initial dose of 200 mg. If no secondary eects were present after the ®rst week, the dose was increased to 400 mg per day. Afterwards, the dose was increased every two weeks for four weeks, up to a ®nal maximum dose of 800 mg per day. In case of grade 52 secondary eects, the dose was reduced until side eects ceased and the schedule was adjusted to The Hematology Journal

Assessment of adverse eects The primary end point of this study was to demonstrate the toxicity and feasibility of the proposed scheme. All 22 patients were evaluated for side eects, independently of the duration of treatment and response. All patients were evaluated every two weeks during the ®rst two months and each month thereafter.


45

present with less than 5% of BM PC, a complete response (CR) was considered. Those patients who ful®lled all the above criteria but who had less than 50% reduction of M-component were considered to have a minimal response (MR). When the criteria for PR or MR were not ful®lled, the case was considered a treatment failure, with a distinction between no change (NC) and progressive disease (PD). Relapse was de®ned as an increase of over 50% from the lowest level of serum M-component achieved with the ThaCyDex therapy, an increase in size or number of lytic bone lesions, or the development of extraosseus plasmacytomas, anemia and/or hypercalcemia. Overall survival (OS) was measured from the inclusion in the protocol to the moment of death, and event free survival (EFS) from the inclusion in the protocol to the moment in which a relapse, progression or death was observed.

Statistical analysis A descriptive statistical analysis was performed after including all data on a FileMaker Pro database (Claris Corp., Santa Clara, CA, USA). Dierences in clinical measurements were evaluated with the SPSS 6.0 statistical software (SPSS, Chicago, IL, USA). To estimate the signi®cance of the dierences between these values, the Chi-square, Mann-Whitney and Wilcoxon tests were used. OS and EFS curves were analysed according to the method of Kaplan and Meier.

Results The main characteristics of the patients included in the study are shown in Table 1. Ten patients (55%) were in ®rst relapse, with a median response duration of 15 months. Two patients were in third and fourth relapse, while the remaining 10 patients had refractory disease (four were primary resistant and six, secondary resistant). Nine of the relapsing patients were under maintenance therapy with interferon and dexamethasone. Eight patients had received 53 protocols before inclusion in the present trial and four patients had been treated with high-dose therapy followed by autologous peripheral blood stem cell transplantation. A high-risk cytogenetic abnormality (deletion of chromosome 13 or complex karyotype)31 was present in 47% of cases.

Adverse eects Most patients tolerated the treatment well. The median dose of thalidomide safely achieved was 400 mg/ month, with 41% patients receiving a higher dosage. The ®nal doses achieved were: 29%, 800 mg/day; 12%, 600 mg/day; 18%, 400 mg/day; 18%, 300 mg/day; and 23%, 400 mg/day. The protocol was interrupted in three cases due to voluntary discontinuation in two (after one and three weeks of therapy) and early death

Table 1

Characteristics of the patients

Characteristic Male sex Durie-Salmon stage III Type of paraprotein IgG IgA Only light chains Number of prior therapy lines One Two 5Three Prior high-dose therapy Age 460 year Hemoglobin 59 g/dl Serum albumin 53,5 g/dl Serum creatinine 41,5 g/dl Presence of plasmacytomas Serum beta-2-microglobulin 46 mg/l Serum C-reactive protein 43 g/l Serum monoclonal immunoglobulin 41 g/l Urine Bence Jones 41 g/24 h 520% Plasma cells in bone marrow aspirate S-phase plasma cells 53% Chromosome 13 deletion Type of refractory Relapse after plateau phase 1st relapse 52nd relapse Primary refractory Secondary refractory

No. of patients 10 (46%) 6 (27%) 17 (77%) 3 (14%) 2 (9%) 9 8 5 4 20 5 12 2 3 8 3 16 6 10 7 10

(41%) (36%) (23%) (18%) (91%) (23%) (55%) (9%) (14%) (36%) (13%) (73%) (27%) (45%) (32%) (45%)

