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      Prognostic utility of serum free light chain ratios and heavy-light chain ratios in multiple myeloma in three PETHEMA/GEM phase III clinical trials

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      1 , * , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 3 , 2 , 1 , 18 , 4 , 3 , 18 , 1 , 1 , * , on behalf of the GEM (Grupo Español de MM)/PETHEMA (Programa para el Estudio de la Terapéutica en Hemopatías Malignas) Cooperative Study Group
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          Abstract

          We investigated the prognostic impact and clinical utility of serum free light chains (sFLC) and serum heavy-light chains (sHLC) in patients with multiple myeloma treated according to the GEM2005MENOS65, GEM2005MAS65, and GEM2010MAS65 PETHEMA/GEM phase III clinical trials. Serum samples collected at diagnosis were retrospectively analyzed for sFLC ( n = 623) and sHLC ( n = 183). After induction or autologous transplantation, 309 and 89 samples respectively were available for sFLC and sHLC assays. At diagnosis, a highly abnormal (HA) sFLC ratio (sFLCr) (<0.03 or >32) was not associated with higher risk of progression. After therapy, persistence of involved-sFLC levels >100 mg/L implied worse survival (overall survival [OS], P = 0.03; progression-free survival [PFS], P = 0.007). Among patients that achieved a complete response, sFLCr normalization did not necessarily indicate a higher quality response. We conducted sHLC investigations for IgG and IgA MM. Absolute sHLC values were correlated with monoclonal protein levels measured with serum protein electrophoresis. At diagnosis, HA-sHLCrs (<0.29 or >73) showed a higher risk of progression ( P = 0.006). Additionally, involved-sHLC levels >5 g/L after treatment were associated with shorter survival (OS, P = 0.001; PFS, P = 0.018). The HA-sHLCr could have prognostic value at diagnosis; absolute values of involved-sFLC >100 mg/L and involved-sHLC >5 g/L could have prognostic value after treatment.

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          Most cited references19

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          A clinical staging system for multiple myeloma. Correlation of measured myeloma cell mass with presenting clinical features, response to treatment, and survival.

          The presenting clinical features of 71 patients with multiple myeloma were correlated with myeloma cell mass (myeloma cells X 10(12)/m2 of body surface area) determined from measurements of monoclonal immunoglobulin (M-component) synthesis and metabolism. Bivariate correlation and multivariate regression analyses showed that myeloma cell mass could be accurately predicted from A) extent of bone lesions, B) hemoglobin level, C) serum calcium level, and D) M-component levels in serum and urine. Analyses of response to chemotherapy and survival indicated significant correlation with measured myeloma cell burden. The results were synthesized to produce a very reliable and useful clinical staging system with three tumor cell mass levels (Table 7). For clinical research purposes, multivariate regression equations were developed to predict optimally the exact myeloma cell mass. Thus, initial staging can be quantitatively related to followup using tumor cell mass changes calculated from changes in M-component production. Use of the clinical staging system sould provide better initial assessment and followup of individual patients, and should lead to improved study design and analysis in large clinical trials of therapy for multiple myeloma.
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            High serum-free light chain levels and their rapid reduction in response to therapy define an aggressive multiple myeloma subtype with poor prognosis.

            Serum-free light chain (SFLC) levels are useful for diagnosing nonsecretory myeloma and monitoring response in light-chain-only disease, especially in the presence of renal failure. As part of a tandem autotransplantation trial for newly diagnosed multiple myeloma, SFLC levels were measured at baseline, within 7 days of starting the first cycle, and before both the second induction cycle and the first transplantation. SFLC baseline levels higher than 75 mg/dL (top tertile) identified 33% of 301 patients with higher near-complete response rate (n-CR) to induction therapy (37% vs 20%, P = .002) yet inferior 24-month overall survival (OS: 76% vs 91%, P < .001) and event-free survival (EFS: 73% vs 90%, P < .001), retaining independent prognostic significance for both EFS (HR = 2.40, P = .008) and OS (HR = 2.43, P = .016). Baseline SFLC higher than 75 mg/dL was associated with light-chain-only secretion (P < .001), creatinine level 176.8 microM (2 mg/dL) or higher (P < .001), beta-2-microglobulin 297.5 nM/L (3.5 mg/L) or higher (P < .001), lactate dehydrogenase 190 U/L or higher (P < .001), and bone marrow plasmacytosis higher than 30% (P = .003). Additional independent adverse implications were conferred by top-tertile SFLC reductions before cycle 2 (OS: HR = 2.97, P = .003; EFS: HR = 2.56, P = .003) and before transplantation (OS: HR = 3.31, P = .001; EFS: HR = 2.65, P = .003). Unlike baseline and follow-up analyses of serum and urine M-proteins, high SFLC levels at baseline-reflecting more aggressive disease-and steeper reductions after therapy identified patients with inferior survival.
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              GEM2005 trial update comparing VMP/VTP as induction in elderly multiple myeloma patients: do we still need alkylators?

              Melphalan (M), in combination with prednisone (MP), has been the backbone of new combinations, including bortezomib plus MP (VMP). However, new alkylator-free schemes, such as lenalidomide plus low-dose dexamethasone, are challenging the role of alkylators in myeloma treatment of elderly patients. Here we have updated, after a long follow-up (median 6 years), the results of the GEM2005 study that addressed this question by comparing VMP with bortezomib plus thalidomide and prednisone (VTP) as induction. Between April 2005 and October 2008, 260 patients were randomized to receive 6 cycles of VMP or VTP as induction. The median progression-free survival was 32 months for the VMP and 23 months for the VTP arms (P 5 .09). VMP significantly prolonged the overall survival (OS) compared with VTP (median of 63 and 43 months, respectively; hazard ratio [HR]: 0.67, P 5 .01). Achieving immunophenotypic complete response was associated with a significantly longer OS, especially in the VMP arm (66%remain alive after 8 years). Melphalan, plus bortezomib, should be maintained as standard care for the treatment of elderly multiple myeloma patients. This trial was registered at www.clinicaltrials.gov as #NCT00443235.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: Methodology
                Role: Data curationRole: SupervisionRole: Writing – review & editing
                Role: Writing – review & editing
                Role: Data curation
                Role: Data curation
                Role: Data curation
                Role: Data curation
                Role: Data curation
                Role: Data curation
                Role: Data curation
                Role: Data curation
                Role: Data curationRole: Supervision
                Role: Data curation
                Role: Data curation
                Role: Data curation
                Role: Data curation
                Role: Data curation
                Role: Data curationRole: Methodology
                Role: Data curation
                Role: Data curationRole: Supervision
                Role: Funding acquisitionRole: SupervisionRole: Writing – review & editing
                Role: ValidationRole: Writing – review & editing
                Role: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                7 September 2018
                2018
                : 13
                : 9
                : e0203392
                Affiliations
                [1 ] Hematology Department, Hospital Universitario 12 de Octubre, CIBERONC, Madrid, Spain
                [2 ] Clinical Biochemistry Department, Hospital Universitario 12 de Octubre, Madrid, Spain
                [3 ] Hematology Department, Hospital Clinic, Institut d'Investigacions Biomédiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
                [4 ] Hospital Germans i Trials, Barcelona, Spain
                [5 ] Hematology Department, Hospital Clínico de Valencia, Valencia, Spain
                [6 ] Hematology Department, Hospital La Paz, Madrid, Spain
                [7 ] Hematology Department, Hospital de Donostia, San Sebastian, Spain
                [8 ] Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
                [9 ] Hospital Morales Meseguer, Murcia, Spain
                [10 ] Hematology Department, Hospital General de Segovia, Segovia, Spain
                [11 ] Haematology, Hospital Univarsitari de la Santa Creu i Sant Pau, Barcelona,Spain
                [12 ] Haematology Department, Hospital Universitario Fundacion Alcorcon, Madrid, Spain
                [13 ] Hematology Department, Hospital Universitario de Salamanca-IBSAL, IBMCC-CSIC, Salamanca, Spain
                [14 ] Haematology Department, Hospital Univarsitari Son Espases, Mallorca, Spain
                [15 ] Haematology Department, Institutd’Oncologia Dr Josep Trueta de Girona, Girona, Spain
                [16 ] Haematology Department, Hospital Universitario San Carlos, Madrid, Spain
                [17 ] Haematology Department, Hospital Universitario de Canarias, Tenerife, Spain
                [18 ] Haematology Department, Clínica Universitaria de Navarra/ CIMA,IDISNA, CIBERONC,Pamplona, SPAIN
                Cleveland Clinic, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                ‡ These authors are joint co-chairs on this study.

                ¶ Membership of the GEM (Grupo Español de MM)/PETHEMA (Programa para el Estudio de la Terapéutica en Hemopatías Malignas) Cooperative Study Group^ is provided in the Acknowledgments.

                Author information
                http://orcid.org/0000-0003-1727-8546
                Article
                PONE-D-18-14575
                10.1371/journal.pone.0203392
                6128544
                30192814
                42a81510-a3d3-4304-9100-0fb5c317794f
                © 2018 Lopez-Anglada et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 30 May 2018
                : 20 August 2018
                Page count
                Figures: 4, Tables: 2, Pages: 14
                Funding
                This research project was supported by grants PI06339, PS09/01370, and PI12/01761 awarded to Sara Borrell (CD13/00340) and Juan Rodes (JR14/00016) from the Fondo de Investigación Sanitaria (FIS), the Red Temática de Investigación Cooperativa en Cáncer (RTICC) of the Instituto de Salud Carlos III (Ministry of Economy, Industry, and Competitiveness, Madrid, Spain), FEDER (RD12/0036/0061, RD12/0036/0048m and RD12/0036/0058) from FIS, the Asociación Española Contra el Cáncer (AECC; GCB120981SAN), and the CRIS Foundation.
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