15 10 4 4 4

(45%) (18%) (18%) (18%)

in the third (caused by an infection that was diagnosed 36 h after the protocol was started). In addition, in another two cases, therapy was stopped due to toxicity directly attributed to the protocol (see below). All these patients that discontinued the therapy stopped the thalidomide administration when they were receiving 200 mg/day, except one case that was receiving 400 mg/day. The median dosage for cyclophosphamide was 50 mg/48 h, while dexamethasone was always given as scheduled except in two cases with intolerance (see below). Most adverse eects were moderate (grade 2 according to the NCI scale), although there were two patients in whom the treatment was stopped due to toxicity: one case, at the second month of therapy, due to peripheral neuropathy aecting the legs and one case of severe somnolence, after three weeks of therapy. Both patients improved after the administration of ThaCyDex was discontinued. The most frequent secondary eect was infection, which was noted in six patients. Four of them required hospitalization for intravenous antibiotic therapy, (two cases were neutropenic, 50.5 granulocytes×109/l) and one died due to septicemia in the context of a severe pneumonia. The other two infections were well controlled with oral antibiotics in an ambulatory context. Constipation (23%), somnolence (32%) and dizziness (13%) were the most frequent adverse symptoms. Four patients (18%) developed grade 2/3 neutropenia, which was quickly resolved after reducing the cyclophosphamide dosage. No cases of thrombocytopenia grade 52 were The Hematology Journal


46

observed and only one patient required a transfusion (2 RBC units); this eect was directly attributed to disease status. There was one case of meralgia paresthetica which rapidly improved with standard doses of carbamazepine. In this case, thalidomide was interrupted for three days only and reintroduced immediately after symptom resolution, without reactivation of the clinical picture. In two patients, an increase in serum creatinine levels of more than 50% was observed, but it was not related to ThaCyDex therapy, since it improved after appropriate therapeutic measures (hydration, captopril cessation). Two patients displayed secondary eects that were attributed to dexamethasone. Speci®cally, one showed hyperglycemia (up to 245 mg/dl) which was resolved with a change of diet and oral hypoglycemic agents together with the replacement of dexamethasone by prednisone. The second case displayed proximal weakness, which was interpreted as steroid myopathy, with a compatible electromyography, which also improved after replacing dexamethasone with 25 mg of prednisone every two days. In responding patients, cyclophosphamide was stopped after one year of therapy, which has happened in ®ve patients. In these patients, thalidomide and dexamethasone have been kept inde®nitely (same time as progression free survival), except in one patient in whom all therapy was erroneously stopped after 13 months of therapy.

Response Seventeen patients were evaluable for response. Thirteen of them (76%) responded to the therapy and four (24%) showed PD. In an intention-to-treat analysis, the global response rate would have been 60% (13 out of 22). Within the responders, nine (53%) achieved a PR (450% in the paraprotein level), including two (12%) who achieved a CR (one with negative immuno®xation). Four patients (21%) had MR (clinical improvement, less than 50% reduction of the monoclonal component). The four patients not responding to therapy displayed speci®c ®ndings. All but one achieved some grade of reduction in the monoclonal component after one to three months of treatment, but they progressed thereafter due to the apparition of new osteolytic lesions (n=2) or an increase in the size of previous plasmacytomas (n=1). The fourth patient showed a continuous progression, with an increase in the Mcomponent size (urine light chains) once the therapy was begun. Using univariate analysis, only those cases associated with non-IgG isotype were associated with a poorer response to the therapy. Thus, all IgG cases valid for response (n=13) responded to ThaCyDex, while none of the IgA (n=3) or only light chain disease (n=1) responded (P=0.00042). In addition, the presence of a high percentage of PC in S-phase or chromosome 13 monosomy were also associated with treatment failure. Although the status at inclusion was slightly linked to the response, it was not a main The Hematology Journal

prognostic factor. Thus, within the 17 evaluable patients, seven were in ®rst relapse, with a response of 1 CR, 3 PR, 1 MR and 1 PD, while in the 10 valid cases treated after a 51st relapse or refractory disease, the response was 1 CR, 3 PR, 2 MR, 1 NC and 3 PD.

Duration of response, event free survival, and overall survival Only two responding patients have already progressed. The response duration seemed to be related to the presence of soft-tissue plasmacytomas, since only three patients had this characteristic: one of them did not respond to the therapy while the other two (one PR and one MR) quickly progressed after initial response. The projected event free survival for all evaluable patients since start therapy is 51% at one year (Figure 1). Seven of the seventeen evaluable patients died: ®ve from disease progression, one from infection and one from sudden death. Median overall survival, estimated to be 52% at 12 months, has not yet been reached (Figure 1).

Discussion The orally administered combination of thalidomide, cyclophosphamide and dexamethasone was highly eective in an unfavorable subset of MM patients with relapsed/refractory disease (53% PR and 24% MR). Although secondary eects were frequent, they were mild (grade 42) and only two patients had to stop the therapy. The ecacy of thalidomide has been demonstrated for cutaneous lesions,32,33 AIDS complications34,35 and sarcoidosis.36 Given its apparent antiangiogenic effect,37,38 and the pathogenic role of angiogenesis in MM,39,40 as well as its ecacy in relapsed/refractory MM,14,41 thalidomide is now considered to be useful for treating this setting of patients. Recent studies have yielded variable response rates for thalidomide alone in relapsed/refractory MM patients, ranging between 25 and 57%.15 ± 18

Figure 1 Overall survival and event free survival curves of patients treated with ThaCyDex.


47

The mechanism of action of thalidomide is not yet clear. Several possible mechanisms that have been proposed include: antiangiogenesis, alterations in cytokine secretion (IFN-g, IL-2, IL-6, IL-1b, IL-10 and TNF), modulation of cell surface molecules and an oxidative DNA damage and stimulatory eect on natural killer cells.42,43 A possible eect of thalidomide in overcoming the resistance of myeloma cells to other drugs, such as dexamethasone, has recently been suggested.19 Since both, thalidomide and dexamethasone, have demonstrated activity in MM, without myelotoxic eects, design protocols combining both drugs have been proposed to treat relapsed/refractory MM,22,23 even in newly diagnosed patients.44 Despite some alarming reports attributing dangerous skin reactions to this association,45 it has been reported to provide a high response rate.23 ± 25,44 The use of cyclophosphamide associated to dexamethasone has also proven to be useful and not toxic in relapsed/ refractory MM patients,20 ± 22 and was used at our center for heavily pre-treated elderly MM patients, who were not candidates for intensive salvage therapy. The addition of thalidomide to the cyclophosphamide/ dexamethasone association has been tested by a German group24 as a second-line therapy in 14 patients, with an overall response rate of 86%, but with intravenous intermediate-dose cyclophosphamide

(300 mg/m /12 h for three days), resulting in a high toxicity, with a high incidence of grade 4 neutropenia (83%). In addition, the protocol requires the use of GCSF. Other associations, such as thalidomide with intermediate-dose cyclophosphamide, etoposide and dexamethasone (Tha-CED)46 or thalidomide, melphalan and dexamethasone47 yield high response rates (81 to 88%), but they seem to be rather toxic, especially in relapsed/refractory MM patients, who are usually elderly and have been typically heavily pre-treated. Our scheme has provided good results in terms of response (76%) with limited and acceptable toxicity. In addition, this approach can be applied to virtually all MM patients, independently of their age, status and previous treatment, without the need for parenteral infusions. However, it is a pilot study including a small number of patients, and only randomized trials with large numbers of patients can assess the real ecacy of the combination, especially if it is better than the association of thalidomide and dexamethasone without chemotherapy. Anyway, this study will be the basis for future trials that are now under development in our group. 2

Acknowledgements The authors thank Mark Anderson for his technical assistance. This work has been supported by the Spanish Public National Health System (INSALUD).

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